god in a cup poetry nov 2018. christian journal for global health 5(3):54. god in a cup martha christine carlougha a md, mph, professor, unc/chapel hill and theology, medicine and culture initiative of duke divinity school, usa i wait slightly less than patiently, taking up slightly more than my share of floor space on the ladies’ side of church. distracted, an inefficient ceiling fan circulates monsoon-laden air; someone’s two-year-old crawls over, sits on my foot. in the interlude, i contemplate the walk home through mud puddles, diesel fumes, and poverty; i wonder is there time for a cold shower before lunch? i receive communion from the common cup then walk back to my space with the woman who always shares my bible, smiling with pride and affection though we both know she cannot read. on the way home, i buy a diet coke. it is cold and sweet but leaves an aftertaste, costing as it did, more than two days’ worth of rice or ten measles vaccinations. in a few days, i will once again board a plane, spending a day, closer to a lifetime, crossing the globe to reach a country called home. as the fabric of my connection to this land i love grows thin at the edges on this mid-monsoon morning, i stretch to remind myself there are other places i also belong where god is served in a cup. submitted 15 july 2018, accepted 17 july 2018 competing interests: none declared. correspondence: martha christine carlough, unc/chapel hill and tmc initiative of duke divinity school, united states of america. martha_carlough@med.unc.edu cite this article as: carlough mc. god in a cup. christian journal for global health. nov 2018; 5(3):54. https://doi.org/10.15566/cjgh.v5i3.234 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:martha_carlough@med.unc.edu https://doi.org/10.15566/cjgh.v5i3.234 http://creativecommons.org/licenses/by/4.0/ editorial july 2018. christian journal for global health, 5(1):1. five years and going strong this is the fifth issue of the journal and we are celebrating our fifth anniversary of publishing. we would like to think we have emerged from infancy even if there is some way to go to reach full adulthood. we monitor readership and find stability or slow growth. there continues to be a satisfactory flow of excellent submissions. the theme for this issue was to be faith-based engagement of the global refugee crisis and we have several good submissions relating to this call for papers. however, a number of them are still in review, so we have decided to publish them together in a month as a supplement to this issue. in the meantime and in advance of the yearly conference of christian connections in international health, we offer a response by professor henry moseley to the critique of evangelical participation in global family planning, published in our last issue. there is also an assessment of both sides of the debate by the editor who wonders if each side has omitted a third option. raymond downing contributes a parallel commentary that asks insightfully if modern medical missions with its technological, institutional, and membership trappings is inconsistent with essential features of a truly biblical gospel witness. an original article by students, staff and faculty from singapore has measured the impact of values-based health education as part of community health evangelism in cambodia. a second original article, from investigators at vanderbilt university, surveys attitudes held by political, religious, and social conservatives in the us toward funding for global health initiatives relating to nutrition and food security and compares them to the general population. benjamin dolittle shares a review of andrew sloan’s book, vulnerability and care: christian reflections on the philosophy of medicine which proposes that biblically-informed medicine will consider care to be the prime purpose associate editor michael soderling reports on a conference in april hosted at the vatican called humanity 2.0 which deals with solutions to human problems, focused on a healthy environment for pregnancy, “conscious capitalist” business ethics and the power and potential of internet media to affect social change. finally, dwight phillips and james smith contribute a letter commenting on mark crouch’s 2017 submission on what constitutes “a proper college” for training in global health practice. we will be issuing another call for papers relating to the imitation of christ in global health, and how he responded to disease, economic disparities, fears and social alienation. registered readers will be notified when the supplementary issue is published online. if you are not currently a registered reader, you are welcome to sign up for free access to this maturing, thought-provoking and practical scholarly work, and to consider how you might contribute to its vital content. . www.cjgh.org book review nov 2017. christian journal for global health 4(3):103-104. finding grace in the face of dementia by john dunlop crossway, 2017 daniel w. o’neilla a md, ma(th), associate clinical professor of family medicine, university of connecticut school of medicine, usa dementia is an increasingly common major neurocognitive impairment which was estimated to affect 35.6 million people globally in 2010. as a major non-communicable disease with 7.7 million new cases per year, this number is likely to double by 2030 and triple by 2050. yet many countries lack awareness and understanding of dementia, resulting in stigmatization, inadequate care, and significant economic hardship. for these reasons, the world health organization has made dementia a public health priority.1 with the globalization of christianity, a distinctly christian approach to dementia is needed in the face of these realities in communities everywhere. john dunlap, a geriatric specialist and ethicist writes this book to provide a theological lens through which we can view dementia, then gives practical ways for professionals, pastors, caregivers, and families to care for people living with the condition. he comes with an american perspective, but his approach can be applied in any context where christian principles and practices can be applied to retain human dignity and embrace the value of care giving toward those losing their cognitive abilities toward the end of life. dunlap, speaking from his personal pain of both parents with the condition and acknowledgment of his own high risk, first presents a very simple treatment of the sovereignty of god in all things, the dignity of all human life from creation, the pain and corruption of the fall, and the hope of full cognitive redemption. he proceeds to provide a helpful distinction between benign senescent forgetfulness and mild cognitive impairment, as well as the various causes of dementia. then using vignettes from his own patients, he lays out the steps and challenges of a proper diagnosis. he takes a very pastoral and practical approach to timing and communicating with family, social support engagement, etc. he describes exacerbants and alleviants of the condition, medication treatment options, and integrates spiritual resources such as prayer and anointing for a refreshing whole-person care approach. in chapter 5, dunlap presents a very valuable empathetic picture of what it is like from the inside of a person with dementia, which can help enhance understanding and compassion. he then lists challenges from the patient and the burdens on the care giver that a deep trust in god can help overcome. chapter 7 is a powerful call to serve and love those with dementia based on clear biblical principles, followed by practical guidance on resource utilization to ease the burden, and a description of the rewards of caregiving, both temporal and eternal. the heart of dunlop’s call begins in chapter 8 with how god can be honored through dementia. this involves applied biblical values, trust, respect, loving care, relationship building, living for the moment, cherishing memories, citing scripture, church involvement, spiritual growth, prayer, and ending life well. a dignifying approach enters their world, follows jesus’ example, gives the gift of time, is person-focused, clearly communicates, respects 104 o’neill nov 2017. christian journal for global health 4(3):103-104. autonomy, preserves dignity, helps find meaning, and maximizes potential. meeting needs in the physical, social, emotional, and spiritual domains attends to every dimension affected. he calls the church to deeper commitments to care for others, embrace a theology of suffering, and to spiritually care for those afflicted and their caregivers. he gives hope for a resultant growth for all those involved. since dementia is a terminal condition, it is highly relevant for palliative and end-of-life care. dunlop finished the book by giving a cogent biblical perspective on death, decision making in the oftenvariable course of the diseases, the futility of some types of treatments, avoidance of artificial hydration and nutrition, the value of comfort care, embracing the mystery of the timing of death, the ethical problem with assisted suicide, and eternal destinies to be embraced. dunlop’s use of scripture and prayer, along with integration of the patient and caregiver’s spiritual life gives an important model for wholeperson care. it is unclear how well this would apply in non-christian contexts, in low-resource settings, or in other cultures whose values toward the elderly and dementia differ from those in the west. however, there are many trans-cultural principles which can be applied, and the light of the gospel, communities of faith, and the deep value of scriptures emerge. the challenges of palliative end-of-life care, loss of capacity, resource allocation especially in lowand middle-income countries, and pressures by government policy makers to support euthanasia are challenges the global church must face.2 dunlop’s pastoral and clinical approach is most welcome in the face of this increasing and very costly global burden of disease. having this degree of clarity regarding intrinsic imago dei human dignity, radical personcentered compassion, the value of caring for the vulnerable, promoting the best palliative care available in a context of scripture and prayer makes this book a high-value resource — one which the global church and others could seek to apply in many contexts. references 1. who. dementia: a public health priority. geneva: who; 2012. [cited 2017 oct 30] available from: http://www.who.int/mental_health/publications/deme ntia_report_2012/en/ 2. swift c. dementia. triple helix [internet]. april 2009;44:6-7. [cited 2017 oct 30] available from: http://admin.cmf.org.uk/pdf/helix/2009easter/theast er09-p6-7.pdf competing interests: none declared. correspondence: daniel o’neill, christian journal for global health and assistant clinical professor of family medicine, university of connecticut school of medicine, usa. dwoneill@cjgh.org cite this article as: o’neill dw. finding grace in the face of dementia by john dunlop – crossway, 2017. christian journal for global health. nov 2017; 4(3):103-104. https://doi.org/10.15566/cjgh.v4i3.200 © o’neill dw. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.who.int/mental_health/publications/dementia_report_2012/en/ http://www.who.int/mental_health/publications/dementia_report_2012/en/ http://admin.cmf.org.uk/pdf/helix/2009easter/theaster09-p6-7.pdf http://admin.cmf.org.uk/pdf/helix/2009easter/theaster09-p6-7.pdf mailto:dwoneill@cjgh.org https://doi.org/10.15566/cjgh.v4i3.200 http://creativecommons.org/licenses/by/4.0/ editorial july 2017. christian journal for global health, 4(2):1-2. the global church and family planning: creative collaboration family planning is both a crucial issue for global health and a sometimes vexatious issue for many individual christians and church institutions. secular approaches to family planning, not infrequently, endorse abortion and sideline the sacramental and spiritual aspects of marriage. for these reasons the journal editors felt that a special issue devoted to family planning would be appropriate for a christian journal devoted to global health. we invited submissions on the subject and were rewarded with an excellent variety of contributions. a print version of a portion of the issue will be available for the july 2017 conference of christian connections for international health at john’s hopkins university in baltimore. this editorial will highlight not only the family planning articles in that version, but additional submissions on other subjects received since our last issue. family planning has been promoted as part of a christian global health agenda, as exemplified in a previous editorial by mosley.1 two case studies illustrate approaches to fostering family planning within this agenda. docking, a nurse midwife from australia, describes how her personal experience of being present at maternal deaths in uganda moved her to create an interactive curriculum called wise choices for life. this has a positive focus on god’s design for true love, commitment, and faithfulness; she strongly advocates for an expanded role of the church in providing training on sexuality. allison & basikoro describe why world vision has refocused its work in family planning, now calling it healthy timing and spacing of pregnancy. the old focus on limiting population growth had failed to result in significant increases in contraceptive prevalence rates. the new focus on maternal and child health resonates better with people and faith leaders. two submissions describe how christian health associations have facilitated the implementation of family planning methods in challenging circumstances. vanenk and her colleagues describe how catholic and protestant health organizations were able to work together in east africa to provide training, supervision, commodity availability, family planning promotion, data collection, and a supportive environment by being sensitive to cultural and doctrinal differences. duah & yeboah report how in ghana, 25 different denominations spanning a wide range of christian beliefs provide family planning services tailored to the sociocultural and religious differences existing among them. the effort has seen a growth in the number of family planning acceptors. faith leaders play an important role in facilitating the acceptance of family planning measures, and alikali assessed the attitudes and activities of pastors and faith leaders in eight provinces of zimbabwe. he found that 44% of them actually counselled their members and 28% had had training in family planning. barriers exist to the implementation of family planning as we published in a recent study in uganda by shumba, et al.2 three submissions described studies to surmount them. one barrier was when stockouts of relevant medicines and equipment occurred. metzger & bormet surveyed 46 facilities in 13 african countries to discover the frequency of stockouts, the family planning products involved, and the types of supply chains that were relevant to the stockouts. otchere and her colleagues initially used a health-promotion strategy called social and behavioral change communication in uttar pradesh, india that employed house-to-house visits and educational games initially. this was followed http://journal.cjgh.org/index.php/cjgh/article/view/173 file:///c:/users/dwone/appdata/local/packages/microsoft.windowscommunicationsapps_8wekyb3d8bbwe/localstate/files/s0/166/allison%20and%20basikoro file:///c:/users/dwone/appdata/local/packages/microsoft.windowscommunicationsapps_8wekyb3d8bbwe/localstate/files/s0/166/allison%20and%20basikoro http://journal.cjgh.org/index.php/cjgh/article/view/164 http://journal.cjgh.org/index.php/cjgh/article/view/175 http://journal.cjgh.org/index.php/cjgh/article/view/188 http://journal.cjgh.org/index.php/cjgh/article/view/130 http://journal.cjgh.org/index.php/cjgh/article/view/177 2 editors july 2017. christian journal for global health, 4(2):1-2. in the second year by interface meetings between village leaders, mothers-in-law, and husbands to educate them regarding government entitlements, reinvigorating village sanitation and nutrition committees, and reopening dormant health centers. the authors provided details on the results of these efforts. bhatta and colleagues leveraged an agricultural program for improving knowledge for family planning options, resulting in increased utilization in at least some areas of practice. meanwhile, several other articles on collaborations are included in this issue. butcher & grills describe the impact of a community health worker training program in india. mitchell & grills reports on a collaboration between australian faith-based development organizations to deal with climate change-related health challenges and disasters in the pacific island region, reasoning that crossdenominational efforts can be more effective influences in civil society. supplementing this report is pallant’s review of mitchell’s excellent book faith-based development, showing how christian organizations can better work in development using the resources of faith. several editors attended a conference at duke university divinity school in may, practice and presence, which focused on ignatian practice of meditation and imaginative prayer, and o’neill proposes an application in clinical and global health contexts. the editors are grateful to have had the collaboration of drs michael j. sleasman and paige comstock cunningham from the center for bioethics and human dignity in the reviewing and editing of this issue, as well as dr douglas huber and mona bormet from christian connections for international health who catalyzed many operational studies. we are grateful to have received a grant from advancing partners and communities from usaid for this issue. the interface between theology, ethics, and practice in the area of family planning requires thoughtful reflection and critique. in a guest editorial, oas opines on how caution is necessary when christian organizations undertake to partner “with institutions that promote an approach to family planning that is at odds with christian values.” a significant number of organizations active globally in family planning continue to advocate for abortion and are vocal in their opposition to provisions in us law that limit the abortion license. but abortion is not the only sticking point. oas’ thoughtful and provocative essay illustrates how terminology and concepts, including many used in the submissions outlined above, do not mean what they seem to mean. often, behind their use is a frame of reference that is at odds with the christian understanding of sexuality, marriage, and the family. some readers may take issue with this frank, but penetrating analysis, which we believe gives them an opportunity to peruse, reflect, and respond. we welcome respectful comments and promise to reply. references 1. mosley wh. (2014). family planning as a christian global health agenda. christan journal for global health nov 2014; 1(2):2-4. https://doi.org/10.15566/cjgh.v1i2.47 2. shumba cs, et al. a qualitative study on provider perspectives on the barriers to contraceptive use in kaliro and iganga districts, eastern central uganda. christian journal for global health, nov 2016; 3(2):60-71. https://doi.org/10.15566/cjgh.v3i2.114. www.cjgh.org http://journal.cjgh.org/index.php/cjgh/article/view/162 http://journal.cjgh.org/index.php/cjgh/article/view/160 http://journal.cjgh.org/index.php/cjgh/article/view/180 http://journal.cjgh.org/index.php/cjgh/article/view/185 http://journal.cjgh.org/index.php/cjgh/article/view/183 https://doi.org/10.15566/cjgh.v1i2.47 https://doi.org/10.15566/cjgh.v3i2.114 editorial may 2016. christian journal for global health, 3(1):1-2 christians and the sdgs: already and not yet this issue of the christian journal for global health highlights a christian response to the sustainable development goals (sdgs) promulgated in september 2015 by the united nations. our call for papers invited authors to participate in conversations about heath, human flourishing, development, community health, social justice and global health access, and to share their insights, reflections, and research. contributions discussing these issues in a christian context are particularly appropriate because of an increasing recognition of how religion and associated health institutions contribute positively to health in both theoretical and practical ways. managing editor, daniel o’neill, provides a theological basis for the potential influence of the christian church in global health given its goals and globally expanding reach. steffen flessa reviews how declarations on the healing mission of the church made at tübingen in 1964 and in 1967 have affected healthcare in the past and how christian influence retains its relevance. his second article also undertakes to tell us where christians, driven by economic realities, need to evaluate their portfolio of services to retain “unconditional reliability” in the future. raymond downing asks whether it is right to aim at development, implying a focus on economic well-being. some might answer that economics is often a proxy for other values like health and educational opportunity. as downing points out, however, the ends to which christians aim may not be evaluable in merely economic terms, nor attainable prior to the renewal of all things. the sdgs have less to say specifically about human health than the millennial development goals. but global health issues do not escape the purview of christians, as evidenced by an international conference on global health issues that was attended by three journal editors. rev morris sing key reports on this, highlighting christian interest in a broad range of topics including emerging infections and disasters, the challenge of economic and resource restraints, new technologies, and dealing with incurable diseases, pain and death. andrew sloane expounds on a presentation at that conference, showing how experience in the recent outbreak of ebola helps to show us that the end of medical efforts is more appropriately seen as caring rather than cure. not everyone may agree with such a strong distinction between caring and curing as the end of medical efforts. however, ebola teaches the lesson that compassionate caring by health workers is a unique demonstration of love even when either the caregiver’s or patient’s life is ultimately lost. ebola reminds us that there is no greater love than this, “that someone lays down his life for his friends.” 1 the editors are pleased at the continuing flow of original articles coming to the journal. original articles are fundamental to its scholarly respectability. we are nearing the number needed to apply for indexing by the national library of medicine (index medicus). in this issue, the team at duncan hospital in bihar, india, reviews their extensive experience with snake bites, a major cause of morbidity and mortality in india. the highlight of their paper is the recommendations – aptly presented in two tables. one is for health care workers with practical advice on the evaluation of patients with suspected bites and the other for educating the community in snake-bite prevention. a second paper from india studies the barriers limiting access to clean water in kolkata. a word about ethical review for studies using survey data may be in order. proposed changes in the common rule exempt “research involving collection of identifiable information through surveys, interviews, or observation of public behavior” if privacy safeguards are mainhttp://journal.cjgh.org/index.php/cjgh/article/view/112 http://journal.cjgh.org/index.php/cjgh/article/view/112 http://journal.cjgh.org/index.php/cjgh/article/view/96 http://journal.cjgh.org/index.php/cjgh/article/view/104 http://journal.cjgh.org/index.php/cjgh/article/view/105 http://journal.cjgh.org/index.php/cjgh/article/view/110/299 http://journal.cjgh.org/index.php/cjgh/article/view/101 http://journal.cjgh.org/index.php/cjgh/article/view/101 http://journal.cjgh.org/index.php/cjgh/article/view/77 http://journal.cjgh.org/index.php/cjgh/article/view/32 2 editors may 2016. christian journal for global health, 3(1):1-2 tained. 2 the editors expect that this change will prove beneficial to many of the journal’s constituents where requirements for institutional review board approval for such low risk research have been a barrier to research. mark strand and his colleagues analyze the reasons health workers prematurely terminate their service abroad and the role of cross-cultural training in preventing this. they propose that onthe-field cross-cultural training and mentoring can facilitate the development of a worker from novice to beginner, to competent, to proficient, to expert. finally, a short report describes the experience of using teleradiology to help mission hospitals obtain expert radiographic readings. indeed, teleradiology now accounts for most outof-hours radiographic interpretation, even in the united states. extension of this service to hospitals in low resource settings is not without effort as is the occasional need to deal with technical issues. however, this model provides diagnostic support to providers, as well as better care access to patients. christine tashobya reviews improving aid effectiveness in global health by elvira beracochea, an excellent compilation with practical approaches that can be applied in the sdg era. in a short communication, the community health global network describes how networking between community health programs can contribute to the sdgs. the importance of a networking approach was recently highlighted at the chgn inter-national forum which is also described. the articles in this issue indicate that christians’ faithful presence, following the call to serve, heal, care, speak, and expand will be important elements in sustainable development for the next 15 years and beyond. however, we would remind our readers of the fundamental christian perspective on human development and the future clearly stated by john stott: “although it is right to campaign for social justice and to expect to improve society further, in order to make it more pleasing to god, we know that we shall never perfect it. christians are not utopians. although we know the transforming power of the gospel and the wholesome effects of christian salt and light, we also know that evil is ingrained in human nature and human society. we harbor no illusions. only christ at his second coming will eradicate evil and enthrone righteousness forever. for that day we wait with eagerness.” 3 reference 1. john 15:13 english standard version. 2. hudson kl, collins fs. bringing the common rule into the 21 st century. new england j med. 2015;373(24):2293-6. http://dx.doi.org/10.1056/nejmp1512205 3. stott jr. the contemporary christian: applying god's word to today's world. downers grove: intervarsity press; 1992. p. 390. www.cjgh.org http://journal.cjgh.org/index.php/cjgh/article/view/102 http://journal.cjgh.org/index.php/cjgh/article/view/107 file:///f:/crossnetwork%20journal/articles%203(1)/layout/christine%20toshobya http://journal.cjgh.org/index.php/cjgh/article/view/116 http://dx.doi.org/10.1056/nejmp1512205 conference report july 2018. christian journal for global health, 5(1):47-49. humanity 2.0 – a healthy environment for pregnancy, business ethics and the media michael j. soderlinga a md, mba (int dev), director, center for health in mission, and co-catalyst, lausanne health in mission network, usa this conference convened at the vatican city on april 19, 2018 by invitation, to address maternal health, business ethics, and the media. the humanity 2.0 forum is a broad spectrum gathering of luminaries and stakeholders at the vatican to explore a specific impediment to human progress and to discuss courses of action aimed at overcoming it. it is the goal of a forum to identify one specific venture that has high probability to fundamentally alter human life on earth and then to rally support for a cross sector collaborative venture.1 the specific venture identified as being an impediment to human progress for this event was the current state of maternal health for those living in under-resourced parts of the world. it was also pointed out that maternal health indices in the united states are among the lowest within countries considered developed. and for minority groups, african-american moms in particular, statistics are barely better than some "developing" nations. opening remarks were given by marie-louise coleiro, president of malta, the honorable linda lanzillotta, former vp of senate, italian republic, louis l bono, charge d'affaires, us embassy to the holy see, rabbi riccardo di segni, chief rabbi of rome, and luca bergamo, vice-mayor of rome. human-centred civilizations the day began with a panel on humancentered civilizations that addressed the topic of tenderness. pope francis in his ted talk in 2017 urged for a “revolution in tenderness.” he reminded us that we are not islands unto ourselves, but rather a common family sharing a common home. the mission is to encourage a culture of love where we recognize each other's dignity and work selflessly to build a civilization of true opportunity. this exploratory panel will delve more deeply into pope francis's remarks and suggest courses of action aimed at realizing the holy father's vision.1 it was encouraging to hear the panel address the question of "what is tenderness?" i was struck by the variety of responses though none referred to the multiple ways in which jesus demonstrated tenderness throughout his 3-year ministry on earth. i can think of no greater demonstration of tenderness than jesus' encounter with the woman at the well or the woman accused of adultery. a fascinating aspect of these two panels was the effort to link the tenderness discussion, with obvious connections to improving the health of pregnant mothers worldwide, with capitalism. present within this panel were multiple individuals representing business initiatives that 48 soderling july 2018. christian journal for global health, 5(1):47-49. promote what one referred to as “consciouscapitalism.” brendan doherty is co-founder of forbes impact that promotes investments that create both financial gain and positive social change. he stated, "every investment has an impact whether we acknowledge it or not. the challenge is to transform the economy to create value not only for the shareholders." i believe we will be hearing a great deal more about this attempt to reform capitalism into a system that functions from a dual or even triple bottom line. a dual bottom line gives value to shareholders and creates a social benefit, whereas a triple bottom line also benefits the environment. square roots lab on maternal health the final session of the morning was hosted by the organization, square roots, founded by morad fareed. this time was focused primarily on the crises in maternal health with the most passionate advocate being jennie joseph, a midwife working in a rural setting in florida. she outlined the effective way in which her center had addressed the problem of prematurity and pre-eclampsia in her region through building strong relationships with the pregnant mothers and their families. joseph was highly critical of the u.s. "healthcare" system, stating that it lets far too many high-risk mothers fall through the cracks, and moms and their babies pay the price. the ultimate price in some cases. the afternoon sessions kicked off with a large panel of working mothers who discussed the challenges they faced during and after their pregnancies. the panelists were primarily from the u.s. but the u.k. was also represented. the panelists came from very diverse backgrounds including a cnn v.p., an nbc executive, as well as an astronaut who had made two journeys into space. one point that was brought out by the u.k. mothers is how well moms are treated in the uk and europe in general. generous maternity leave is provided while the sense in the u.s. is that one is expected to return to work within at least 6 weeks after giving birth. there was also the feeling that the business environment in the u.s. is also not very friendly to moms as they tend to lose their seniority and chance for advancement simply because they took time off to have a child. the u.k. mothers had not had that experience. the next forum discussed the forthcoming "lab" that will be developed in rome to demonstrate how the ideas shared during this forum can be implemented, measured. and shown to be effective. power and pitfalls of media a final panel was led by award-winning journalist sally lehrman. ms. lehrman leads the trust project, an international consortium of news organizations collaborating to use transparency to build a more trustworthy and trusted press. this initiative is hosted by santa clara university’s markkula center for applied ethics. this panel discussed the present situation facing the media in today's environment of "fake news." i did not hear an explanation of how this ties into the overall theme of the day but the panel discussion was a fascinating one. there is great concern amongst many in the media today regarding the perceived, and probably justified, public opinion that fewer and fewer news media outlets are trustworthy. this attitude creates challenges for those who are trustworthy sources of news, the greatest being, quite possibly, that it threatens their very existence. if the public lumps all news sources into one category, not reliable to tell the truth, then those who are expending valuable resources to be trustworthy may not survive in this new online environment where all news is expected to be offered at no cost to the consumer. this project is engaging many of the major players such as facebook, bing, google, and twitter. attempts are being made to create the means by which a consumer can explore an online article to discover its trustworthiness. one example would be to provide a way in which the reader could explore 49 soderling july 2018. christian journal for global health, 5(1):47-49. the background of the articles author. a link could be in place so that when clicking on the author’s picture, it will direct one to a location containing all the necessary information about that author. it is hoped that ai will assist in creating a system whereby the reader can easily be reassured that what is written is reliable. reflections overall, this was a most interesting event. it occurs to this author that this represents a reaction, in a sense, to modernism and post-modernism (and post-post modernism or even metamodernism!). as religion has been increasingly marginalized and deemed irrelevant, secular-humanism has tried to fill the cultural void leftover and has been found wanting. there is little to no meaning in life if the secular-humanist religion is to be believed and pursued. and thus, the capitalism that results from this shift has been found to be lacking any heart or soul and is seen as being a system that only cares about short-term gain and shareholder income. so, we had wonderful discussions on the theme of tenderness, and how that concept can be applied to big business, and how that could create a social good and even perhaps have a positive effect on the environment. as funding for initiatives led by followers of jesus dry up, this current movement toward conscious-capitalism could be very beneficial so long as we can convince the investors that we are engaged in something that potentially benefits all of humanity and are doing our work with the highest of standards and are measuring our outcomes. references 1. humanity 2.0 – a shared horizon for humanity. available from: https://humanity2-0.org/ competing interests: none declared. correspondence: michael soderling. center for health in mission. mjsoderling@gmail.com cite this article as: soderling mj. humanity 2.0 – a healthy environment for pregnancy. christian journal for global health. july 2018; 5(1):47-49. https://doi.org/10.15566/cjgh.v5i1.219 © soderling mj. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://humanity2-0.org/ mailto:mjsoderling@gmail.com https://doi.org/10.15566/cjgh.v5i1.219 https://creativecommons.org/licenses/by/4.0/ conference report july 2017. christian journal for global health, 4(2):103-105. practice and presence: a gathering for christians in health care – finding god in all things daniel w. o'neilla a md, ma(th), assistant clinical professor of family medicine, university of connecticut school of medicine, usa with the complexities and time demands of health care in the late modern world and the scientific reductionist frameworks which tend to depersonalize medicine, as well as the complex systems which frame clinical and global health practice, there is a need for reflection and connection. this year’s gathering from 19-21 may 2017 at duke university divinity school in durham, north carolina, usa by christians practicing medicine, chaplains, and other health professionals focused on ignatian practices of meditation and imaginative prayer. organized by the department of theology, culture, and medicine, the conference accomplished its objectives of tuning our eyes and hearts to see god’s presence in our work in healthcare; to engage in imaginative, contemplative reading of scripture and prayer; to learn from ignatian practices of discernment and decisionmaking; and to grow in friendship with one another.1 seeing and seeking god in the opening session john hardt, phd., associate professor in neiswanger institute for bioethics, stritch school of medicine, and vice president and associate provost of mission integration, loyola university health system and health sciences division, introduced the ignatian concepts of seeing god in all things and seeking god as “a beggar, a supplicant” through contemplation to attain divine love. required was an awareness that god works and labors for us in all creation, so that in all things we may serve him. this takes several steps: 1. a reorientation to establish new standards of excellence and new definitions of success, humbly recognizing our sinfulness, our gifts and our dependence as creatures; 2. fostering gratitude which moves us back into the world to serve others; and 3. practicing reverence for god “in retreat and in the street,” living our lives as if we really believe that god saved the world in christ. the cross is the “still point of the turning world” (t.s. elliott) which shatters death and defeats the constraints of time, allowing us to live for the moment, to take a “long loving look at the real,” becoming a “friend of time” (john swinton), finding moments of light as gifts even in the mundane exigencies of everyday life, and walking with the “three mile an hour god” at the speed of love (kosuke koyama). imaginative prayer in the second session, david de marco, sj, md, a jesuit priest and assistant professor in the division of general internal medicine, department of medicine and chaplain at marcella niehoff school of nursing at loyola university, chicago, introduced imaginative prayer as part of the spiritual disciplines and an “indispensable companion of reason” (c.s. lewis), integrating head and heart. this requires us to be open to sacred moments, god’s prompting, and interior movements of the heart. cultivating an attitude of open-ness to the spirit, we can draw upon narrative in both the gospel and our 104 o’neill july 2017. christian journal for global health, 4(2):103-105. own experiences toward deeper intimacy and identification with the person of jesus. using reflective imagination to create scenes along the lines of scripture can then be related to our current real-time context, testing our thoughts and attitudes against those of jesus. this allows us to “enter the patient’s chaos” and “hold the patient’s story,” making internal movements toward god. as richard weinberg writes, the “communion” experienced with those for which we care is a connection through shared stories leading to healing moments.2 discernment and decision-making in the third session, martha carlough, md, mph, professor in family medicine and public health, university of north carolina at chapel hill, former missionary to nepal and ignatian-trained spiritual director, discussed discernment and decision-making. to discern is to “sift through, or to sort out” and is an essential link between prayer and the active christian life (apostolic action). to be truly prophetic is to be consistent, to move toward god, and to exercise a link between words and signs. the scriptural basis of discernment includes moses’ exhausting but delegating judgments (ex 18:13-37) and his call to “choose life” and reject death (deut 30:15-20); the psalms speaking peace (consolations) or unsettledness (desolations) (ps 131, 94); testing the spirits (1 jn 4); growing in maturity (1 cor 3:13); and walking by the spirit not by the flesh (gal 5:16-21), culture, principalities, or powers. the affective components of the inner life that st. ignatius of loyola emphasized were also important to john wesley and jonathan edwards in other christian traditions of discernment. the emotions help us control what we decide and how we understand ourselves and therefore god (augustine). dr. carlough shared principles used for decisionmaking and the importance of paying attention, deep listening, imagination, and decision making in times of tranquility. the prayer of examine can be used as a daily exercise of reflection, discernment, and transformation—settling down in god’s presence, praying in thankfulness, reviewing the day, praying imaginatively from one moment of the day, and looking toward tomorrow. this could make us more aware of disordered attachments (e.g., obligation, power, money, accolades) and the difference between true consolation (which draws us toward god) and false consolation. sacred moments in the final session, dr. demarko brought the discussion and exercises together, noting that the contemplative physician cannot attain perfection, but seeks to walk the path toward god, experiencing sacred moments in the exam room and finding freedom there. it opens up new avenues of meaning in the often hurried, economically-driven practice of medicine. it speaks truth to power structures and is a way to be prophetic to the patient’s life and to the community. becoming aware of the interior movements of others, understanding and “holding” their story, is a way to make sense of suffering and walk with others through it in compassion and care. becoming conscious of the moving of the spirit and our dependence on god in prayer and reflection helps us amend our ways toward christlikeness. story-telling and christ the healer several breakout workshops were offered by the speakers in ignatian contemplation, medical ethics in the catholic tradition, and practicing decision making, as well as medicine and storytelling (ray barfield, md, phd), and cultivating awareness of christ in health care contexts (cathy lewis, phd, msw) where there was rich interaction. times of fellowship over meals, worship in song led by jonathan and amanda noel, and an imaginative performance of christ the healer from scripture by lauren greenspan, mdiv and rachel campbell rounded out a refreshing weekend 105 o’neill july 2017. christian journal for global health, 4(2):103-105. that equipped participants to practice god’s presence in their service to patients. respectful connectedness richard foster describes contemplative love as a “stream” of christianity that “leads us forth in partnership with god into creative and redeeming work.”3 experiencing god’s presence in the mundane and challenging practice of medicine, public health, and community development is essential to sustain love for the suffering and allow our work to retain deep purpose. according to brother lawrence, when the soul looks to god daily in intimate familiarity, “it passes almost its whole life in continual acts of love, praise, confidence, thanksgiving, offering, and petition,” in a ceaseless exercise of god’s divine presence.4 listening to and holding the story of the people we serve, knowing what has been described as their “thread” is vital to being a “witness” who considers their dignity in fostering a healing environment.5 this respectful connectedness is also an important element in development which is truly sustainable. listening to the voice of god in our own lives, in other people’s lives and in the surrounding culture, allows discernment in order to understand systems, origins of disease, and disordered relationships. it also guides us in seeking god-informed, innovative solutions personally, clinically, and globally toward health and wholeness. references 1. theology, medicine and culture, duke divinity school. available from: https://tmc.divinity.duke.edu 2. weinberg r. communion. ann intern med. 1995;123:804-805. https://doi.org/10.7326/00034819-123-10-199511150-00011 3. foster r. streams of living water: celebrating the great traditions of christian faith. san francisco: harpercollins; 1998. p. 58. 4. lawrence b. the practice of the presence of god. new kensington: whitaker house; 1982. p. 72. 5. chochinov hm. health-care provider as witness. lancet. sept 2016;388(10,051):1272-73. https://doi.org/10.1016/s0140-6736(16)31668-3 competing interests: none declared. correspondence: daniel w. o'neill, university of connecticut school of medicine, usa. dwoneill@cjgh.org cite this article as: o’neill dw. practice and presence: a gathering for christians in health care finding god in all things. christian journal for global health. july 2017; 4(2):103-105. https://doi.org/10.15566/cjgh.v4i2.185 © o’neill dw. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://tmc.divinity.duke.edu/ https://doi.org/10.7326/0003-4819-123-10-199511150-00011 https://doi.org/10.7326/0003-4819-123-10-199511150-00011 https://doi.org/10.1016/s0140-6736(16)31668-3 mailto:dwoneill@cjgh.org https://doi.org/10.15566/cjgh.v4i2.185 https://creativecommons.org/licenses/by/4.0/ guest editorial june 2014. christian journal for global health, 1(1):3-5 speaking out into a new future ted lankester a a ma, mb, bchir, mrcgp, rcpsglasg is founder of community health global network and director of health services, interhealth, uk. for generations, christian health professionals have pioneered and provided health care for the neediest people on our planet. 1 for the most part, their work has been largely unrecognized. many have been so busy caring for people and programmes that they have never documented their activities. after all, when you are operating on the war wounded through the night, driving back late from your remote clinic, or trying to run a hospital with three senior staff members off sick, there is not much time to write up perfect reports or manicure statistics. as for writing research papers or contributing to health policy, well, that will have to wait - probably indefinitely. as a result, some of the greatest stories of practical service and health impact have never been told. many have not even been recorded, meaning that governments may be almost entirely unaware of their existence, let alone their contributions. in addition, the secular mind sets of donors, policy makers, and the media have often done little to correct these misconceptions. as a result, faith-based organisations (fbos) are frequently the hidden providers of health care, and more often than not, the unsung heroes. but, the good news is that, over the past few years, perceptions and realities are starting to change. bodies, such as the world health organization, have documented the role of fbos, and major donors have acknowledged their special contribution. 2,3,4,5 policy makers, albeit grudgingly, are starting to recognize a truth, only too obvious to most field workers, that a worshipping community, be it temple, mosque, or church, is present in virtually every place on earth where people gather, work, or live together. moreover, members of such groups are the obvious proponents and providers of service to their communities, if only they can be identified, trained, and resourced. christians and members of other faiths are beginning to find a voice. that voice is a good start, but to have any impact a voice needs to be amplified. the christian journal of global health is designed to be one such amplifier. through the journal, stories, anecdotes, operational research, and the impact of faith-based programmes have a vehicle to make their previously little known contributions clearly available to a wider audience. when jesus told us to pray regularly “your kingdom come, your will be done on earth as it is in heaven,” (matthew 6:10) 6 he was calling us to a here-and-now mandate to serve the world with compassionate and creative love to show, practically, how god’s “saving health” (psalm 67:2) 7 can be shown in the slum alleyways, refugee camps, and in distant hilltop communities. incarnation usually comes before redemption. the living embodiment of a god who is here with us in our pains, sorrows, and celebrations is the forerunner of what that same god enacts with and through us in redeeming the world for a new future. christian and other faith-based health professionals are in a privileged position to help bring this about with a measured and unwavering voice to share widely just how this is happening. by the end of 2015, we will be coming to the end of the millennium develop4 lankester june 2014. christian journal for global health, 1(1):3-5 ment goals (mdg). 8 we have much to celebrate. soon, we will be transitioning to universal health coverage 9 and the sustainable development goals. 10 as people of faith, we should embrace these new initiatives with eagerness and not carp and criticize that they won’t always live up to our perfectionist hopes. they, and other emerging goals, give us a renewed mandate to become deeply re-involved through service, policy formation, evidence based health programmes, and creative models of service. we have an open door and a wide road stretching before us. it’s a moment in history to grasp the promises of god and claim the energy “he mightily inspires within us” to make an even greater contribution to the welfare of our world. it’s an opportunity to promote healthcare not only for its primary purpose of bringing renewed health and wellbeing to communities but also by pursuing community-agreed health priorities to act as an agent for reconciliation. we must also work with a new confidence to share expertise and motivation with governments, donors, and policy makers. this will often mean forgetting our small differences for the sake of a more effective service for humankind. without losing our distinctives, we can unashamedly contribute and influence the practice of global health in a new generation. the christian journal of global health can be a vehicle in which we encourage, document, speak, and promote the unique contributions of the church and other faith communities. with god as our creator and our legitimate claims to sometimes “hear his voice and understand his ways,” we should be surfing the crest of the wave and not waiting till that same wave has broken farther up the beach. we should be in the forefront of creative policy and not spend energy in playing catch-up. and yet, whilst recognizing the value of our faith-based distinctives, we must also affirm that humanitarianism has its roots in christian values 11 , and, as a result, we have a valid and essential overlap of policy and practice with those who may not share our faith, but who do inherit a god-given instinct to make the world a fairer, safer, and healthier place. we must share our insights and pioneer collaborations that will lead to a greater good. we need to clearly believe and demonstrate that the kingdom of god carries a far greater model for service than simply encouraging christians to serve and protect their own. this is not the time to hold back and to retreat into our religious corners. neither is it a time to make triumphalist claims about aspirations we have not yet reached, but it is an opportunity for us to demonstrate, more intentionally, a range of models which combine compassion, evidencebased healthcare, and useful collaborations as we move into the post-mdg era. i hope and pray that, within a few years, we will look back at the contribution this journal has made to these new goals, more complex needs, and larger populations, and thank god we are making a valid -and carefully captured - record of what is being done in god’s name. references 1. browne sg, davey f, thomson war, editors. heralds of health: the saga of christian medical initiatives. london: christian medical fellowship; 1985. 2. towards primary health care: renewing partnerships with faith based communities and services. geneva: report of world health organization consultation with faith based organisations; 17th-18th dec 2007. 3. schmid b, thomas e, oliver j, cochrane jr. the contribution of religious entities to health in subsaharan africa, study commissioned by bill and melinda gates foundation. cape town: african religious health assets programme; 2008. 4. a firm foundation: the pepfar consultation on the role of faith based organizations in sustaining community and country leadership in the response to hiv/aids. atlanta, georgia: report of the u.s. president’s emergency plan for aids relief and the interfaith health program; 2012. (project number asph s3552-24/29). http://bit.ly/xwhwje http://bit.ly/xwhwje http://bit.ly/xwhwje http://bit.ly/xwhwje http://bit.ly/xwhwje 5 lankester june 2014. christian journal for global health, 1(1):3-5 5. faith partnership principles working effectively with faith groups to fight global poverty. report of the department for international development; united kingdom; 2012. available from https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/67352/faithpartnership-principles.pdf 6. the english standard version bible. oxford: oxford university press; 2009. 7. the holy bible, containing the old and new testaments, king james version: new york: american bible society; 1999. 8. millennium development goals [internet]. geneva: the world health organization; 2000. available from http://www.un.org/millenniumgoals/ 9. united nations resolution on universal health coverage [internet]. geneva: the world health organization; [updated 2012 dec 12; cited 2014 mar 17] available from http://www.who.int/universal_health_coverage/en/ 10. sustainable development goals [internet]. geneva: the world health organization; [updated 2013 dec; cited 2014 mar 17] available from http://sustainabledevelopment.un.org/index.php?men u=1300 11. the universal declaration of human rights [internet]. new york, ny: the united nations; [10 december 1948; cited march 17, 2014] available from http://www.un.org/en/documents/udhr/ __________________________________________________________________________ competing interests: none declared. dr. lankester is a member of the international advisory board of cjgh correspondence: dr. ted lankester, 63 67 newington causeway, london, se1 6bd. ted.lankester@chgn.org cite this article as: lankester, t. speaking out into a new future. christian journal for global health (2014), 1(1):3-5. © lankester. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ __________________________________________________________________________ www.cjgh.org http://bit.ly/kzos24 http://bit.ly/kzos24 https://www.gov.uk/government/uploads/system/%20uploads/attachment_data/file/67352/faith-partnership-principles.pdf https://www.gov.uk/government/uploads/system/%20uploads/attachment_data/file/67352/faith-partnership-principles.pdf https://www.gov.uk/government/uploads/system/%20uploads/attachment_data/file/67352/faith-partnership-principles.pdf http://www.un.org/millenniumgoals/ http://www.who.int/universal_health_coverage/en/ http://sustainabledevelopment.un.org/index.php?menu=1300 http://sustainabledevelopment.un.org/index.php?menu=1300 http://www.un.org/en/documents/udhr/ mailto:ted.lankester@chgn.org http://creativecommons.org/licenses/by/4.0/ editorial nov 2016. christian journal for global health, 3(2):3-5. “exporting” medical education vinod shah a , h elliott larson b , nathan grills c , daniel o’neill d , michael soderling e a md, christian medical college vellore, india, chairman, int’l christian medical & dental association b md, frcp, fidsa, editor-in-chief, cjgh c mbbs, mph, dphil, associate editor, cjgh; nossal institute of global health, university of melbourne, australia d md, ma(th), managing editor, cjgh; assistant professor of family medicine, university of connecticut school of medicine, usa e md, mba, associate editor, cjgh, chief catalyst and global networker, centre for health in mission transferring quality healthcare knowledge and skills across generations, disciplines, and cultures is a challenging endeavor. four conference reports in this issue deal with efforts to provide assistance to medical education in low and middle income countries (lmic). this has been a major effort by mainly north american physicians to improve the standards of medical teaching and practice in the developing world. the conferees met immediately prior to the global missions health conference in november, 2015, in louisville, kentucky, usa in four subgroups dealing with fostering undergraduate medical education, family and internal medicine residency training, surgical residency training, and recruitment of academic faculty to meet these opportunities. the conferees and the reports give background for, summarize current status of, and describe challenges and obstacles to these efforts. the contributors to the pre-conference were individuals with extensive experience in medical education in north america, africa, latin america, and asia. their discussions showed awareness of the enormous challenges posed when attempting to deliver medical education in cross-cultural lmic settings. a number of issues potentially important to the effort to provide medical education as medical mission deserve further elucidation and development. we propose to outline them here in the hope that ongoing discussions can take them up more fully. critical thinking and participatory learning medical education in lmics affords challenges in teaching and learning techniques and styles. the focus of medical education in most lmics seems to be delivering information rather than fostering comprehension. the fact that interactivity and asking questions is inappropriate in cultures where teachers are put on a pedestal compounds this problem. comprehension is aided by “diffuse thinking” — a process of “meditating” on the information and the concepts that have been delivered in the class room. it does not happen when you are keenly engaged with a single subject — a phenomenon called “focused thinking.” grappling with a math problem is an example of focused thinking; however, reflecting on the problem and integrating it with experience when walking is an example of diffuse thinking. the latter is what fosters comprehension. one can encourage diffuse thinking by asking students to complete a project after doing their own reading and reflecting. such participatory approaches to medical education are important as it encourages comprehension and creativity. the conference report on mobilizing and training academic faculty for medical mission mentions training in interactive teaching methods as a goal in developing national medical educators. just because a teacher has taught does not make facts inviolable. critical thinking, the need to challenge all the assumptions in the information that has been delivered is important. the socratic approach, that is, teachers asking 4 shah, larson, grills, o’neill & soderling nov 2016. christian journal for global health, 3(2):3-5. leading questions, helps students to analyze and evaluate information. students asking teachers a lot of questions is counter-cultural in india and many lmics; however, if this can be changed, their evaluation of and approach to real-life problems will be more effective. creativity is aided by the breadth in one’s education. a mature medical student who has studied humanities is more likely to be creative and integrative than a narrow math/biology whiz kid. this has a basis in neuro-science. among many other things, creativity is a function of being able to make connections in the brain between disciplines. unfortunately, in most developing countries, the pursuit of medicine or other allied health professions is decided at a very early stage as young as 16. after this, educational opportunities become more and more narrow. influencing the teaching and learning methods in health-related education can greatly impact the quality of the average doctor, nurse, and public health professional in the developing world. taking bio-medical and public health knowledge and the approach to medical education from a high income country (hic) and transferring it to low income settings without contextualization can be problematic at a number of levels. the transfer of medical education systems from high to low and middle income countries may not prepare health professionals for the context in which they work. will they be prepared to work in an under-resourced indigenous setting with limited access to sophisticated diagnostic and treatment options? or does training that is based on hic models merely facilitate the “brain drain” of health professionals who emigrate to hics? do hic standards of practice increase cost and further burden an already strained health system? developing alternative, shorter, more focused medical courses not fully equivalent to physician training in hics is an appealing option and has been attempted in lmic settings. this should not mean training sub-par doctors, but the crossdisciplinary training of doctors, nurses, and others who are able to function well and lead in the system of the country where they will be practicing and in underserved areas where they may be needed the most. an example is denis burkitt’s training of “dressers” in uganda. these were individuals who could perform simple surgical procedures, but willing and able to work in rural and medically deprived areas. the problem is that most lmic have already established medical training and curricula patterned on a western reductionist and specialization paradigm. attempting to change this expectation with a more contextualized, cross-disciplinary, and integrated approach adds another layer of complexity to the effort. mutual learning and leadership another requirement is to understand the importance of input from local leaders and indigenous health practitioners in lmic. their leadership for culturally-appropriate future educational efforts is highly desirable for capacity-building and sustainability. it is the hope that publication of the proceedings of the 2015 louisville pre-conference in this issue will stimulate both interest and participation in future planning and conferences throughout the world. transitions of leadership and empowerment can be a delicate process, and servant leadership models are particularly needed to avoid paternalism and neo-colonialism. recognizing the limitations of short-term efforts to educate across cultures and between disparate health systems is to practice cultural humility. mutual learning occurs by seeking first to understand, then to be understood (james 1:1). thoughtful cooperation across cultures with multiple stakeholders is vital in planning effective learning environments. professionalism and ethics one issue that deserves further exploration is corruption. an education in medicine in a lmic is a highly privileged opportunity. it can often be seen as entrée to preferment in government and business. this is one reason why some medical graduates do not continue in medicine; they may never have intended to have 5 shah, larson, grills, o’neill & soderling nov 2016. christian journal for global health, 3(2):3-5. a career caring for the sick. because of preferment status, admission to a medical education may be highly dependent on political and social connections. this can be a reason why the students who end up in a medical school may not always be the most suitable ones. cheating on exams can be widespread and payment to teachers for improved grading common in many countries. 1 this practice produces students compromised not only in their medical knowledge, but in the ethics they will use in approaching the care of patients. international campaigns against corruption in medicine have begun in countries like india, starting with ethics training in undergraduate curriculum, thus hoping for widespread global impact. 2 gordon hadley was a pathologist and dean of loma linda university school of medicine from 1977 to 1986. repeatedly over his professional career, he taught pathology to students in lmics, with stints at vellore medical college, kabul medical university, and nangrahar university in jalalabad, afghanistan. he even taught in kabul when the taliban were in control. once, he told one of us (el) that often there was no electricity, but the classes started on time! gordon was of the firm conviction that afghan students could learn well and become excellent doctors, but that integrity, missing from their education, had to become part of that experience. it was a battle with numerous fronts: the students themselves, the teachers and professors, and the government. he lost many of those battles despite his gracious and mild manner because the lack of integrity had a long history and reinforced personal privilege. after one faculty meeting in jalalabad where he resisted altering the grades of failed students, the tires on the car of an expatriate faculty member were slashed. early in the karzai administration in kabul, the president of the country himself lowered the passing grade from 50% to 30%, “just this time,” to circumvent dr. hadley’s standards. he instituted photo identification for admission to exams and caught two students taking exams for others. not infrequently, his approach was opposed by non-christian expatriates, in one case a fulbright scholar, on the grounds that this was against the “the afghan system.” corruption may be the major issue in development. 3 it is certainly key in education. non-christians can have a hard time “seeing” corruption. pointing it out can involve unpleasant confrontations with local colleagues. but it is a matter of justice, and justice is an essential agenda for christian witness. medical education in lmic often involves dealing with those countries’ elites. this can call to mind jesus’ dealing with the elites of his time, the religious leaders and roman authorities. his words to them were consistent. he never shirked from explaining and illustrating the truth to them. if as christians we want to make a difference in health-related education in lmic, can we do less? references 1. hrabak m, vujaklija a, vodopivec i, hren d, marušić m. marušić a. academic misconduct among medical students in a post-communist country. med educ. 2004;38:276–85. http://dx.doi.org/10.1111/j.1365-2923.2004.01766.x 2. anita j, samiran n,kamran a.corruption: medicine’s dirty open secret. bmj. 2014;348: g4184 http://dx.doi.org/10.1136/bmj.g4184 3. heritage.org [internet]. washington, d.c.: the heritage foundation. available from: http://www.heritage.org/index/explore © shah v, larson he, grills n, o’neill d, soderling m this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1111/j.1365-2923.2004.01766.x http://dx.doi.org/10.1136/bmj.g4184 http://www.heritage.org/index/explore http://creativecommons.org/licenses/by/4.0/ commentary mar 2017. christian journal for global health, 4(1):30-33. the proper college mark crouch a a md, public health officer, staff physician, kudjip nazarene hospital, in his image international, papua new guinea “the hospital is the only proper college in which to rear a true disciple of aesculapius.” 1 unprepared for a little over a year, i have known a young man from a nearby village. we will call him endy. he first came to our district mission hospital suffering from weight loss and sores on his skin. though we treated him, he never improved. a test for hiv confirmed my suspicion that endy, through some poor past decisions, had contracted this incurable virus and was suffering from aids. despite my best efforts to treat him, endy's condition deteriorated. a blood test showed that his hiv had become resistant to his medicine. an ultrasound showed disease in his liver. endy was dying. i pushed endy's wheelchair back into my exam room while his uncle and sister filed in behind us. in my second language, i explained to endy that he was about to die from aids, and i was powerless to save his life. he understood, and while his uncle and sister cried, endy showed a steely determination. he had accepted christ during the course of his illness and felt he would soon leave his earthly form and enjoy a new, completely healthy body. “endy, it has been a pleasure to know you.” “doctor, one day i will see you again.” we prayed together and i prescribed some medications to help endy's pain and nausea. i then continued to see patients with complicated orthopedic injuries, major obstetrical complications, and unusual tropical fevers before finishing my day meeting with a major international non-governmental organization to address our hospital's cure rates for tuberculosis. training in a u.s. medical school and residency could not have adequately prepared me for this kind of medicine. background i recently read the latest edition of the christian journal for global health (november 2016). many of the articles center on the topic of health education in the developing world. this topic lies close to my heart. i currently serve at a mission hospital in a lowincome country in the pacific. our hospital is a churchrun facility, partnered with the national department of health, serving the rural area around us for the past 50 years. we perform surgeries, handle 24-hour emergency services, deliver babies, provide immunizations, care for hiv and tuberculosis patients, and encounter a never-ending stream of sickness in our out-patient department. i left the united states to serve as a medical missionary with every intention of teaching. i imagined that young national physicians were just waiting for me—to mentor and disciple, to teach excellent standards of care and medicine as part of my ministry. i believed i might quickly train them to take my place and return to my home country to serve as a mission mobilizer for the next generation. perhaps i could also serve as a financial benefactor to my hospital and successors. i still nurture this desire. i work with a young national physician in our hospital who has embraced the challenge of caring for her people. she has a wealth of practical experience i initially lacked, despite my more “advanced” medical training. she married a fellow national surgeon, and i have watched them both prayerfully consider their future—how they might 31 crouch mar 2017. christian journal for global health, 4(1):30-33. blend their medical care with ministry to the suffering people in their country. i also recognize how naïve it was for me to expect that i could move to the mission field and immediately start teaching. the kind of medicine i brought with me, not to mention the culture and language i learned it in, differed significantly from the medicine i now practice every day. in the last cjgh issue, smith, et al. remarked, “in the last several years, there has been an increasing recognition that treating individual patients in hospitals by expatriate health care professionals is neither sustainable nor capable of building long-term capacity.” 2 a statement from the american academy of family practice also prioritizes teaching over clinical medicine in global health. “in countries outside of the united states, the most critical role for a family physician is to train local health care professionals and support them in the development of family medicine programs.” 3 while affirming the need and value of health educators, i would caution the medical mission community not to forsake clinical medicine. training received in the developed world cannot fully prepare physicians to teach immediately in other countries. furthermore, to assume humbly the mantle of teacher, one must first consider if he truly understands the culture, medicine, and students he plans to instruct. finally, the sheer volume of suffering in the world, along with christ's example and instructions to “heal the sick,” 4 compels christian physicians to care for patients. a sterile discipline as shah, et al. pointed out, “taking bio-medical and public health knowledge and the approach to medical education from a high income country (hic) and transferring it to low income settings without contextualization can be problematic at a number of levels.” 5 medicine as it is practiced in the united states looks very different than the medicine most of the world practices—particularly in countries with limited resources, difficult social situations, and heavy burdens of disease. those planning a career in medical education overseas do well to recognize the limitations of their own medical training. for many medical missionaries, this means reflecting on the environment in which we learned to be health professionals. in the united states, many of the difficult cases and advanced presentations of diseases are buffered by the health system and advanced technology of the profession. few non-surgical residents will see complicated lacerations and injuries, usually handled in the emergency or operating room. emergency department trainees will rarely, if ever, encounter challenging obstetric cases typically triaged and managed in the maternity department. surgical residents in the us will see greater amounts of traumatic injuries, but commonly in a well-equipped trauma bay or operating room with excellent lighting, anesthesia, diagnostic imaging, and a preserved clean field for surgery. in other parts of the world, patients present late with diseases that often disfigures them. there are few truly clean locations in which to reduce open fractures, clamp arteries, deliver babies, or repair obstetrical lacerations. injuries can be truly horrifying and patients are often crowded about by grieving family members soaked in blood from carrying their loved ones. the practice of medicine in these environments is often more raw than those coming from developed nations of which they are accustomed. in short, much of the mud and blood of medicine has been autoclaved away by early presentations of disease, our excellent health system management, and the advanced technology of our hospitals. medicine in more advanced countries of the world has become a sterile discipline. for those who profess to teach medicine, recognizing the limitations of their own perspective is an essential step to take before instructing doctors in a totally different environment. motivations “not many of you should presume to be teachers…” 6 why do medical missionaries choose to become teachers? i would respond that in doing so, medical missionaries amplify their efforts and create a more 32 crouch mar 2017. christian journal for global health, 4(1):30-33. sustainable impact. teaching medicine, particularly to national physicians or healthcare workers, results in a more amplified impact of our missionary service. nationals possess a greater understanding of their people than expatriates. furthermore, national physicians who remain in their country will likely outlast their teachers. they often become leaders in their nation. they go on to train the next generation of health professionals. this perpetuates the medical practices and attitudes they receive from expatriate mentors. if one could put a thousand to flight, two could put ten thousand. 7 problems arise when the value placed on sustainably educating nationals exceeds that placed on serving the needs of the people. sustainability ought to be pursued, but only if the gains made actually fit the needs of the community. a nation will not benefit if expatriate workers create a durable cadre of physicians practicing an inappropriate or ineffective medicine. teaching health workers overseas ought to be pursued with eyes fixed on the patients they will one day encounter. this is difficult to do without an experiential background at the patient bedside. a fantastic health education ministry suggests in one of its resources that “all those who are skilled and experienced teachers should consider whether they can spend some time every year, or the final years of their career before retirement, working as medical teachers in developing countries.” 8 while skilled and experienced teachers are needed, this ethos ought to be tailored to the medical climate of the receiving nation. temporary visitors serving as teachers in a foreign environment creates difficulties if they do not alter their instruction to fit the context of the receiving nation. perhaps the focus of newly arriving health educators should be supporting the ongoing long-term efforts of workers and teachers already on the ground. more seasoned academicians from hic offer a wealth of experience in effective teaching methods. likely, their greatest benefit in a teaching role would be to demonstrate how medicine is best taught, rather than teaching the specifics of medicine in a setting with which they are unfamiliar. good learning precedes good teaching. training in the developed world does not give license to teach that type of medical practice the world over. in fact, a perspective limited to hic settings may work against the medical teacher. hic physicians working overseas ought to spend a reasonable amount of time learning the medicine they want to teach. without that experience, the motivation for teaching could become an educational paternalism—espousing great knowledge from the high vantage of “superior” training. the greater need is not addressed by temporary visitors or retiring physicians who move overseas to teach hic medicine, but rather physicians who are willing to shoulder clinical burdens seeing patients and learning all they can about a country's culture and illnesses. those who do will be best positioned to adapt their own medical training into the new and difficult situations they encounter alongside national medical students and other trainees—learning and teaching together. a sacred place christ's ministry involved mobilizing the twelve while also caring for individuals. he felt compassion —“suffered with”—those that he served. for three years, he walked the same stony roads that they did. he ate their food. he spoke their language. 9 he saw their illnesses and, for some, miraculously healed them. 10,11 christ treated individual patients alongside his disciples, who learned from his example, creating perhaps the most sustained change in the course of history. what if christ had proclaimed the kingdom of god but never spent time personally absorbing the burdens of his broken world? christians do not enter the world to create better church-run programs than their secular counterparts. christ gave no command to ensure sustainable medical care, but did demonstrate god's love by touching the suffering. we are compelled to bring the kingdom of god in the same ways he did. with christ as our example 12 and his commands in our hearts 13 , we combat the very real misery that breaks the heart of god. to the neglected and forgotten peoples of the world, a compassionate physician embracing their physical struggles is a powerful, tangible expression of the love of god in their lives. can expatriate 33 crouch mar 2017. christian journal for global health, 4(1):30-33. physicians neglect this incredible opportunity simply because it is unsustainable? “until the suffering of any and all is met with compassion and care there is a place, may i say a sacred place, at the patient bedside” 14 the blood and mud the obligation of health educators remains “to teach to their students habits of reliance and to be to them examples of gentleness, forbearance and courtesy in dealing with their suffering brethren.” 15 [italics added] we cannot teach medicine we do not really know. we cannot expect a national medical student or resident to show christ-like care in a terribly limited environment, with frequent devastating outcomes, if we have not first made the difficult journey ourselves. as christians, we are compelled by the love of christ and the suffering in the world. as physicians, we are uniquely equipped to bring demonstrations of god’s kingdom into those situations. expatriate christian physicians working in medical missions should be examples of christ-like care in a hurting world to those under our instruction. to teach well, let us also embrace clinical medicine as our “proper college.” references 1. abernethy, john. quoted in: aequanimitas – with other addresses to medical students, nurses and practicioners of medicine. william osler. second edition. philadelphia: p. blakiston's son & co; 1910. 2. smith jd, holland rp, phillips jd, falkenheimer sa. mobilizing and training academic faculty for medical mission: current status and future directions. christ j global heal. nov 2016; 3(2):168-75. http://dx.doi.org/10.15566/cjgh.v3i2.134 3. aafp.org [internet]. american academy of family practice. [cited 2016 nov 23, available from: www.aafp.org/global-health/] 4. matthew 10:8. the holy bible, new international version. international bible society, 1984. 5. shah v, larson he, grills n, o'neill d, soderling m. “exporting” medical education. christ j global heal. 2016 nov;3(2):3-5. http://dx.doi.org/10.15566/cjgh.v3i2.150 6. james 3:1. the holy bible. new international version. international bible society. 1984. 7. deuteronomy 32:30. the holy bible. new international version. international bible society; 1984. 8. morgan, h. teaching medicine: a christian approach. east sussex, united kingdom: prime – partnerships in international medical education; 2008. 9. john 1:14. the holy bible. new international version. international bible society. 1984. 10. john 5:2-15. the holy bible. new international version. international bible society. 1984. 11. john 9:1-12. the holy bible. new international version. international bible society. 1984. 12. matthew 14:14. the holy bible. new international version. international bible society. 1984. 13. matthew 10:8. the holy bible. new international version. international bible society; 1984. 14. mccoy w. personal communication with, staff physician, nazarene health ministries, november 2016 15. osler w. aequanimitas — with other addresses to medical students, nurses, and practicioners of medicine. second edition. philadelphia: p. blakiston's son & co; 1910. peer reviewed competing interests: none declared. correspondence: mark crouch, kudjip nazarene hospital, papua new guinea. crouchm@gmail.com cite this article as: crouch m. the proper college. christian journal for global health. mar 2017; 4(1):30-33. © crouch m this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.15566/cjgh.v3i2.134 http://www.aafp.org/global-health/ http://dx.doi.org/10.15566/cjgh.v3i2.150 mailto:crouchm@gmail.com https://creativecommons.org/licenses/by/4.0/ why world vision supports healthy timing and spacing of pregnancies to improve maternal and child health: a faith-based perspective www.cjgh.org july 2017 | 75 case study christian journal for global health | why world vision supports healthy timing and spacing of pregnancies to improve maternal and child health: a faithbased perspective adrienne a. allisona and eloho e. basikorob a ma, mpa, senior technical adviser, world vision, usa b phd, world vision, usa abstract world vision, a christian humanitarian organization, began large family planning programs in 2007, with support from the united states agency for international development (usaid). as new data were published in 2008 and again in 2014, measuring the impact of the length of the preceding birth-to-conception interval on maternal, infant, and child mortality and child stunting, world vision adopted the term “healthy timing and spacing of pregnancies” (htsp) as its approach to family planning. this term refocused family planning efforts to emphasize the health benefits for mothers and children, and was quickly accepted by faith leaders. the data are explained, and the consequences of shorter and longer birth intervals outlined. background in 2008, the icf macro team analyzed data from 52 demographic health surveys (dhss) conducted from 2000 to 2005 on the relationship between the duration of birth-to-conception interval, and maternal and child mortality and nutritional status for 1.12 million births.1 the analyses clearly showed that a longer birth-to-conception interval resulted in the lowest levels of maternal, infant, and child mortality. the data also showed a clear and compelling relationship between the length of the pregnancy-to-conception interval and stunting. as the interval lengthened, stunting steadily declined.1 (in addition to being too short for their age, stunted children experience cognitive delays and other irreversible physical and mental impairments.) a follow-on dhs study included two additional variables: birth order and age of mother. data from 45 dhss, conducted between 2006 and 2012 included 340,000 living children under the age of 5.2 the data affirmed earlier findings. impact on mortality: • birth-to-conception intervals of less than 18 months has an increased risk of neonatal mortality. • children conceived within 6 months of the preceding birth are 2.2 times more likely to die before age five, compared to those conceived 36 to 47 months after the previous birth. impact on stunting: • birth-to-conception intervals of less than 1,000 days increases the prevalence of stunting. • children conceived after an interval of 12 to 17 months are 23 percent more likely to be stunted than those conceived after an interval of 36 to 47 months. impact of age of mother on stunting and child mortality: • children of mothers less than 18 years have a greater risk of being stunted and underweight. http://www.cjgh.org 76 | christian journal for global health 4(2) www.cjgh.org these children also face a greater risk of dying before their fifth birthday. • children of mothers more than 34 years old have a greater risk of dying during infancy. however, children born to older mothers are less likely to be stunted and underweight than those born to mothers less than 18 years of age.2 in 2012, the lancet published a report on birth timing and spacing that verified this research, and supported the integration of family planning with maternal and child health programs. the main findings were: • the risk of prematurity and low birth weight doubled when conception occurred within 6 months of the previous birth, compared to those conceived 36 to 47 months after the previous birth. • children born to girls younger than 18 years had an excess mortality risk rate of about 40 percent compared to women 20 to 24 years of age. • meeting the need for contraception would have reduced maternal deaths by 30 percent.3 world vision (wv), a christian humanitarian organization dedicated to working with children, their families, and their communities worldwide, supports the implementation of voluntary family planning programs based on the best medical knowledge and good medical ethics. wv does not recommend, provide, or support abortion. the organization respects the rights of women and men to make their own decisions about family size and pregnancy spacing. the world vision partnership has confirmed that htsp directly supports the organizational goal to “sustain the well-being of children, families, and communities.” based on the data cited above, wv refocused family planning to emphasize the health benefits of timing and spacing pregnancies to save lives. wv replaced “family planning” with “htsp,” and integrated htsp counseling and services within maternal and child health programs generally implemented by ministries of health. to make messages about timing and spacing more easily understood and remembered, wv created posters and counseling materials to encourage women and men to avoid pregnancies when a mother was “too young or too old” or has pregnancies that were “too many, too soon.” what is healthy timing and spacing of pregnancies (htsp)? htsp promotes informed decision-making about delaying, spacing, or limiting pregnancies to achieve the optimal results for women, newborns, infants, and children. htsp emphasizes healthy pregnancy. hence, its messages have been especially appealing to faith-based organizations (fbos) and faith leaders.4 htsp includes four key messages: 1. delay the first pregnancy until a girl is at least 18 years old. pregnancy and childbirth are the leading causes of death in girls aged 15-19 globally.5 girls of this age are twice as likely to die in childbirth compared to women aged 20-24, and their infants are up to 10 times more likely to die before their second birthdays. in sub-saharan africa, more that 50 percent of first births are to adolescent girls.5 2. wait until a child is at least 2 years old before trying for another child. infants thrive when they have a full two years of breast-feeding. well-nourished children are less likely to be vulnerable to illnesses that result in poor mental and physical growth. if the next child is conceived while the older child is still breast-feeding, breast-feeding may falter and the child may be weaned too soon. it is the older child who is more likely to die.5 3. wait at least 6 months after miscarriage before trying for another child. infants conceived less than 6 months from the previous pregnancy are more likely to be premature, be small for gestational age, have low birth weight, or be stillborn. mothers are also more likely to die.5 allison and basikoro christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 77 4. limit pregnancies to a mother’s healthiest years—ages 18-34. the risk of a mother dying in childbirth increases sharply when she is more than 34 years old, or when she has more than four children.5 family planning and htsp family planning programs were introduced in the 1960s to slow population growth rates in developing countries that did not have resources to meet the needs of their rapidly growing populations. the demographic rationale became the dominant rationale in family planning.6 more recently, the concept of a “demographic dividend” has been studied and supported in several countries. this theory links economic growth to the population age structure, finding that countries with higher numbers of working adults and fewer dependent children have a stronger, more sustained economic growth compared to countries with fewer skilled laborers and higher dependency ratios. a larger working class population stimulates job growth, economic productivity, and higher incomes, which will in turn, lead to increased savings and investment.7,8 the demographic and economic rationales for family planning resonate with governments but not with people. for example, senegal adopted a population policy in the 1960s that supported contraceptive usei i contraceptive methods include hormonal contraception (pills, injectables, and implants), intrauterine devices (iuds), barrier methods (male and female condoms, spermicides), emergency contraceptive pills (ecps), fertility awareness methods (fams), withdrawal, and sterilization. many faith leaders show a preference for natural fams of family planning, such as the standard days method (sdm) and lactational amenorrhea method (lam), and withdrawal. these methods have no side effects and do not require medical procedures, devices, or hormones. sdm helps couples to avoid pregnancies at the times when the woman is most fertile by tracking her menstrual cycle, and requires a couple to avoid sex or use a barrier method during this time. lam protects women from conception for the first six months after birth. once the mother introduces complimentary feeding, she no longer is amenorrhoeic and needs an alternative method of contraception. withdrawal involves a man withdrawing his penis during to reduce family size.9 yet, 50 years later, the contraceptive prevalence rate was just 11 percent. their policy that focused on limiting population yielded little impact. within the developing world in general, “family planning” is often associated with government efforts to limit family size, which can be viewed as a form of intrusion into the customary cultural context.6 political, religious, and cultural barriers reduced contraceptive use. htsp messages, with their new focus on improving health and saving lives to benefit the well-being of families and communities, are more acceptable to faith leaders. religious beliefs and principles are powerful influences on individual behaviors and community actions, including health-related practices. in sub-saharan africa, a 2006 survey found that people trust faithbased organizations more than they trust their own national governments.10 as such, fbos and religious leaders have an immense opportunity to educate communities about the healthy timing and spacing of pregnancies, and methods of family planning. mobilizing faith leaders to provide information on htsp and contraception within the values and belief systems of their communities is emerging as a productive approach to building support for htsp. this could help reduce maternal mortality by 35 percent, cut abortion in developing countries by 70 percent, and lower the infant mortality rate by 10 to 20 percent.11 the health rationale of htsp surmounts religious barriers. faith leaders often determine and dictate which sexual and reproductive health behaviors are prescribed or prohibited. wv creates a safe space for them to discuss religious teachings, and learn, share, and debate their perceptions and understanding of htsp and contraception. this process often transforms their own understanding and changes their practices. as they adopt new behaviors, they and their families become models for htsp within their faith communities. sex and ejaculating outside of the vagina to prevent sperm from entering the woman’s body. allison and basikoro christian journal for global health | http://www.cjgh.org 78 | christian journal for global health 4(2) www.cjgh.org wv, with support from usaid, implemented htsp programs in haiti, india, and senegal. in uttar pradesh, india, community health workers worked with local faith leaders to build their support and advocacy for htsp. within 14 months, there were 67,989 new contraceptive users with an estimated contraceptive prevalence rate (cpr) of 77 percent in targeted communities. (cpr = number of women of reproductive age (wra) using contraception / total number of wra x 100). religious leaders played an essential role in building support for htsp in fatick district, senegal. when the imams learned that timing and spacing births would lower mortality rates and improve the wellbeing of their communities, they became strong advocates for family planning, particularly as the koran encouraged mothers to breastfeed their children for a full two years. the catholic sisters, who supported three health posts, counseled clients on the lactational amenorrhea method and the standard days method, and referred them to moh health posts for other methods. the cpr at these health posts increased from 12 to 17 percent in one year. implication for policy and practice 1. by focusing on the health benefits of using contraception to time and space pregnancies, faith leaders, civic leaders, mothers, and fathers often change their earlier opinions and adopt better and healthful behaviors, and influence others to do the same. 2. nutrition programs need to include htsp counseling and access to contraceptive services, as the icf macro analyses show that there is a 50 percent reduction in stunting when the birth-to-conception interval is 36 to 47 months. by leveraging the benefits of htsp with the right supportive policies and practices, countries can be well on their way to achieving the demographic dividend. 3. community conversations led by trained providers can introduce villagers to new concepts and a new, stigma-free vocabulary in communications on htsp. such communications, especially at the household level, are crucial for influencing and mobilizing communities to change harmful socio-cultural norms and practices around gender, hiv/aids, and child protection that undermine maternal and child health. 4. the risk of adolescent girls’ mortality is very high, as is the risk of mortality for newborns. adolescent girls and boys need age-appropriate information, counseling, and services to protect them from unplanned pregnancies. the htsp approach in family planning helps to expose adolescents to a wide range of family planning friendly services, which protects them from unplanned pregnancies and sexually transmitted diseases. allison and basikoro christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 79 references 1 rutstein s. further evidence of the effects of preceding birth intervals on neonatal, infant, and under-five-years mortality and nutritional status in developing countries: evidence from the demographic and health surveys [internet]. dhs working paper; 2008. available from: https://dhsprogram.com/pubs/pdf/wp41/wp41.pdf 2 rutstein s, winter r. contraception needed to avoid high-fertility-risk births, and maternal and child deaths that would be averted [internet]. dhs analytical studies; 2015. available from: https://dhsprogram.com/pubs/pdf/as50/ as50.pdf 3 cleland j, conde-agudelo a, peterson h, ross j, tsui, a. contraception and health. the lancet. 2012 july 10;380(9837): 149-156. https://doi.org/10.1016/s01406736(12)60609-6 4 united states agency for international development [internet]. htsp 101: everything you want to know about healthy timing and spacing of pregnancy. [2008]. available from: http://www.who.int/pmnch/topics/maternal/htsp101. pdf 5 united states agency for international development. reproductive health report [internet]. 2017. available from: https://www.k4health.org/search/toolkits/ mchip%2520kpc%2520survey\ 6 seltzer jr. the origins and evolution of family planning program in developing countries. california: rand publications; 2002 7 kabeer n. reversed realities: gender hierarchies in development thought. london: verso; 1994 8 united states agency for international development [internet]. healthy timing and spacing of pregnancies: a family planning investment strategy for accelerating the pace of improvements in child survival. [2012]. available from: https://www.usaid.gov/sites/default/files/documents/1864/calltoaction.pdf 9 allison a, foulkes e. engaging faith leaders in family planning [internet]. the john templeton foundation; 2014. available from: http://www.ccih.org/wv-engaging-faith-leaders-in-family-planning.pdf 10 tortora b. africans’ confidence in institutions [internet]. gallup news services [2007]. available from: http:// www.gallup.com/poll/26176/africans-confidence-institutions-which-country-stands-out.aspx 11 coleman i, lemmon g. family planning and u.s. foreign policy [internet]. council on foreign relations; 2011. available from: https://www.cfr.org/report/family-planning-and-us-foreign-policy peer reviewed competing interests: none declared. correspondence: adrienne allison, aallison@worldvision.org; eloho basikoro ebasikoro@worldvision.org cite this article as: allison a and basikoro e. why world vision supports healthy timing and spacing of pregnancies to improve maternal and child health: a faith-based perspective. christian journal for global health. july 2017; 4(2)75-79; https://doi. org/10.15566/cjgh.v4i2.169. © allison a. and basikoro e. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ allison and basikoro christian journal for global health | http://www.cjgh.org https://dhsprogram.com/pubs/pdf/wp41/wp41.pdf https://dhsprogram.com/pubs/pdf/as50/as50.pdf https://dhsprogram.com/pubs/pdf/as50/as50.pdf https://doi.org/10.1016/s0140-6736(12)60609-6 https://doi.org/10.1016/s0140-6736(12)60609-6 http://www.who.int/pmnch/topics/maternal/htsp101.pdf http://www.who.int/pmnch/topics/maternal/htsp101.pdf https://www.k4health.org/search/toolkits/mchip%2520kpc%2520survey\ https://www.k4health.org/search/toolkits/mchip%2520kpc%2520survey\ https://www.usaid.gov/sites/default/files/documents/1864/calltoaction.pdf https://www.usaid.gov/sites/default/files/documents/1864/calltoaction.pdf http://www.ccih.org/wv-engaging-faith-leaders-in-family-planning.pdf http://www.ccih.org/wv-engaging-faith-leaders-in-family-planning.pdf http://www.gallup.com/poll/26176/africans-confidence-institutions-which-country-stands-out.aspx http://www.gallup.com/poll/26176/africans-confidence-institutions-which-country-stands-out.aspx http://www.gallup.com/poll/26176/africans-confidence-institutions-which-country-stands-out.aspx https://www.cfr.org/report/family-planning-and-us-foreign-policy https://www.cfr.org/report/family-planning-and-us-foreign-policy https://doi.org/10.15566/cjgh.v4i2.169 https://doi.org/10.15566/cjgh.v4i2.169 http://creativecommons.org/licenses/by/4.0/ editorial nov 2017. christian journal for global health 4(3):6-11. bioethics, the global church, and family planning michael j. sleasman a , paige comstock cunningham b a phd, managing director & research scholar, the center for bioethics & human dignity, affiliate professor of bioethics, trinity international university, usa b jd, phd, executive director, the center for bioethics & human dignity, affiliate professor at trinity law school and trinity graduate school, trinity international university, usa the center for bioethics & human dignity (cbhd) was pleased to be invited to collaborate with the christian journal for global health in the call for a themed issue on “the global church and family planning,” papers from which were to be jointly published in our respective publications. despite the significant progress made through the millennium development goals (mdgs) and the subsequent adoption of the sustainable development goals (sdgs), maternal and infant mortality remains unacceptably high in certain parts of the world. the work of aid organizations to decrease such tragedies in global health is laudable, and many faith-based organizations (fbos) are at the forefront of commendable efforts in this regard. part of the purpose of this themed issue was to raise particular ethical and theological questions surrounding the practice of family planning and its relationship to these broader efforts to reduce maternal and infant mortality, particularly within the context of faith-based organizations. embedded in the broad international discussions of family planning is the assumption that there is an “unmet need” for contraception, a concept which is regularly promoted within international health organizations such as the united nations population fund. what is lacking is an awareness that this terminology implicitly makes ethical claims about contraception, procreation, and sexuality. for example, one of the criticisms about “unmet need” made in a previous paper is that it assumes that if a woman is not currently using contraception, regardless of her reason, she has an “unmet need.” 1 this assumption might imply an ethical obligation to use contraception throughout one’s childbearing years to avoid having an unacceptably high number of children. 2 thus, it was of particular interest to cbhd to address questions concerning family planning and the global church in light of christian bioethical and/or christian bioethical resources that could be brought to bear on the conversation. how might these resources guide the church’s response to these questions as well as the work of confessionally-oriented fbos? furthermore, questions remain that are germane to christians within the aid work and global health communities. are concepts and practices derived within the context of international health organizations adequately examined for assumptions or latent agendas that may be in conflict with or even antagonistic to christian ethical and theological commitments regarding the beginning of life, abortion, marriage, sexuality, and procreation? what are the explicit and implicit assumptions of the relationship, if any, of family planning and birth spacing to contraception and abortion within the broader international health context, and for christian fbos in particular? how does natural family planning fit within both international and christian conversations, in light of significant christian ecclesial traditions’ long7 sleasman & cunningham nov 2017. christian journal for global health 4(3):6-11. standing and well-articulated resistance to contraception, and the even broader christian rejection of abortive practices? the international conversation around family planning methods skews toward provision of “modern contraceptives,” access to “safe abortion,” and the appropriate spacing of children. yet, natural family planning such as fertility awareness based methods, which may have success rates as high as many “modern methods” both for avoiding and achieving pregnancy, is excluded from assessment and recommendation because it is categorized as a “traditional method.” 3,4 tension also arises over the vigorously disputed relationship between contraceptive use and reduced incidence of abortion. much of the data regarding maternal mortality, including from induced abortion, is based upon estimates. conclusions about these matters all too often depend upon the particular goal of the researchers or the funders of the study. cbhd’s interest also has been to foster greater awareness of the issues in global health, particularly women’s health, within the context of christian bioethics and to promote the ethical engagement of the church on a set of important social issues. of special interest was fostering awareness of the needs and issues to address, and to assist in initiating a conversation within local churches, who are seen as a key factor in encouraging uptake of family planning services. we would encourage not only scholars and clinicians, but also pastors to engage such issues in global health, and specifically maternal and infant mortality in an informed manner thoroughly rooted in their biblical and theological convictions. how do we balance biblical notions of children as blessings and gifts from god with the stark realities of starvation? how do we balance biblical commitments to the sacred relationship between a husband and wife, and the realities that many pregnancies occur outside this relationship, within abusive or coercive relationships, under the duress of poverty, or at a time the parents do not desire? is it appropriate to introduce biblical stewardship in the conversation regarding family size? we were dismayed at the lack of response from the bioethics community to the initial call for papers, as we had hoped for a robust christian bioethical analysis of these profoundly important questions. 10 most of the accepted papers were drawn from the public and global health communities. these, naturally, presented operational models of family planning as implemented by fbos. the papers described a variety of practical challenges, such as unavailability of drugs, increasing community awareness about family planning services, and the lack of involvement of faith leaders. in some cases, model programs were discussed, while others provided empirical analysis of practices and attitudes. 11-17 each advocated, to greater or lesser degrees, for the expansion of family planning services and solutions. given their focus on operational concerns, for the most part these papers did not examine the theological or ethical justifications for expansion. nor did they place these practices within a broader theological and ethical framework of the christian life, marriage, sexuality, and procreation. while such discussions may have been understandably bypassed, many of them nonetheless uncritically accepted and used the language of family planning and “unmet need” that make implicit assumptions about such broader framework concerns. it must be recognized of course that such considerations are generally beyond the scope of papers focused on operational concerns and empirical analysis of best practices, and perhaps beyond the expertise of the contributors. nonetheless, the absence of substantive christian analysis illustrates an apparent divide, even if not done so intentionally, between scholarship in the christian public health and global health literature, and the relevant scholarship in theology and christian (bio)ethics. 18 is this division evidence of 8 sleasman & cunningham nov 2017. christian journal for global health 4(3):6-11. a mutual hermeneutic of suspicion about underlying assumptions? we are genuinely grateful, and even more so given that there was not a more robust response from the broader christian bioethics community, for the contributions of rebecca oas and monique and jeffrey wubbenhorst in their respective editorials and commentaries for raising important questions and issues for future consideration and discourse. oas’s editorial questions the legitimacy of the assumed existence of a broadly “unmet need.” 1 oas raises important areas of concern specifically for those who are firmly located within the theological and ethical commitments of the roman catholic tradition, but also those from other ecclesial traditions that share prolife convictions and a concern for the promotion of marriage and family. in this volume, wubbenhorst and wubbenhorst, likewise, raise a variety of considerations from an evangelical perspective, many of which would be applicable across the broad spectrum of confessional christianity. 19 they provide important background materials to contextualize the discussion, including the historical reception of contraceptive practices within the various christian traditions, as well as the international health context in which contemporary discourse about family planning occurs. they conclude with a pointed set of convictions which they argue all confessionally-oriented fbos and church-based ministries should uphold. perhaps most controversially, wubbenhorst and wubbenhorst challenge the assumption that family planning is the best approach for reducing maternal and infant mortality, questioning several of the underlying claims and assumptions on theological grounds, as well as pointing to disagreements in the medical and social science literature regarding the impact and health benefits of birth spacing and claims surrounding unmet need and population health. as relative newcomers to this conversation, cbhd does not have a particular stake in individual perspectives and does not take a formal position on the issue of family planning (when not associated with abortion). indeed, even between the present two authors of this editorial there is not complete agreement about the use of contraception and the appropriate role for churches in advocating family planning practices. however, as a christian bioethics research center, there are several points of contention that we believe are essential to address if there is to be any hope for robust engagement on these issues. the first is the use of language, particularly when many of the terms utilized within discussions of a given controversy have emerged within valueladen and ideologically charged contexts. this does not mean that terms must be abandoned, but philosophical precision becomes a necessity. one fbo may use a definition to avoid conceptual baggage, yet colleagues or other fbos do not find the definition persuasive or indicative that underlying problems do not exist. furthermore, bioethics has demonstrated time and again that terms often become proxies for politicized discourse and can be employed to obfuscate deeply held assumptions or to sway public opinion. those familiar with prolife controversies easily recognize the obfuscation triggered by separating fertilization as the beginning of an individual human life vs. implantation as the beginning of pregnancy. on the other hand, linking abortion with all contraception as an instance of the “contraceptive mentality” is equally problematic. another example of terminological disputes for rhetorical rationale occurs in end-of-life ethics with the various uses of euthanasia, physician-assisted suicide, aid in dying, and dignity in dying. we suggest greater methodological self-awareness be directed to the ways in which christians utilize terminology in the discourse of family planning. a second area of contention arises at the limits of medical and scientific research and the challenge of data and studies that appear to be in conflict. the purpose of a study may influence not 9 sleasman & cunningham nov 2017. christian journal for global health 4(3):6-11. only what is studied, but also the stated outcomes and conclusions. for example, studies on the maternal mortality ratio (mmr) as a major indicator of public health have been critiqued for shifting their emphasis to numbers, perhaps to satisfy business-oriented private donors who have inordinate influence, and away from attention to social justice, to national health information systems, and to other factors that affect maternal health. 20 tensions about how studies are designed raise a more fundamental question—whether family planning actually achieves the very thing it purports to do. does family planning actually reduce the risk of maternal and infant mortality? it clearly reduces the number of pregnancies, but do such interventions actually result in safer pregnancies? it depends on what is being assessed, and how. more work needs to be done to demonstrate clear evidence in this regard. a third area arises particularly within protestant ecclesial contexts, but increasingly among the laity within orthodox and catholic traditions as well, and that is the lack of a theologically robust and ethically consistent view of marriage, sexuality, procreation, and the appropriate role of technology to facilitate, assist, or hinder procreation. these concerns go well beyond a discussion of family planning to include consideration of the wide range of contraceptive practices as such, the use of the spectrum of assisted reproductive and fertility interventions, and the increasingly common use of a variety of reprogenetic technologies in the procreative process. the inability of many christians to identify these as more than merely medical decisions that require substantive theological and moral consideration portends broader concerns that the church will not be equipped to adequately engage biotechnologies and other emerging technologies with distinctly christian commitments and values. perhaps more sobering is that even where orthodoxy is taught and known, orthopraxis does not necessarily follow. at a recent colloquium hosted by cbhd, eastern orthodox, roman catholic, and evangelical scholars admitted that their congregations often choose a utilitarian path of avoiding or obtaining a child of one’s own at any cost with little regard to pastoral guidance or the moral pronouncements of the church. we pose these not as contentions with any of the specific papers in this themed issue, but rather as a collegial challenge for others to take up these issues and bring greater clarity to a discourse about the global church and family planning. we do so not with a naïve expectation that universal agreement will be reached. indeed, some of the disagreements seem intractable, particularly some of the differences between those working in public and global health vs. those within prolife advocacy contexts regarding partnership with international health organizations that promote abortion. these issues aside, we believe that all sides will benefit from more thoughtful engagement, and hope that conversation initiated in this themed issue will foster a more robust dialogue in years to come. even more to be desired is a greater unity about the obligation for all christians to engage theologically and reflectively with all the technologies that threaten respect for persons and that undermine our common human flourishing. references 1. oas r. communities of faith and the global family planning movement: friends or foes? christian journal for global health 2017; 4(2):3–9. https://doi.org/10.15566/cjgh.v4i2.183 2. see, e.g., the discussion between philosophers travis rieder and rebecca kukla, as environmental catastrophe looms, is it ethical to have children? foreign policy, may 31, 2017. available from: http://foreignpolicy.com/2017/05/31/is-it-ethical-tohave-children-climate-change-family-planning/ 3. frank-herrmann p et al. the effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study. human reproduction 2007; 22(5):1310-319. https://doi.org/10.15566/cjgh.v4i2.183 http://foreignpolicy.com/2017/05/31/is-it-ethical-to-have-children-climate-change-family-planning/ http://foreignpolicy.com/2017/05/31/is-it-ethical-to-have-children-climate-change-family-planning/ 10 sleasman & cunningham nov 2017. christian journal for global health 4(3):6-11. https://doi.org/10.1093/humrep/dem003 4. frank-hermann p et al. natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a german prospective long-term study. advances in contraception 1997; 13(2–3):179–189. https://doi.org/10.1023/a:1006551921219 5. malarcher js et al. fertility awareness methods: distinctive modern contraceptives. global health: science and practice 2016; 4(1):13–15. http://dx.doi.org/10.9745/ghsp-d-15-00297 6. malarcher js et al. response to austad: offering a range of methods, including fertility awareness methods, facilitates method choice. global health: science and practice 2016; 4(2):346–349. http://dx.doi.org/10.9745/ghsp-d-16-00115. 7. for a comprehensive review, see manhart md et al. fertility awareness-based methods of family planning: a review of effectiveness for avoiding pregnancy using sort. osteopathic family physician 2013; 5(1): 2–8. https://doi.org/10.1016/j.osfp.2012.09.002 8. but see also this concern about women’s sexual agency, and the definition of “modern methods” as designed to “overcome biology.” austad k et al. fertility awareness methods are not modern contraceptives: defining contraception to reflect our priorities. global health: science and practice 2016; 4(2):342–345. https://doi.org/10.9745/ghsp-d-1600044 9. malarcher js et al. fertility awareness methods, 13– 15. further, inclusion of fertility awareness methods as modern contraceptives is “the technical position of the office of population and reproductive health of the united states agency for international development.” malarcher et al., 13. 10. the center for bioethics & human dignity aggressively promoted the call for papers. despite nearly 3,000 views from our constituents, no proposals were submitted. in response, we personally invited scholars to contribute. 11. otchere s et al. social accountability and education revives auxiliary nurse-midwife sub-centers in india, reduces travel time and increases access to family planning services. christian journal for global health 2017; 4(2):10–18. https://doi.org/10.15566/cjgh.v4i2.177 12. metger a and bormet m. pharmaceutical stockouts: problems and remedies for faith-based health facilities in africa. christian journal for global health 2017; 4(2):19–29. https://doi.org/10.15566/cjgh.v4i2.130 13. ghanshyam kb et al. the increasing access to family planning services through a non-health sector: technical integration coverage and access (tica) in nepal. christian journal for global health 2017; 4(2):30–42. https://doi.org/10.15566/cjgh.v4i2.170 14. vanenk l et al. closing the gap: the potential of christian health associations in expanding access to family planning. christian journal for global health 2017; 4(2):53–65. https://doi.org/10.15566/cjgh.v4i2.164 15. alikali m. the attitudes and activities of pastors and faith leaders in zimbabwe on the use of family planning methods among their members. christian journal for global health 2017; 4(2):66–74. https://doi.org/10.15566/cjgh.v4i2.188 16. allison a and basikoro e. why world vision supports healthy timing and spacing of pregnancies to improve maternal and child health: a faith-based perspective. christian journal for global health 2017; 4(2):75–79. https://doi.org/10.15566/cjgh.v4i2.169 17. duah j and yeboah p. christian journal for global health 2017; 4(2):80–86; docking ml. increasing the church’s relevance and impact in poor-resource areas by adding sexual reproductive health to missional activities. christian journal for global health 2017; 4(2):95–99. https://doi.org/10.15566/cjgh.v4i2.175 18. an historical example may illustrate this tension. pope benedict xvi was widely criticized by the hiv/aids and public health communities for his observation that the strategy to reduce hiv/aids in africa via promoting condom use “aggravates” the problem. pisa n. anger as pope benedict xvi says condoms make aids worse, the telegraph, march 17, 2009. available from: http://www.telegraph.co.uk/news/worldnews/africaa ndindianocean/cameroon/5007124/anger-as-popebenedict-xvi-says-condoms-make-aidsworse.html. he focused on the effectiveness and morally preferable behavioral change. a leading hiv/aids researcher eventually concluded that the pope was correct: green e. condoms, hiv-aids https://doi.org/10.1093/humrep/dem003 https://doi.org/10.1023/a:1006551921219 http://dx.doi.org/10.9745/ghsp-d-15-00297 http://dx.doi.org/10.9745/ghsp-d-16-00115 https://doi.org/10.1016/j.osfp.2012.09.002 https://doi.org/10.9745/ghsp-d-16-00044 https://doi.org/10.9745/ghsp-d-16-00044 https://doi.org/10.15566/cjgh.v4i2.177 https://doi.org/10.15566/cjgh.v4i2.130 https://doi.org/10.15566/cjgh.v4i2.170 https://doi.org/10.15566/cjgh.v4i2.164 https://doi.org/10.15566/cjgh.v4i2.188 https://doi.org/10.15566/cjgh.v4i2.169 https://doi.org/10.15566/cjgh.v4i2.175 http://www.telegraph.co.uk/news/worldnews/africaandindianocean/cameroon/5007124/anger-as-pope-benedict-xvi-says-condoms-make-aids-worse.html http://www.telegraph.co.uk/news/worldnews/africaandindianocean/cameroon/5007124/anger-as-pope-benedict-xvi-says-condoms-make-aids-worse.html http://www.telegraph.co.uk/news/worldnews/africaandindianocean/cameroon/5007124/anger-as-pope-benedict-xvi-says-condoms-make-aids-worse.html http://www.telegraph.co.uk/news/worldnews/africaandindianocean/cameroon/5007124/anger-as-pope-benedict-xvi-says-condoms-make-aids-worse.html 11 sleasman & cunningham nov 2017. christian journal for global health 4(3):6-11. and africa – the pope was right. washington post, march 29, 2009. http://www.washingtonpost.com/wpdyn/content/article/2009/03/27/ar2009032702825. html 19. wubbenhorst m and wubbenhorst j. should evangelical christian organizations support international family planning? christian journal for global health 2017; 4(3):20-38. https://doi.org/10.15566/cjgh.v4i3.184 20. storeng kt and béhague dp. “guilty until proven innocent”: the contested use of maternal mortality indicators in global health. critical public health 2017; 2:163–176. https://doi.org/10.1080/09581596.2016.1259459 competing interests: none declared. correspondence: michael j sleasman, msleasman@cbhd.org and paige comstock cunningham, pcunningham@cbhd.org the center for bioethics & human dignity, https://cbhd.org cite this article as: sleasman mj, cunningham pc. bioethics, the global church, and family planning. christian journal for global health. nov 2017; 4(3):6-11. https://doi.org/10.15566/cjgh.v4i3.203 © sleasman mj, cunningham pc. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.washingtonpost.com/wp-dyn/content/article/2009/03/27/ar2009032702825.html http://www.washingtonpost.com/wp-dyn/content/article/2009/03/27/ar2009032702825.html http://www.washingtonpost.com/wp-dyn/content/article/2009/03/27/ar2009032702825.html https://doi.org/10.15566/cjgh.v4i3.184 https://doi.org/10.1080/09581596.2016.1259459 mailto:msleasman@cbhd.org mailto:pcunningham@cbhd.org https://cbhd.org/ https://doi.org/10.15566/cjgh.v4i3.203 https://creativecommons.org/licenses/by/4.0/ commentary mar 2017. christian journal for global health, 4(1): 24-29. avoiding pitfalls in overseas medical educational experiences kristen l sessions a , j dwight phillips b , stephen p merry c a msiv, school of medicine, mayo clinic, rochester, mn, usa b md, professor, department of pediatrics and adolescent medicine, mayo clinic, rochester, mn, usa c md, mph, assistant professor, department of family medicine, college of medicine, mayo clinic, usa abstract in the united states, there are a growing number of medical students participating in international health electives. these experiences have the potential to be mutually beneficial to both the host country and the student. however, there is a significant risk of unethical and damaging practices during these trips, including concerns for sending trainees without appropriate pre-travel preparation with inadequate accountability to local health care providers at a stage in their education that imposes an undue burden on the local health facilities. this article describes one first year medical student’s experience in navigating common challenges faced in international health electives and offers practical advice enlightened by the literature on how to overcome them. we emphasize the need for students to ensure adequate pre-trip preparation, communicate their level of training clearly, practice cultural humility, ensure personal safety, and engage in projects needed by the host community. background in the united states, american medical students are increasingly participating in international health electives in low and middle income countries (lmic). one study reported that 63% of u.s. students entering medical school expressed a desire to participate in international rotations, and over one-third of graduating medical students had completed at least one international health elective. 1 this growing interest to serve the poor within medical training aligns with the christian call to ministry and service, both domestically and globally. however, with growing interest also brings about an increased concern for ethical practices in global health training and common pitfalls of “voluntourism”. 2 increased interest in global health has significant potential benefits for both host countries, and participating individuals and institutions. medical students who participate in an international rotation are more likely to work in a resource-poor setting, care for poor and ethnic minorities, and choose primary care specialties after graduating. 3,4 these experiences allow students to learn about culture and health in unique ways, improve their diagnostic skills, see a wide variety of new pathology, work in limited resource settings, and practice caring for diverse patient populations. 5-8 the host communities and health systems benefit from the increased access to health care, health system strengthening by partnering with hospitals and schools in higher-income countries, and the improved quality of care through the academic rigor resulting from the medical students’ curiosity or 25 sessions, phillips & merry mar 2017. christian journal for global health, 4(1): 24-29. research projects they perform. one study noted that lmic patients receiving care looked favorably on medical student involvement on health teams. 9 despite these benefits, there is real risk of disempowering, demeaning, dangerous, and unethical practices by medical trainees that can harm the very communities they are trying to serve. 2,10-14 these electives can be self-serving, doing little to strengthen or build sustainable health systems and imposing undue burden on the local health facilities, particularly if trainees are sent without appropriate training or accountability. 14 such electives can “undermine existing health care and cause great harm.” 15 research efforts can be specifically concerning if proper measures are not taken to ensure culturally appropriate informed consent and consistently followed ethical guidelines to protect vulnerable populations. 11 global volunteerism, in general, has been criticized for being relief rather than development focused, ineffective, and often detrimental to host communities when poorly conceived and executed, and medical student lmic electives often bear many resemblances to these widely criticized efforts. 16 there is a growing body of literature on best practice guidelines, curriculum development, and ethical frameworks for short-term medical experiences in global health. 3,5,7,14,17-21 recommendations for medical students embarking on international electives include recognizing that the primary purpose of the trip is medical education, communicating level of training clearly to all parties, practicing cultural humility, ensuring personal safety, and focusing on activities relevant to and needed by the host. this article serves to offer practical advice aimed at medical students participating in international rotations in order to make trips maximally beneficial to both students and their host communities. it explores the learning of a first-year medical student trainee doing clinical rotations in uganda, presenting experiences which were tested against the existing recommendations from the literature. practical lessons be a learner and communicate your level of training clearly at 24, the medical student standing next to me on rounds was my same age yet four years above me in training. she was a year short of having an m.d. and i was only half way through my basic science training. due to the different structures of medical training in uganda and the u.s., i was woefully under-qualified for my age and with that came a clear need for me to repeatedly explain my level of training and capabilities. more than once, i was asked about differential diagnoses or recommendations for treatment, tasks entirely appropriate for the fourth year ugandan medical student but a mystery for my first-year self. there were many occasions where i was faced with admitting my own lack of knowledge or staying quiet and undertaking tasks above my level of training. medical students, particularly those in their pre-clinical years, may simply and appropriately be learners. 22 short-term experiences for medical students and residents are meant to expose students to new diseases, patient populations, and resource limitations as a foundation for their careers. however, while medical students are there to learn and expand their skills, students must be aware of their current skill level and limitations and communicate their level of training to the host staff and ensure supervision is comparable to the oversight they would receive in the u.s. 15,22 on providing a clear understanding of a student’s level of training to the host staff, students can begin to find ways to contribute to the team. for example, pre-clinical year medical students may assist with taking vitals, writing notes, as well as many other non-clinical responsibilities. more experienced trainees will be able to additionally contribute to patient care and perform more procedures but should continually seek the expertise of host site physicians and other health care providers. this practice ensures patients’ safety as well as protecting the trainee from situations they are not 26 sessions, phillips & merry mar 2017. christian journal for global health, 4(1): 24-29. equipped to handle. it also relieves team stress by establishing clear understanding of roles and responsibilities and provides opportunities for appropriate teaching. simple clarification early on can save time, energy, and inappropriate task assignments which may otherwise be given throughout the rotation. practice cultural humility bwindi community hospital (bch) was founded to provide care for the indigenous batwa people after they were forced to leave their huntergatherer lifestyle in 1992. the majority of the community bch serves lives on less than $2 a day. while the physicians and staff speak english, the patients speak rukiga, a local language. in one short month, i would not be able to fully appreciate the complexities, history, and culture of the community in which i was working. however, the staff, community members, and patients were all eager to teach when i was eager to learn. for a short stay, “cultural humility” became more important, and obtainable, than “cultural competency.” while information about the culture, politics, and history of a community are important pre-travel reading, a student cannot achieve “cultural competency” prior to arrival (implying that a foreign medical student could not be well-versed in the culture, beliefs, language, and nuances of a host community through simply reading about them). even for expatriates who have spent significant time in a new community, full “competency” may never be obtainable. instead, the focus should be shifted toward practicing cultural humility. immersion in local activities can help build cultural understanding. volunteers at all levels should continually seek to respect and learn about the culture in which they are living, understanding their own lack of knowledge while desiring insight into the lives of the people with whom they are working. cultural humility means leaving judgments and superiority behind, and approaching each person with genuine respect and curiosity. wear refers to this idea as “insurgent multiculturalism” challenging students to “ask tough questions about the roots of inequality and racism” and “examine power structures.” 15,23 trainees should be careful what they say about their local hosts and colleagues on social media; some, in expressing their initial reactions to new situations, have inadvertently insulted their hosts on globally visible internet sites. while trainees may not have a complete understanding of the community they are serving, several skills can be universally applied and should be incorporated into pre-trip preparation. for example, learning appropriate use of a translator and skills in non-verbal communication may be more effective during pre-trip preparation than learning phrases in the local language. situational simulations and case-based ethics trainings can also help to prepare students for diverse settings despite limited understanding of that culture. 24,25 ensure personal safety despite recommendations from his mentor back home, chris* chose not to take hiv medications with him to uganda. the likelihood of a needle stick seemed remote, and he felt confident, despite limited knowledge of the hospital, that he would have access to medications should he need them. while in uganda, he quickly discovered that “bota-botas,” or small motorcycles, were the primary form of transportation, and even on the unpaved roads with no helmet, he found he used them regularly. while each trip was short, over his seven months in uganda, chris took countless unhelmeted rides and worked with almost a hundred hiv positive patients. *name changed reports have shown that students take risks abroad they would not take at home. 7,26 novelty and excitement, compounded with a sense of limited options, can make safety a low priority for trainees abroad. risks occur inside and outside the hospital. medical risks include needle sticks, respiratory disease exposure, and lack of timely access to medical care. outside the hospital, unsafe transportation and unfamiliar areas can put trainees 27 sessions, phillips & merry mar 2017. christian journal for global health, 4(1): 24-29. at risk. for example, in uganda, bota-botas are the primary, and often only available, mode of transportation. while riding on the back of a motorcycle without a helmet would be out of the question for many students in the u.s., in uganda it can easily because a regular occurrence. one ride may seem “normal” or individually benign but continued indiscretion can result in substantial cumulative risk to a trainee over the course of a rotation. this risk can be avoided by good pretravel planning. each participant should have a pretravel medicine consultation that includes transportation and body fluid safety discussions in addition to the usual topics of malaria prevention, immunization, and diarrhea self-management. hiv post-exposure prophylaxis should be provided to all trainees who will be engaged in direct patient care with a discussion about universal precautions. the global ambassadors for patient safety is an online training to help students effectively plan global health trips. 27 resources such as these can help trainees think through potential safety concerns for themselves and their patients before departing. 28 ensure projects are relevant to and needed by the host our team spent two months establishing baseline research about hiv before departure with the aim to work with the hiv clinic at bch. when we arrived, however, staff had changed, and it became evident that most volunteers worked in hiv or maternal health. this area was well covered but their newly established mental health clinic was “less attractive” to donors and volunteers alike. while they were happy to have help in all areas of research, community understanding of mental health was poorly explored and significantly more needed than the list of proposed projects we had developed. it became evident they were going along with our wishes. after further discussion, we realized that a mental health services quality improvement project would be more beneficial to the hospital than our original plans. listening to them allowed us to contribute in significantly more meaningful ways. quality improvement projects can provide much needed services to a hospital or health system. medical students should look for ways to engage in activities most needed by the community they are serving. trainees pre-planning with an open mind and actively searching for under-studied topics within health systems can contribute in meaningful ways, even on short term trips. research and quality improvement projects can raise significant ethical concerns and result in significant unforeseen costs. the costs for printing or translation services, and other community or staff involvement, may further stress already overworked human resources and should be carefully considered and counted when designing a project. global health ethics training using case studies can help students work through how they would handle ethical conflicts before they are in-country. while programs sending students to other countries should have clear protocols for student engagement, it is ultimately the student’s responsibility to ensure that project methods and topics are respectful, ethical, and beneficial to the hospital. conclusion informed by globalization and compelled by altruism and an ethic of social justice, more medical students and residents are traveling abroad each year on international health electives, thus helping to meet the need for culturally-sensitive and globally-educated physicians. while wellintentioned and potentially beneficial, critics have appropriately raised multiple concerns about the self-serving and potentially harmful nature of their involvement. however, training and pre-travel preparation by students can help make these trips mutually beneficial. trainees should approach trips with honesty about their skill sets, practice cultural humility, and seek to design relevant and needed quality improvement or research projects requested by their hosts. in this way, students can feel comfortable in their role as a learner while finding 28 sessions, phillips & merry mar 2017. christian journal for global health, 4(1): 24-29. meaningful ways to contribute to the host health care team. references 1. matriculating student questionnaire: all schools summary report. washington, dc: association of american medical colleges; 2010. 2. mclennan s. medical voluntourism in honduras: 'helping' the poor? prog develop stud. 2014;14(2):163-79. http://dx.doi.org/10.1177/1464993413517789 3. crump ja, sugarman j. ethical considerations for short-term experiences by trainees in global health. jama. 2008;300(12):1456-8. http://dx.doi.org/10.1001/jama.300.12.1456 4. ramsey ah, haq c, gjerde cl, rothenberg d. career influence of an international health experience during medical school. fam med. 2004;36(6):412-6. 5. crump ja, sugarman j. working group on ethics guidelines for global health t. ethics and best practice guidelines for training experiences in global health. am j trop med hyg. 2010;83(6):1178-82. http://dx.doi.org/10.4269/ajtmh.2010.10-0527 6. thompson mj, huntington mk, hunt dd, pinsky le, brodie jj. educational effects of international health electives on u.s. and canadian medical students and residents: a literature review. acad med. 2003;78(3):342-7. http://dx.doi.org/10.1097/00001888-20030300000023 7. wilson jw, merry sp, franz wb. rules of engagement: the principles of underserved global health volunteerism. am j med. 2012;125(6):612-7. http://dx.doi.org/10.1016/j.amjmed.2012.01.008 8. sawatsky ap, rosenman dj, merry sp, mcdonald fs. eight years of the mayo international health program: what an international elective adds to resident education. mayo clin proc. 2010;85(8):73441. http://dx.doi.org/10.4065/mcp.2010.0107 9. decamp m, enumah s, o'neill d, sugarman j. perceptions of a short-term medical programme in the dominican republic: voices of care recipients. glob public health. 2014;9(4):411-25. http://dx.doi.org/10.1080/17441692.2014.893368 10. martiniuk al, manouchehrian m, negin ja, zwi ab. brain gains: a literature review of medical missions to low and middle-income countries. bmc health serv res. 2012;12(1):134. http://dx.doi.org/10.1186/1472-6963-12-134 11. provenzano am, graber lk, elansary m, khoshnood k,rastegar a, barry m. short-term global health research projects by us medical students: ethical challenges for partnerships. am j trop med hyg. 2010;83(2):211-4. http://dx.doi.org/10.4269/ajtmh.2010.09-0692 12. roberts m. a piece of my mind. duffle bag medicine. jama. 2006;295(13):1491-2. http://dx.doi.org/10.1001/jama.295.13.1491 13. snyder j, dharamsi s, crooks va. fly-by medical care: conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. globalization and health. 2011;7:6. http://dx.doi.org/10.1186/1744-8603-7-6 14. suchdev p, ahrens k, click e, macklin l, evangelista d, graham e. a model for sustainable short-term international medical trips. ambul pediatr. 2007;7(4):317-20. http://dx.doi.org/10.1016/j.ambp.2007.04.003 15. pinto ad, upshur re. global health ethics for students. dev world bioeth. 2009;9(1):1-10. http://dx.doi.org/10.1111/j.1471-8847.2007.00209.x 16. corbett s, fikkert b. when helping hurts: how to alleviate poverty without hurting the poor... and yourself. chicago: moody publishers; 2014. 17. kittle n, mccarthy v. teaching corner: raising the bar: ethical considerations of medical student preparation for short-term immersion experiences. j bioeth inq. 2015;12(1):79-84. http://dx.doi.org/10.1007/s11673-014-9601-9 18. lahey t. perspective: a proposed medical school curriculum to help students recognize and resolve ethical issues of global health outreach work. acad med. 2012;87(2):210-5. http://dx.doi.org/10.1097/acm.0b013e31823f3fb1 19. loh lc, cherniak w, dreifuss ba, dacso, mm, lin hc, evert j. short term global health experiences and local partnership models: a framework. globalization and health. 2015;11:50. http://dx.doi.org/10.1186/s12992-015-0135-7 20. chad s, brian t. systems thinking in short-term health missions: a conceptual introduction and consideration of implications for practice. christian j glob health. 2015;2(1):7-22. http://dx.doi.org/10.15566/cjgh.v2i1.50 21. reynolds ec. dealing with ethical challenges when leading student mission trips. j am dent assoc. 2014;145(5):486-87. http://dx.doi.org/10.1016/s00028177(14)60046-5 22. american association of medical colleges [internet]. guidelines for premedical and medical students providing patient care during clinical experiences abroad, 2011.available at: https://www.aamc.org/download/261648/data/coabull etin10.5.pdf 23. wear d. insurgent multiculturalism: rethinking how and why we teach culture in medical education. acad med. 2003;78(6):549-54. 24. rosenman jr, fischer pr, arteaga gm, hulvalkar m, butteris sm, pitt mb. global health simulation during http://dx.doi.org/10.1001/jama.300.12.1456 http://dx.doi.org/10.4269/ajtmh.2010.10-0527 http://dx.doi.org/10.1097/00001888-200303000-00023 http://dx.doi.org/10.1097/00001888-200303000-00023 http://dx.doi.org/10.1016/j.amjmed.2012.01.008 http://dx.doi.org/10.4065/mcp.2010.0107 http://dx.doi.org/10.1080/17441692.2014.893368 http://dx.doi.org/10.1186/1472-6963-12-134 http://dx.doi.org/10.4269/ajtmh.2010.09-0692 http://dx.doi.org/10.1001/jama.295.13.1491 http://dx.doi.org/10.1186/1744-8603-7-6 http://dx.doi.org/10.1016/j.ambp.2007.04.003 http://dx.doi.org/10.1111/j.1471-8847.2007.00209.x http://dx.doi.org/10.1007/s11673-014-9601-9 http://dx.doi.org/10.1097/acm.0b013e31823f3fb1 http://dx.doi.org/10.1186/s12992-015-0135-7 http://dx.doi.org/10.15566/cjgh.v2i1.50 http://dx.doi.org/10.1016/s0002-8177(14)60046-5 http://dx.doi.org/10.1016/s0002-8177(14)60046-5 https://www.aamc.org/download/261648/data/coabulletin10.5.pdf https://www.aamc.org/download/261648/data/coabulletin10.5.pdf 29 sessions, phillips & merry mar 2017. christian journal for global health, 4(1): 24-29. residency. global pediatr health. 2016 aug 22. http:dx.doi.org/10.1177/2333794x1666354525 25. butteris sm, gladding sp, eppich w, hagen sa, pitt mb, sugar investigators. simulation use for global away rotations (sugar): preparing residents for emotional challenges abroad — a multicenter study. acad pediatr. 2014;14(5):533-41. http://dx.doi.org/10.1016/j.acap.2014.05.00426 26. wilkinson d, symon b. medical students, their electives, and hiv — unprepared, ill advised, and at risk. brit med j. 1999;318(7177):139-40. http://dx.doi.org/10.1136/bmj.318.7177.139 27. minnesota uo. global ambassadors for patient safety, 2016. 28. mohan s, suzanne s, davidson h. human immunodeficiency virus postexposure prophylaxis for medical trainees on international rotations. j trav med. 2010;17(4): 264-8. http://dx.doi.org/10.1111/j.1708-8305.2010.00421.x peer reviewed competing interests: none declared. correspondence: kristen l sessions, mayo clinic, united states. sessions.kristen@mayo.edu cite this article as: sessions kl, phillips jd, merry sp. avoiding pitfalls in overseas medical educational experiences. christian journal for global health. mar 2017; 4(1): 24-29. © sessions kl, phillips jd, merry sp this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1177/2333794x1666354525 http://dx.doi.org/10.1016/j.acap.2014.05.00426 http://dx.doi.org/10.1136/bmj.318.7177.139 http://dx.doi.org/10.1111/j.1708-8305.2010.00421.x mailto:sessions.kristen@mayo.edu https://creativecommons.org/licenses/by/4.0/ capacity building nov 2016. christian journal for global health, 3(2): 134-139. prime partnerships in international medical education restoring a christian ethos to medical education worldwide huw morgan a a retired gp/medical missionary, medical educator, staff tutor and executive member of prime, emeritus director of gp training, bristol, uk abstract modern medicine has developed from an essentially christian world-view and in western countries has been greatly influenced by the christian tradition of hospitality and caring for the sick. however, during the 20 th century, medical education became increasingly secularised and focussed on the bio-physical model of disease, losing sight of a holistic view of the person that includes awareness of a spiritual dimension. former communist countries in particular have little recent tradition of caring, and medical education there tends to be characterised by poor role-models and out-dated didactic teaching. in the resource poor countries of the global south there are many christian hospitals and clinics but often a lack of experienced medical teachers. partnerships in international medical education (prime)’s vision and mission is to support health-care education worldwide to restore a christian-based holistic approach to patients, and act as a resource where needed, tailoring medical educational programmes to meet the needs of overseas partners (or colleagues in the nhs). using interactive leaner-centred and problem based educational methods, prime tutors (all experienced and qualified christian medical educators) seek to model patient-centred care by using learner-centred teaching, valuing each person as a bearer of the image of god. most of prime’s teaching involves the doctor-patient relationship, communication skills, compassion, ethics and professionalism, often based around particular clinical scenarios to suit the learners. small teams of voluntary tutors visiting partner institutions and colleagues for a few weeks a year can have a surprisingly large impact, as those grasping the vision become advocates for positive change in their own situations. training of trainers and teachers in learner-centred, androgogic methodology to build capacity and sustainability is also a major part of the work. introduction prime, http://www.prime-international.org is a christian medical education charity, an international network of christian healthcare professionals who are involved in teaching their discipline. in this paper, i will briefly outline the historical context of prime’s work and the challenges and opportunities we face in contemporary medical education around the world and then describe how prime is working to meet them. (“medical” here is used to include nursing and professions allied to medicine.) http://www.prime-international.org/ 135 morgan nov 2016. christian journal for global health, 3(2): 134-139. historical context modern medicine and medical teaching have developed in the western world, influenced by both the christian tradition of hospitality pioneered by the european monasteries 1 , and the judao-christian value system that has historically underpinned the major institutions of our society (government, law, education, commerce, etc.). 2 this is particularly the case in western and northern european countries that experienced the protestant reformation in the 16 th century. in addition, it can be argued that the scientific advances that have led to the development and success of modern medicine stem from the reformation’s effect on thought that saw the investigation of the material world as a legitimate and necessary enterprise in understanding god’s creation (“thinking god’s thoughts after him” – johannes kepler, 1599). 3 the remarkable advances in medicine in the 19 th and 20 th centuries such as greatly improved public health, the development of surgery and anaesthesia, immunisation, antibiotics, treatment for hormone deficiencies (insulin, thyroxine), effective treatment for many chronic diseases and for mental illnesses all flowed from this, and christian doctors were involved in many of these advances. in addition, the missionary movement that started in the 19 th century resulted in mission hospitals and community health programmes being established in many remote areas in the majority of the world, bringing the advantages of modern medicine delivered with a christian ethos to the poor and marginalized in many developing countries. 4 the challenge we face however, the reformation also paved the way for the enlightenment, which gradually eroded belief in god from the scientific and public arenas through the 17th century and following, so that the moral and spiritual framework that had guided the development of modern science and medicine was lost. 5 the subsequent atheistic and reductionist approach presupposed that the material world was all that existed and that everything could be understood in terms of its molecular structure. thus francis crick, one of the discoverers of the structure of dna, famously said, “you, your joys, sorrows, memories and ambitions are in fact no more than the behaviour of a vast assembly of nerve cells and their associated molecules.” 6 this perspective has tended to dehumanise the practice and teaching of medicine, leading to the loss of understanding that patients, students, and doctors are all human beings made in god’s image. there has been too much emphasis on narrow scientific knowledge, abusive teaching methodologies inappropriate for a caring profession, and lack of a whole person perspective and compassion in teaching and practice. 7 so the realities of medical practice in the world today include the following:  gross inequalities in access to health care within and between nations  poor governmental management of health care systems  loss of humanity and compassion by health care workers  failure to respect human life from conception to natural death  medical practice increasingly divorced from an ethical framework  the threats of unregulated germ-line gene therapy and selective embryo screening  lack of acknowledgment of a spiritual perspective in human suffering  excessive emphasis on science and systems in the teaching and practice of medicine  gradual loss of idealism and growth of cynicism amongst students and young doctors and nurses 8 in the former communist countries, there tends to be little recent tradition or history of a caring approach to patient-care. there are also frequently only limited, out-date didactic teaching and text books with little exposure to real patients or opportunities for students to develop problem solving skills. there are also often poor rolemodels and widespread corruption in health care and its teaching, where bribes are necessary to be seen or taught by a doctor and to pass examinations. 9 in the resource poor countries of 136 morgan nov 2016. christian journal for global health, 3(2): 134-139. the global south (such as in africa, asia, and south america) the too few doctors and healthcare professionals often have to work in isolation with little opportunity for continuing professional development and so lack appropriate training and skills. there is an understandable tendency for doctors and nurses to immigrate to richer countries to work, further adding to the resource problem. 10 a door of opportunity there is light dawning, however! the “modern” era is ending and “post-modernism” is challenging the closed scientific world-view of modernity. people are dissatisfied with dehumanising medical treatments (successful as they may be) and are searching for alternatives. 11 spirituality and concern for the whole person are making a comeback. many medical schools are teaching communication skills and using humanities to aid reflection on the human condition. in our now electronically interconnected world, there is more awareness of the global inequalities in health-care and a desire to redress them. the world health organisation (who) reports: until recently the health professions have largely followed a medical model, which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and to faith in healing, in the physician and in the doctorpatient relationship. this reductionist or mechanistic view of patients is no longer satisfactory. patients and physicians have begun to realise the value of elements such as faith, hope, and compassion in the healing process. 12 so as this new millennium began, christians had a great opportunity to reclaim the teaching of medicine as a spiritual and ethical practice. we need to practice and teach in a way that demonstrates respect for our patients and learners as people made in god’s image. we must also ensure our teaching embodies the concept of whole person care for our patients, including a spiritual perspective, alongside evidence-based scientific truth. it is in that context that prime has developed, and grown remarkably, from small beginnings in the uk twenty years ago to a world-wide network of several hundred christian medical educators sharing the same vision and mission today. prime’s mission prime is a global network of christian healthcare professionals (nurses, doctors, paramedics) involved in teaching their discipline. there are four major components of our mission:  to support and improve medical education in resource-poor countries  to demonstrate and teach compassionate person-centred medical practice  to model the example of jesus as the perfect physician and teacher  to restore christ’s values to medical education and practice all this is with the aim of restoring a christian ethos to medical education worldwide and so improving health-care for all. it has wisely been said that, “a (medical) teacher. . . can influence the lives of many times more patients through his or her students. . . than through a career of surgeries or clinics.” 13 prime is linked to the christian medical fellowship (cmf), uk and the international christian medical and dental association (icmda). it responds to specific invitations for partnership from groups of doctors or other health professionals in developing and restructuring countries. it has also worked with groups of pastors in some countries, teaching them basic health care and encouraging them to see this as part of their church’s ministry to the community. its usual pattern of work is to make recurrent short-term (usually 1-3 week) visits to host countries with teams of 2 or 3 tutors to run teaching programmes and maintain relationships with hosts via email and skype between visits. it provides teaching and training in person-centred and evidence-based medical practice for underresourced doctors from a christian perspective and where possible, advises on local curriculum development, training methods, and health care 137 morgan nov 2016. christian journal for global health, 3(2): 134-139. management. prime’s teaching is in the context of forming genuine relationships with our hosts (generally essential to work effectively in nonwestern cultures). it emphasizes the importance of a compassionate, whole person approach to patients, builds ethical frameworks for decision making, and includes a spiritual perspective on patient care. its teaching is learner centred, interactive, and problem based (a patient-centred approach to medical practice needs to be taught using a learner-centred approach). 14 it aims for sustainability by training medical teachers in good educational methodology whenever possible. prime operates its courses with the approval of the university of brighton and sussex department of postgraduate medicine and (where possible) host country university departments. it is staffed by volunteer christian doctors and nurses with experience and qualifications in medical education, and runs a small office with a part-time manager and administrators. it produces educational materials to spread its vision (mostly electronic on cd’s or online, but with some paper publications). it now has branches in australia, portugal, kenya, and nigeria that plan and run their own teaching programmes internationally and has specialised mental health and palliative care sections. most of prime’s teaching focuses on compassionate, holistic care, communication skills, professionalism and ethics sometimes structured around clinical topics. for example, there is a “values added” modular course aimed at junior doctors in the early years of their training (based on small groups looking at a dvd/cd and then discussing the questions raised with a more experienced facilitator/tutor) that aims to add a christian perspective to their standard training and encouragement in its practical application to patient care and teaching. prime has found that because all people are made in god’s image, most respond positively to compassion and godly values displayed in healthcare and its teaching. it has worked with hindus, muslims, buddhists, sikhs, and atheists, but all agree about the core principles of good medical practice, and all can see that jesus was an exemplary physician and teacher in his dealings with people. this enables prime to maintain and promote its christian basis and values whilst being acceptable to people of all faiths and none. participants are always asked to evaluate prime courses and sometimes follow-up studies are conducted a few months later to see if those who took part have sustained any change in practice as a result. whilst it is very hard to measure this objectively, there have been numerous personal testimonies to the transforming nature of prime programmes such as, “today i became a doctor,” ”before this i wanted to leave (my country) to earn more money, now i want to stay and serve our people compassionately,” “i now understand that all patients are human beings like me and will treat them accordingly,” and “now i know how to serve jesus through practising medicine.” an example – teaching whole person care in kenya in 2002, three prime tutors (british gp educators, two of whom had worked in kenya years previously) were invited to kenya to facilitate the inaugural four-day conference of the kenyan association of family physicians (kafp). many of the members of this were christians and also members of the kenyan christian medical and dental association (cmda). the programme was a values-based introduction to holistic care, good communication skills, professionalism, and various other topics; all taught interactively with an implicit (and sometimes explicit) christian perspective. the tutors were invited back in 2003 to facilitate the second annual conference (one of the original team and another tutor with previous experience of working in kenya went on this occasion). the programme for this visit focussed on chronic disease management and good practice organisation to provide holistic care and took place in two centres. email contact with key kenyan christian medical leaders was maintained through the years (one ex-patriot family physician in particular), and in 2010, three other prime tutors ran a programme at the invitation of kafp at a conference on empowering medical educational leadership. then in 2014, one of the original prime 138 morgan nov 2016. christian journal for global health, 3(2): 134-139. team to visit kenya was invited by the ex-patriot family physician in partnership with the leaders of the cmda to formally launch prime in kenya. the idea was to establish an indigenous prime kenya, to spread the vision of faith-based, person-centred, holistic care throughout the country and wider to other east african countries through members of the cmda teaching prime concepts and using prime materials. the core prime seminars on “whole person care” and “teaching to change hearts” were taught in a number of centres around the country, and in each place, key local doctors were identified who would be active in taking the vision forward. a kenyan surgeon based in nairobi became a very active and enthusiastic advocate and teacher of the prime vision around kenya and in other east african countries, and other doctors with faculty positions in a new medical school were able to incorporate aspects of the prime material into the curriculum they were teaching. thus over a twelve-year period, recurrent visits and maintained personal relationships between prime tutors and in-country colleagues led to the forming of a true partnership, with kenyan partners eventually totally owning and running with the vision themselves in their own situations and more widely across east africa. to give an idea of prime’s activity, in 2015, 115 international prime tutors carried out 76 separate programmes in 24 different countries in africa, asia, and europe, providing 687 days of teaching (out of 1451 days in the host country) and training to nearly 4,500 individuals. at current standard ngo consultancy rates for teaching and subsistence, this would have cost £535,000. the actual cost (met by tutors) was £31,850. the fact that tutors give their time and expertise freely, adds powerfully to the christian impact of the work. there is also the vast amount of work done in-country by national teachers and tutors who replicate the teaching and methods in their day-to-day work and teaching. prime believes that this training will improve the care provided to the thousands of patients each of those individuals will treat, or the hundreds of healthcare students they will teach in the course of their careers. so in summary, prime teaches and encourages healthcare professionals worldwide to teach and practice whole person medicine, using patient and learner-centred teaching methods. it promotes compassionate medicine using jesus as a role model and seeks to use the basis of christian values as a central platform for change wherever it’s tutors work. any health-care professional committed to a compassionate, holistic approach to patient care is welcome to join the prime network, and those involved in teaching who are able to give a week or two a year at their own expense are welcome to apply to be prime tutors (details and application forms from admin@prime-interational.org.uk). in the next few months, prime is running training programmes in australia, kenya, nigeria, peru, and uk. references 1. crislip at. from monastery to hospital: christian monasticism & the transformation of health care in late antiquity. ann arbor: university of michigan press; 2005. http://dx.doi.org/10.3998/mpub.93465 2. pannenberg w. christianity and the west: ambiguous past, uncertain future. first things: mon j relig publ life. 1994;18. available from: https://www.firstthings.com/article/1994/12/christi anity-and-the-westambiguous-past-uncertain-future 3. hookyaas r. religion and the rise of modern science. edinburgh: scottish academic press; 1972. 4. hardiman d, editor. healing bodies, saving souls: medical missions in asia and africa, wellcome series in the history of medicine, clio medica 80. amsterdam and new york: rodopi; 2006. 5. israel ji. radical enlightenment: philosophy and the making of modernity 1650-1750. oxford: oxford university press; 2001. 6. crick f. the astonishing hypothesis: the scientific search for the soul. london: simon and schuster; 1994. 7. coulehan j. viewpoint: today's professionalism: engaging the mind but not the heart. acad med. 2005;80: 892-8. mailto:admin@prime-interational.org.uk http://dx.doi.org/10.3998/mpub.93465 https://www.firstthings.com/article/1994/12/christianity-and-the-westambiguous-past-uncertain-future https://www.firstthings.com/article/1994/12/christianity-and-the-westambiguous-past-uncertain-future 139 morgan nov 2016. christian journal for global health, 3(2):134-139. http://dx.doi.org/10.1097/00001888-20051000000004 8. steinbeck b, london aj, aras jd. ethical issues in modern medicine: contemporary readings in bioethics. boston: mcgraw-hill; 2009. 9. rechel b, mckee m. health reform in central and eastern europe and the former soviet union. lancet. 2009;374(9696):1186-95. http://dx.doi.org/10.1016/s0140-6736(09)61334-9 10. chudi ip. healthcare problems in developing countries. med practice rev. 2010;1(1):9-11. 11. rayner l, easthope g. postmodern consumption and alternative medications. j sociol. 2011 ; 37 (2) :157-76. http://dx.doi.org/10.1177/144078301128756274 12. world health organization. whoqol and spirituality, religiousness and personal beliefs: report on who consultation. geneva: who; 1998. available from: http://apps.who.int/iris/bitstream/10665/70897/1/w ho_msa_mhp_98.2_eng.pdf 13. smith bh, edwards e, murchie p. society for academic primary care: scotching the myths. br j gen prac. 2005;55:513 (316). 14. stewart m. patient-centered medicine: transforming the clinical method. oxford: radcliffe publishing; 2003. peer reviewed competing interests: dr. morgan is a staff tutor and executive member of prime correspondence: huw morgan, united kingdom. jhcmorgan@gmail.com cite this article as: morgan h. prime partnerships in international medical education restoring a christian ethos to medical education worldwide. christian journal for global health (nov 2016), 3(2):134-139. © morgan h. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1097/00001888-200510000-00004 http://dx.doi.org/10.1097/00001888-200510000-00004 http://dx.doi.org/10.1016/s0140-6736(09)61334-9 http://dx.doi.org/10.1177/144078301128756274 http://apps.who.int/iris/bitstream/10665/70897/1/who_msa_mhp_98.2_eng.pdf http://apps.who.int/iris/bitstream/10665/70897/1/who_msa_mhp_98.2_eng.pdf mailto:jhcmorgan@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ opinion piece nov 2017. christian journal for global health 4(3):96-101. anatomy lessons reena mary georgea and shefali mathewb a mbbs, ma (christian studies), professor, palliative care/radiation oncology, christian medical college, vellore, india b ba, student at the english and foreign languages university, hyderabad, india abstract the microcosm of the human body, like the great rhythm of the universe, is silent, intricate, delicately balanced. anatomy supports physiology as organs and tissues connect, communicate and nourish life. in illness, they speak through the patient's history. even in this era of cutting-edge technology, the clinical history remains the foundation of palliative and patient centred care. in listening to anatomy speak, we understand how and where the body hurts. in health and infirmity, may we also marvel at the human form we touch and inhabit — so carefully, fearfully and wonderfully made. bored of anatomy i confess that as a student i did not like the subject of anatomy. mathematics called for logic, the languages inspired creativity, physiology offered an intriguing interplay of feedback cycles, but anatomy demanded that i laboriously read pages of dead, boring detail. it fogged my memory with long names swirling in fumes of formalin. before the days of integrated medical education, the first one and a half years of preclinical studies in indian medical schools were completely separated from the clinical world. we lived far away from the hospital, but only a short walk from the dissection room. the dirty grey-brown tissues on the cadavers looked nothing like the color diagrams in our atlas. our seniors told us that the living body in the operation theatre looked very different. since i did not have the qualities to be a surgeon, anatomy was only a subject to endure until my clinical years. then i would search for a nonsurgical discipline that seemed a natural home for my interests and limitations. anatomy revisited radiation oncology was not a popular specialty in those days but it attracted me for many reasons. there was so much one could learn from a long relationship with patients and from ongoing discoveries in science. it offered physics and mathematics; psychology and statistics; medicine and surgery; pharmacology and pathology. it had clinical conundrums ranging from neurology to urology. as a trainee radiation oncologist, i realized that anatomy mattered very much. we did not have a fluoroscopic simulator. drawing upon our knowledge of surface anatomy, we would mark a field, paste radio-opaque metal markers, and take a plain x-ray. this “check film” became the litmus test of our radiotherapy planning skills. was the pituitary fossa bang in the middle of the ‘5 by 5’ field that we had drawn? had we correctly targeted the vertebra that had a painful deposit? we felt very happy if the check film occasionally showed we were spot on. the blue lines we had drawn on the patient’s skin did not have to rubbed out with methylated spirit and redrawn with a wooden twig dipped in gentian violet 97 george & mathew nov 2017. christian journal for global health 4(3):96-101. before being tattooed for future reference. our artistically minded ancestors must have used similar implements, vegetable dyes and twigs for cave drawings, before they progressed to doing body tattoos. “image-guided” radiotherapy has taken on a whole new meaning beyond those primitive “check films.” radiation oncology now uses amongst the most sophisticated and expensive technology in health care to pinpoint tumors in the three dimensions of space and through the movements of time. anatomy speaks although my own life has moved away from the precision of radiation oncology to the complex uncertainties of palliative care, anatomy still matters. it is a good friend now because it has remained true and steady. its fundamentals have changed less than that of many of the other subjects that i studied in medical school. i am grateful to the teachers who enabled deep, long-term learning. but it is no longer the quick fix of check films that is rewarding. it is my wonder at the design and economy in the anatomy of the human body, where structure and location so logically and elegantly facilitate function and sustain life.1 i was wrong to think that anatomy was a dead, boring subject. i realize now that anatomy is alive because it speaks, as creatively as any rich language, not only through the history of my patient but also in the history of humankind. many of our patients in india are too ill or too poor to afford mris and pet scans. i need the guidance of anatomy to know when to send for more expensive imaging. when my patient with lung cancer has recently become happy go lucky and expansive, my own heart sinks. it may not be because he has moved from grief to acceptance and positive thinking. very often the imaging will show frontal lobe secondaries in the brain — that sanctuary from chemotherapy. the body carefully shelters what is most vulnerable. the small, fragile pituitary that determines human size and virility is kept safe in the bony vault of the sphenoid. close to it, in their own osseous bunkers, are the nerves of our major sense organs. the eyes are protected by two parents — tough bony brows and tender, sensitive eyelids. we used to tell our patients with maxillary cancers to keep their eyes open and gaze into the cobalt beam. the maximum dose of radiation then fell behind the cornea, and it reduced the risk of a corneal opacity. the eyes, the windows to the soul for the poet, are the peep-hole to the living body, for the physician. with an ophthalmoscope, we can witness the inner ravages caused by raised intracranial tension when brain secondaries grow. the ear pinna resembles the diaphragm of our stethoscope, wide open to receive sound waves. and like the instrument’s rubber tubing, the middle ear shepherds the sound waves through a narrow path guiding them to audibility. the middle ear canal is far shorter than my stethoscope’s tubing because it has the incus, malleus, and stapes to amplify the signals. these tiny ossicles with imperious names sit beneath the brain, deep inside a petrous submarine. only the eustachian periscope peeps into the nasopharynx. i remember an old man whose partial deafness and middle ear effusion was caused by an undetected, nasopharyngeal cancer blocking the eustachian tube. it was only when the tumor grew to infiltrate the base of the skull and neuropathic pain demanded an investigation that the enemy was uncovered. no one had heeded what the secret agents in the middle ear had been whispering for months. there is an economy, not only in structure and location but also in function. air, before it reaches the lungs, wafts smells through the perforated cribriform plate to waiting olfactory nerves. air also makes a little detour from the pharynx into the mouth so that the sweet, salt, sour, and bitter of our taste buds become a thousand flavors of the world's cuisines. a common cold reminds us that the tongue is not the only organ of taste. changes in smell, taste, and saliva all contribute to the altered “taste” after radiotherapy. conformal techniques have reduced the gustatory price to pay for a cure. 98 george & mathew nov 2017. christian journal for global health 4(3):96-101. the slender, minimalist human neck can also swivel, if not to the same degree as a radiotherapy machine. the flexible neck allows us to look beyond the tunnel vision of our bone-sheltered eyes. the eyes, ears, and the nose are placed high to enable our human ancestors to look, listen, and breathe above the forest undergrowth. the neck connects the processing engines within the abdomen and thorax to the outside world of food and air. fleet-footed air speaks and sings its way through the flute of the larynx. with less delicacy, food pushes its way down the esophagus. bullied by the bolus, the esophagus remains silent and hides behind the trachea. very rarely does it speak up. we are worried when a patient with esophageal cancer coughs on swallowing. "drink a few sips of water," we say, and in the clinic, a trachea-esophageal fistula may hoarsely announce its presence even before a confirmatory endoscopy. unlike most other parts of the body, the thorax and the abdomen can expand and contract. both have to accommodate what enters from the outside, and so they have adapted to the needs of their residents. the latticed window of the thoracic cage allows both ventilation and protection. the lungs and the heart coordinate our gas supply. the body's biggest and busiest vascular channels run between them. in the body's economy, it is natural that these organs are in proximity. when things go wrong in the vital communication between the heart and the lung, the story of the pulmonary embolus can be breathlessly acute and scary. various body fluids keep their organ masters in good humor. we acknowledge them only when the patient complains of a post-radiotherapy stenosed vagina, dry mouth, or dry eye. newer radiotherapy techniques recognize the value of tears. i never understood the term “a potential space” throughout my pre-clinical studies. it sounded as mysterious and unreal as the wardrobe to narnia. finally, in my clinical years, i saw the potential space becoming oppressively real in a patient with a malignant pleural effusion. i admire the clinicians of yesteryears who discovered for us that vocal fremitus decreases with fluid in the pleural cavity but increases with the consolidation of the lung parenchyma. a helpful clinical distinct-ion when the patient is not able to come to the hospital for an xray. left untreated, an ipsilateral tracheal shift is the next danger sign the lung has collapsed, after a knockout punch inflicted by just a few liters of pleural effusion. a few liters of ascitic fluid do not tell such a violent story. the abdomen does not have ribs to constrain its expansion. easygoing, it expands with a smiling umbilicus. this laxity enables it to make room for the growing fetus and to stock up food reserves. its capacity fluctuates as food changes to fluid, flatus, and feces. we were taught these various f's in the differential diagnosis of a distend-ed abdomen by our clinical teachers. but like most students, we forget what we do not reinforce through regular use. a pair of senior physicians were debating over a sinisterly hard, but very mobile lump in the abdomen. was it benign or malignant? a gynecologist friend laughingly pointed out that it was the fetal head swimming in amniotic fluid. i would not have believed this story if i had not heard it first-hand. we may not realize when our professional knowledge erodes our human wisdom. i remember a medical teacher who said, “if we are not careful, as the years pass we will know more and more about less and less.” that is why, not just patients, but even the health care system, needs its general practitioners. common diagnoses are common, but common sense, sadly, is not. within the abdomen, the more delicate vulnerable structures are housed with extra care. the vascular liver and spleen are protected in the basement of the bony thorax. in the sterile retroperitoneum, the kidneys lie not far from the major vessels whose blood they have to purify. many of the catecholamines and mineralocorticoids that control the pressures and chemical balance of our inner world are produced by the adrenals that humbly wait upon the kidney. very few of the medications we use in oncology are produced by the body itself. but the “original glucocorticoid molecules,” 99 george & mathew nov 2017. christian journal for global health 4(3):96-101. indispensable to oncology, palliative care, and to life itself, were first synthesized by the adrenals. the adrenals determine life and death, hunger and thirst, love, fear, and happiness through electrolytes, hormones, and neurotransmitters. yet, they remain content with a name subsidiary to the kidney. perhaps they were labelled when we judged them by their position and not by their vital contribution. i think of those who quietly work hard to keep our big hospitals running every day: the electricians, the secretaries, the accountants, the cleaners, the plumbers. the liver, the largest organ in the abdomen, is close enough to the upper gut to take over the portal circulation. it is as if the body has outsourced the processing of nutrient-laden blood to this factory of portal circulation. the liver adds chemical preservatives, conjugates, sorts, and stores after the pancreas has done the enzymatic slicing and chopping of food. it was in a patient with pancreatic cancer that i first realized how anatomy tells stories. it was a sad story of a tumor in the pancreas that had blocked the common bile duct. the skin and urine were a deep yellow, as were the desperate, wide-open eyes of a young man who would not live to see his children grow up. anterior to the retroperitoneum, in the roomy abdominal cavity, many meters of intestines and miles of villi happily cohabit in a common dormitory. the near constant supply of food and drink keeps them in good spirits. the ileum is especially trouble-free. we see very few cancers there. frequent surveillance endoscopies of the ileum would be both difficult to perform and unpleasant to experience. the ileum goes the extra mile when other routes are blocked, emerging as an ileostomy or even an ileal conduit for urine, another quiet, faithful, unappreciated worker with an undistinguished name. in good health, the peritoneum provides smooth, thick, waterproof insulation. the visceral peritoneum protects the abdominal cavity from the murky contents of the gut. a perforated bowel cancer changes the easygoing abdomen into a tense guarded structure that rebounds in pain. cancer that seeds the peritoneum, more insidiously, sows discord within a once happy intraabdominal family. when cliques of matted omentum advance upon their wounded neighbor, even bowel resection surgery cannot bring catharsis and reconciliation. it is left to palliative care physicians to impose an uneasy curfew with anticholinergics and numb the deep visceral pain caused by broken relationships. pain is the most frequent spokesperson for anatomy in oncology. unlike visceral pains, nociceptive and neuropathic pains are quite precise in their history telling. but sometimes you have to know from where they are coming. if a patient with breast cancer starts getting supra-scapular pain, i worry about recurrence near the deep brachial plexus, even if the chest wall is pristine. i also remember the patient whose high interscapular pain turned out to be an extra mucosal recurrence of a post-cricoid cancer goring into the prevertebral tissues. a patient may have multiple bone metastases, but when his deep tendon reflexes are brisk, we cannot ignore these hyperactive nerves — danger is near. an mri is needed to screen for cord compression. unlike most other cells in the body, the neurons travel far, communicate fast and shock us into attention. they are our high tension electric wires. despite the speed with which our nerves convey orders, our responses are surprisingly accurate. this is partly because the motor homunculus has designated offices. the homunculus of the brain gives much more to the hands than to the feet. in spite of such unfair treatment, the feet steadily carry the load, allowing freedom for our hands to learn new skills. the loyalty of the feet has, in turn, enabled them to grow – human lower limbs are stronger, longer, and more autonomous than the lower limbs of most animals. the big and the little toes are parallel to each other, but the thumb is placed almost perpendicular to the other fingers. this little difference has altered human history. would we have ventured to plant seeds, light fires, cook food, sail ships, draw maps, 100 george & mathew nov 2017. christian journal for global health 4(3):96-101. teach children to write, perform surgery, administer chemotherapy, or do radiotherapy contouring if we were created with thumbs that were parallel to the fingers? the brachial plexus that enabled all of these milestones in human history can be damaged by many cancers: breast, lung, and supraclavicular nodes from different primaries. breast cancer is very versatile in the stories it can tell. its metastases range from choroidal to krukenberg. some breast cancers write long-running sagas. every few years there is a distant site of relapse and therapy. the cancer-encuraisse on the other hand, like a parochial soap opera, revels in causing may-hem and misery in its neighborhood. the breasts, we had learnt in anatomy, develop on the mammary line that extends from the axilla to the abdomen. other mammals have many pairs of mammary glands to feed multiple offspring. only one pair remains in human beings. before in-vitro fertilization and neonatology, twins sometimes survived, but triplets rarely did. a woman’s only pair of breasts is located closest to where the baby can hear his mother’s heartbeat as he feeds, where her elbow can comfortably cradle him, where she can smile at him, sing to him. most mammalian offspring are not carried with such tenderness. as infants, we had to be carried because we are born helpless. unlike puppies, calves, or foals, the newborn human being cannot run or jump to claim nourishment. even when we can physically stand on our own feet, we cannot manage to earn a livelihood for many years. perhaps it is such vulnerability that created human civilization. babies needed parents for many years just to survive. and that dependence created families. for a decade or two children are given not only food, but love, knowledge, values, and laughter. work and creativity, faith, and learning were shared and fostered across gen-erations. one reason why the child is born almost prematurely helpless is because the head to body ratio is larger than in most animals. and before the head gets too big to escape the bony pelvis, the baby leaves the womb and moves into the care of its parents. it seems unfair when the wombs that have been a safe home to many children are attacked by cervical cancer. the assailants come in different guises. some invade frontally with early bloodshed. the injury is worrying enough to bring the patient to the hospital. (except when, as a doctor from africa said, some simple postmenopausal women rejoice that their fertility has returned and keep waiting for the next pregnancy.) the exophytic bleeding cancers that do reach a radiotherapist are usually gratifying to treat. they often shrink quickly with external radiotherapy, and then brachytherapy can deliver tumoricidal doses. the most lethal villains are the other types of cervical cancer, the ones that creep silently and suddenly garrote both ureters. then there are obnoxious bullies who slowly torture before they kill. they gouge into the bladder or rectum, causing fistulae. stigmatized by fetid smells, the patient, for no fault of her own, becomes the lonely pariah. friends move away. at the very end of the torso, are orifices born of the lowly primitive cloaca. it too has adapted to serve the body. it allows the intestines which were anteriorly placed in the abdomen to emerge posterior-most as the rectum. the ureters that were situated posteriorly in the sterile retroperitoneum drain urine through the anterior sluice valve of the urethra. our ancient female ancestors and their babies might have more easily died of urinary or puerperal sepsis if stool came out anterior to the urethra and vagina. the occasional unfortunate patient with a rectovaginal fistula illustrates the mess when stool takes the front seat. living art it took the mutilation and mystery of cancer to teach me how anatomy works. as clinicians, we witness the tentacles of cancer rip a finely balanced work of art into a tremulous jigsaw. in listening to the patient, we try to understand how the jigsaw fits. through individualized, attentive treatment we try to put back the pieces. 101 george & mathew nov 2017. christian journal for global health 4(3):96-101. yet, we know that with or without cancer, human bodies will ultimately return to the earth. they will become dust and ashes just like our discarded drawings and paintings. only a select few will be preserved — priceless children’s drawings treasured by their parents; expensive masterpieces in our art galleries and museums. they speak deeply to us without articulating a single word. a few human bodies endure too. they are in our medical school museums, where cadavers continue to teach the ancient art of anatomy to today’s medical students. and for the many faceless ones, who in brokenness and silence, taught me to listen to their voice in my patients — i write this tribute. . references 1. brand p and yancey p. fearfully and wonderfully made. grand rapids, michigan: zondervan publishing house: 1980. peer reviewed competing interests: none declared. correspondence: reena george, cmc vellore, india. reena.vellore@gmail.com cite this article as: george rm, mathew s. anatomy lessons. christian journal for global health. nov 2017; 4(3):96-101. https://doi.org/10.15566/cjgh.v4i3.198 © george rm and mathew s. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:reena.vellore@gmail.com https://doi.org/10.15566/cjgh.v4i3.198 http://creativecommons.org/licenses/by/4.0/ case study nov 2017. christian journal for global health 4(3):47-52. starting a palliative care initiative using a transformational development approach eleanor fostera a bsc, md, ccfp(pc), dipcs, clinical lecturer, university of calgary cumming school of medicine, canada formerly with africa inland mission introduction his first eye had been removed at 4 months of age for retinoblastoma, and his second eye a year and a half later when there was a recurrence. since there was no evidence of metastases, his family mustered what little resources they had to fund his chemotherapy. on completion, they returned to their rural home with hope. a year later his mother brought him to malindi sub-county hospital with rapidly progressing swelling in his limbs, forehead, and the floor of his mouth. he was able to chew only bananas and drink milk and was hungry and in constant pain, crying and squirming. his mom was tired, stressed, and hopeless – for a long time there had been nothing she could do to make him happy or comfortable and neither of them could sleep. the pediatric intern asked the palliative care team for help and together, along with his mother, we agreed on a goal to make him smile. the head nurse on the pediatric ward found it quite irregular to allow morphine to be given to one of her patients but she acquiesced. three days later the mother was smiling; her son was improving. the morphine and dexamethasone were controlling the pain and swelling, and the plumpy nut malnutrition supplement the nutritionist had given him was satisfying his hunger. a few days after, i came across the mom feeding her son some ice-cream; he had a huge grin. mom and son were able to forget about his illness and enjoy relationship and life together for the short time he had left. palliative care and transformational development together palliative care and transformational development both involve a holistic approach to relieving suffering and in the process, improving quality of life. the focus of palliative care is relieving the suffering of the patient who has a life limiting illness, and also the suffering of their family. transformational development involves communities as they struggle with the suffering caused as a result of sin in this world; this might be children dying as a result of the lack of clean, accessible water, or in this case, community members with life limiting illnesses living and dying in miserable circumstances. the world health organization definition of palliative care is, ‘an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.’1 a palliative care approach involves caring for a person with a life limiting illness, and their family, with the attitude of giving them the best quality of life by actively preventing and relieving suffering, whatever the origin of the suffering. there is no universally agreed upon succinct definition for transformational development (td). world vision defines it as, “the process through 48 foster nov 2017. christian journal for global health 4(3):47-52. which children, families, and communities identify and overcome the obstacles that prevent them from living life in all its fullness.”2 bryant myers, in walking with the poor: principles and practices of transformational development, uses the term transformational development to reflect his, “concern for seeking positive change in the whole of human life, materially, socially, and spiritually…..the transformational journey is about finding and enjoying life as it should be, as it was intended to be.” he describes it as “a process of change that affirms the joint roles of god and human beings, the need to focus on restoring relationships.”3 but what does this process look like? practically speaking, td involves humbly walking along side of communities, building relationships with them, learning from them, helping them to identify their god given strengths and resources and use them to address the challenges they face, and at all times maintaining their dignity as image-bearers of god. the rationale of transformational development the theological foundation of transformational development is that god gave man, from the beginning, four areas of relationship – with god, with those around him, with the created world, and with man himself (genesis 2). at the fall, each of those areas of relationship was marred (genesis 3), but through jesus’ sacrifice those relationships can be restored. disease is a result of the fall, and so are the other strained relationships it brings. today god is actively working to restore those relation-ships so that we live in joyful intimate relationships with him, with others, and with the rest of creation, reveling in the dignity he has bestowed on us. we get to work with him when we address these issues; this is not our initiative, it is his.4 when seeking to start a palliative care program, how can a td be approach be helpful? firstly, when a palliative care practitioner is invited to a community to begin a palliative care program, unless they also have intimate knowledge of the community’s resources, needs, or culture, they do not have the knowledge necessary to practice palliative care in that setting. there is no “cookie cutter” palliative care program that can be duplicated from one community to the next; each community is unique and it is through relationship building and dialogue that the community is able to determine their own needs. the td focus on relationship building and the practice of appreciative inquiry provide direction for a strong beginning.4 secondly, palliative care requires a multidisciplinary team in order to meet the needs of patients.1 only the various disciplines themselves are able to determine what they can bring to the table and how they might integrate their services. the asset based community development (abcd) strategy used by td practitioners provides guidance for helping people discover how and what they can contribute.4 thirdly, people are invested in things that they have had a hand in crafting. if the ultimate goal is to have a locally integrated program, it must be birthed and owned locally.4 the most detrimental stumbling block to effective community participation, according to a group of experienced volunteers in a successful community based palliative care initiative in india, is a strong hierarchical organizational structure with powerful people at the top, people who are hardworking and consider themselves indispensible.5 using the inclusive participatory “learning process” approach to development with its action-reflection cycle safeguards against such impediments of sustainability.4 lastly, td recognizes that god has gifted the community to be able to work together towards meeting the needs of one another; this is his work and his responsibility. this allows the practitioner to watch the process and be amazed at what god does, rather than fretting about how much progress is or is not being made. starting palliative care how does one start a palliative care initiative? the world health organization suggests applying a 49 foster nov 2017. christian journal for global health 4(3):47-52. public health strategy to palliative care and identifies four fundamentally important components that need to be established if palliative care is to be incorporated into a country’s health care system, namely adequate drug availability, widespread education, implementation through all levels of society, and appropriate policies to undergird the first three.6 these components have been used as a framework for structuring a variety of successful programs, for example those reported in mongolia, jordan, and nepal.7-9 in these three cases the examples of addressing the four components are all very large scale and are from a national perspective involving ministers of health and medical training colleges, importation laws and quotas. while these specific examples are on a much grander scale than would be applicable to a small local initiative, the four components are equally as relevant for small fledgling programs as they are for national initiatives; in order for any palliative care initiative to succeed and grow there must be drugs available to control symptoms, education for all (for example community members, health care workers, public officials), there must be provision of services that are widely accessible, and when the need arises there must be policies that govern the services, education and drugs. these are concurrent activities, not sequential. so what does it look like to combine the four components of the public health strategy with td? it begins with listening and relationship building. in the west it is said, there can be no relationship without trust. in africa, there can be no trust without relationship. in 2011, i was invited by the government hospital in malindi, kenya, to mentor the startup of their palliative care program. in the first months i often felt guilty because i was not busy seeing patients. i would see the patient or two who had been referred, then sit around the wards talking to nursing staff, interns, cleaners, pharma-cists, the physiotherapist, the nutritionist; whoever was around. they would tell me about a family member who had died, a neighbor who was sick, or their own passion to help those less able. i didn’t feel like i was doing palliative care ‘work’. but in retrospect those relationships, built by showing up every day, established trust, were a means of education, and opened many doors later in the process as staff grew to understand palliative care and were eager to play their part. a helpful resource for these conversations was the palliative care toolkit, an excellent book available free of charge online in six different languages, written with the intention of assisting and encouraging fledgling palliative care start-ups, which suggests asking four questions (appreciative inquiry): 1. who needs palliative care where we are working? 2. what are their main problems? 3. what help are they getting at present? 4. what could be added to improve their care and make it holistic?10 the combination of td and the public health strategy for palliative care also involves teamwork and collaboration. as you listen and build relationships you will find people from a variety of walks of life with whom the concept of palliative care resonates. most often they have experienced a significant loss or have a family member with a disability; look for some who could be members of a palliative care committee. seek advice from those around you. develop and maintain strong ties with the national palliative care organization. learn from the nearest palliative care initiative – how did they start, how do they access (and mix) morphine, how can you collaborate, and what pitfalls should be avoided. go with the cultural flow; if some are passionate about an activity that you are not, encourage them to run with it. together, begin to address the four components of the public health strategy for palliative care: widespread education, implementation through all levels of society, adequate drug availability, and appropriate policies to undergird the first three. how will you educate? much of the education is informal and begins with simply raising 50 foster nov 2017. christian journal for global health 4(3):47-52. awareness. speak about palliative care to anyone who is interested to listen wherever the opportunity arises, whenever there is an invitation; friends, service clubs, health care staff (both professional and support staff), as well as community health workers. often informal conversations with the cleaner or the night guard will strike a resonant chord more so than with fellow physicians. as you speak with people they will speak with others and word spreads. courses and seminars are also effective. the palliative toolkit trainer’s manual comes in five languages with ready-made lesson plans covering everything from the definition of palliative care, teamwork, and breaking bad news, to how to prescribe opioids, providing spiritual care, and more; everything needed to teach for a day, three days, or five days!11 this curriculum recognizes that adult learners already have a foundation of knowledge and experiences and want new learning to be useful in their daily life. much of the lesson time is spent in small groups learning from each other; story-telling and reflection are important components. there also may be a national training curriculum that could be used. fit in with the (organizational) culture. wednesday afternoons at malindi sub-county hospital there was a continuing education meeting for anyone who was interested – the person in charge was often looking for facilitators to teach sessions and i volunteered whenever there was opportunity. mentoring is the optimal method of educating those who will be involved in front line care. make it a point to bring a learner with you whenever you interact with palliative patients, whether it is breaking bad news or doing holistic assessment and treatment. afterwards, discuss what went well and how you might do better next time, and when the next time comes, let the learner take the lead. implementation features implementation begin providing services. a listening ear, medications, prayer; whatever is possible, wherever possible, whenever possible. don’t let lack of funds or venue be a deterrent. model holistic care, ensuring physical as well as social, spiritual, and psychological care. meet the needs that you are able to, recognizing that you will not be able to ‘fix’ everything (or even close to everything), and bring the rest before god. work with your team to access appropriate medications. morphine is important, but if you have access to methadone instead, use that, or codeine, or tramadol, while you work towards find-ing better opioids. unfortunately, drug trafficking regulations often make access to morphine and other narcotics problematic. however, with patience, advocacy, and continued relationshipbuilding you may be able to make progress. the who has a list of essential medicines in palliative care with their indications and dosages that can be tailored to local needs.12 when there are insufficient local policies, address the issues and work together to create the appropriate policies to allow you to move forward. the issues we encountered mostly involved the access, reconstitution, and appropriate storage and dispensing of morphine. over many months of meetings with the medical superintendent, head pharmacist, and hospital matron, the palliative care committee crafted policies that worked for the hospital, the palliative care department, and the patients. recognize that god brings opportunities and resources. from the beginning it was my prayer to see this initiative at the grassroots community level, and have an emphasis on spiritual care. a local catholic nun who was a nutritionist and ran a community health worker (chw) program was visiting at the hospital, heard about palliative care, and requested that we teach palliative care to their chws. in this way palliative care was integrated into the chws’ activities and an understanding of palliative care began to take root in the community. a priest who had been trained in clinical pastoral education and had a vision to train other spiritual leaders approached us about working together and we were able to teach about palliative care in their training. calvin college sends summer interns to 51 foster nov 2017. christian journal for global health 4(3):47-52. developing countries to do research, and one worked with us to determine community percep-tions about end of life. she asked the communities about their current practices, what was good and what they would like to see improved. this helped the palliative care team understand what kind of educational material they needed to develop to fill the gap. as the program grew, god, in his timing, also provided material needs. the kenya hospice and palliative care association had successfully lobbied the government to put palliative care on its list of essential services, so the sub-county hospitals were mandated to begin offering palliative services and the hospital provided a furnished building for palliative care services along with a supply of medications. two very capable nurses found sponsorship to take a modular two-year higher diploma in palliative care. they then took the lead in the malindi sub-county hospital palliative care department, one in inpatient care, and the other in outpatient care and training. palliative care now i left kenya in 2014. what is happening with the initiative today? in an official capacity, not very much. there have been very rocky times recently in the health sector in kenya. in late 2016 and early 2017 there was a 100-day doctors’ strike, and shortly thereafter a prolonged nurses’ strike began which is ongoing as of october 2017. although no new palliative patients have been assessed for many months and the previous structured palliative care program is no longer functioning at present, its impact is still felt, to a large extent due to the td method of implement-ation. palliative patients who were receiving morphine for their pain are still able to collect it from the hospital pharmacy – the head pharmacist was an enthusiastic member of the palliative committee. one of the nurses with a higher diploma in palliative care has left the public sector and is now a nurse manager at a new private hospital in malindi and carries her experience and training with her. the other nurse is still enthusiastic about palliative care and is looking forward to resuming her role when the strike is over. many clinical officer and medical officer interns have moved on to new positions in the country and likewise use their palliative training wherever they are; one was hired by the palliative care program in mombasa, 120 km from malindi. and community health workers now have tools to help when their community members face death. not long after the chw training, some visiting nursing students accompanied a chw supervisor on a home visit to a 27 year old mother of 5 children with end stage esophageal cancer, lung metastases and a tracheoesophageal fistula. they watched in awe as he asked pertinent questions about the effectiveness of the patient’s medications for pain and shortness of breath, then skillfully addressed the psychosocial and spiritual issues of the family – how was the husband coping emotion-ally and financially? what were their spiritual resources? her husband was battling with burdens of guilt, uncertainty, and feelings of inadequacy. after praying a blessing on the household and asking god to be present during this dark time, the chw supervisor made arrangements to follow up closely with the whole family – the wife with her palliative care needs, the husband who was about to be bereaved, and the children whose swollen bellies and rust colored hair betrayed their precarious nutritional status. god is at work and through palliative care we are privileged to join him in relieving suffering and restoring relationships and mentoring others to do the same. as we faithfully offer up to him our skills and abilities, he uses us to bring healing, sometimes physical, sometimes psychosocial, and sometimes spiritual. references 1. world health organization. definition of palliative care. available at http://www.who.int/cancer/palliative/definition/en/ http://www.who.int/cancer/palliative/definition/en/ 52 foster nov 2017. christian journal for global health 4(3):47-52. 2. world vision [internet]. johannesburg: campaigns and projects / transformational development; c2017 [cited 2017 nov 05]. available at: http://www.worldvision.co.za/campaignsprojects/transformational-development/ 3. meyers b. walking with the poor: principles and practices of transformational development. new york: orbis; 1999. pp. 2,15. 4. corbett s, fikkert b. when helping hurts: how to alleviate poverty without hurting the poor and yourself. chicago: moody; 2009. pp. 56-62,136138,125-130, 144. 5. kumar s. community programmes in palliative care: what have we learned? indian j palliat care. 2005 ;11:55-7. available at http://www.jpalliativecare.com/text.asp?2005/11/1/ 55/16648 6. stjernswärd j, foley km, ferris fd. the public health strategy for palliative care. j pain symptom manage 2007 may;33(5):486-93. https://doi.org/10.1016/j.jpainsymman.2007.02.016 7. davaasuren o, stjernswärd j, callaway m, tsetsegdary g, hagan r, govind s, et al. mongolia: establishing a national palliative care program. j pain symptom manage 2007 may;33(5):568-572. https://doi.org/10.1016/j.jpainsymman.2007.02.017 8. stjernswärd j, ferris fd, khleif sn, jamous w, treish im, milhem m et al. jordan palliative care initiative: a who demonstration project. j pain symptom manage 2007 may;33(5):628-33. https://doi.org/10.1016/j.jpainsymman.2007.02.032 9. brown s, black f, vaidya p, shrestha s, ennals d, lebaron vt. palliative care development: the nepal model. j pain symptom management 2007 may;33(5):573-7. https://doi.org/10.1016/j.jpainsymman.2007.02.009 10. lavy v, bond c, woolridge r. palliative care toolkit. worldwide hospice palliative care alliance. london 2016. available from: http://www.thewhpca.org/resources/item/palliativecare-toolkit-2016 11. lavy, v. palliative care toolkit trainer’s manual. help the hospices. london 2009. available from: http://integratepc.org/wpcontent/uploads/2012/12/pall-care-toolkittraining-manual-final.pdf 12. world health organization. essential medicines in palliative care. 2013. available from: http://www.who.int/selection_medicines/committee s/expert/19/applications/palliativecare_8_a_r.pdf peer reviewed competing interests: none declared. correspondence: dr. eleanor foster, eleanor.foster@ahs.ca cite this article as: foster e. starting a palliative care initiative using a transformational development approach. christian journal for global health. nov 2017; 4(3). © foster e. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.worldvision.co.za/campaigns-projects/transformational-development/ http://www.worldvision.co.za/campaigns-projects/transformational-development/ http://www.jpalliativecare.com/text.asp?2005/11/1/55/16648 http://www.jpalliativecare.com/text.asp?2005/11/1/55/16648 https://doi.org/10.1016/j.jpainsymman.2007.02.016 https://doi.org/10.1016/j.jpainsymman.2007.02.017 https://doi.org/10.1016/j.jpainsymman.2007.02.032 https://doi.org/10.1016/j.jpainsymman.2007.02.009 http://www.thewhpca.org/resources/item/palliative-care-toolkit-2016 http://www.thewhpca.org/resources/item/palliative-care-toolkit-2016 http://integratepc.org/wp-content/uploads/2012/12/pall-care-toolkit-training-manual-final.pdf http://integratepc.org/wp-content/uploads/2012/12/pall-care-toolkit-training-manual-final.pdf http://integratepc.org/wp-content/uploads/2012/12/pall-care-toolkit-training-manual-final.pdf http://www.who.int/selection_medicines/committees/expert/19/applications/palliativecare_8_a_r.pdf http://www.who.int/selection_medicines/committees/expert/19/applications/palliativecare_8_a_r.pdf mailto:eleanor.foster@ahs.ca http://creativecommons.org/licenses/by/4.0/ conference report nov 2016. christian journal for global health, 3(2): 143-150. fostering international undergraduate medical education james d smith a , dan poenaru b , j dwight phillips c a md, professor emeritus, oregon health science university, portland, oregon, united states b md, mhpe, frcsc,facs, fcs(ecsa), professor of surgery and pediatrics (adj), clinical director, bethanykids africa, montreal university health center, montreal, canada c md, professor of pediatrics, mayo clinic, rochester, minnesota, united states introduction health professional education represents an expanding frontier of medical missions. in november 2015, 67 medical missionaries and academicians met in conjunction with the global missions health conference (gmhc) in louisville, kentucky. most of the participants involved in the discussion were of north american origin, some originated and resided on other continents, and most participants had spent years working professionally outside of north america. a subgroup of 10 educators reviewed the current status of christian health care education and discussed potential challenges for groups starting new medical schools. recommendations were made as to how educators from high-income countries (hics) can support schools in lowand middle-income countries (lmics). further discussions have been held since that 2015 meeting. arising from those discussions, this paper represents a consensus on the current status of undergraduate health care education in missions and includes future directions and recommendations. current status of health care education the 2015 louisville workshop started with four questions:  what are some of the challenges in starting new medical schools in lmics, especially in africa?  how can hic educators help overcome the challenges faced in medical educational institutions in lmics?  can general recommendations be made for christian groups wanting to start new medical schools or wanting to help existing ones?  what forum or specific organizations would best accomplish the above goals? responses to these questions provide the framework for this paper. overcoming challenges in starting medical schools in lmics one challenge facing international health care education is the acute need for more health care professionals in most countries. even in hics such as the us, there is a call for more medical schools as the association of american medical colleges (aamc) predicts a shortage of 45-90,000 doctors by 2025. 1 this shortage is minuscule compared to the need for physicians in lmics, where multiple studies have documented an inadequate health care work force and associated poor outcomes. 2 the existing shortage is further aggravated and perpetuated by health care worker migration to help fill the shortage in hics. it is very disconcerting when a large percentage of graduating classes in lmic medical schools anticipate emigrating to hics soon after graduation, with enormous human and financial capital losses. 3 to meet the need for health care professionals, many governmental, nongovernmental (christian and secular), and for-profit 144 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. organizations and groups are starting new medical schools in lmics. 4 however, these groups face multiple potential obstacles to educating quality health care professionals. the working group identified several such challenges, detailed below.  adequate facilities and resources for lectures and laboratories in the basic science years, and of clinical settings for the clinical years. the latter of these is most critical in light of the many new medical schools being opened without advance consideration of clinical teaching, resulting in medical schools literally competing for patients in both public and private hospitals. such, for instance, is the status quo in addis ababa, where multiple new public and private medical schools literally compete for patient exposures in their clinical years in the city’s hospitals. another aspect of the resources is the adequacy (or lack thereof) of internet connectivity. this is the case in some african countries like ethiopia and democratic republic of congo (drc). not only does the connectivity limit access to online resources, but it also impairs the possibility of telemedicine. among laboratories, the greatest challenge is anatomy. human cadavers for dissection are very difficult to obtain in most resource-limited countries (such as ethiopia), and totally unavailable in others (such as somaliland and drc). replacing the cadavers with “digital dissection programs” is attractive, yet very expensive or must rely on fast internet connections.  qualified faculty, for both the basic sciences and clinical years. there are many reasons for this problem, including lack of local training facilities for basic science faculty in lmics and low salaries. clinical teachers typically carry heavy patient loads, resulting in limited time to teach. this is further exaggerated by the relatively few faculty and, in both public and some private settings, large numbers of students. clinical teachers’ income is often poorly compensated by the schools for the extra time teaching requires, so there is little incentive to take on teaching responsibilities. finally, clinical teachers often lack training in teaching and are reluctant to make onerous teaching commitments. most foreign ngos and christian schools compensate for the limited availability of local faculty with expatriate faculty. this is not a durable solution as few faculty from hics are willing to commit to full-time ministry or even consider multiple short-term visits, leading to unpredictable availability and consistency. expatriate faculty may also face language issues, especially in nonenglish-speaking countries. the reverse problem occurs in countries where medical schools recruit foreign students to raise tuition income, then teach the students in english using faculty whose command of english is suboptimal, thus leading to a poor atmosphere and outcome. moreover, it is often difficult to attract expatriates to work in harsh living conditions or where there are limited educational opportunities for their dependent children. hiring national faculty ultimately remains the best option, as this option builds local capacity and therefore sustainability. unfortunately, local faculty, especially in some academic areas, are conspicuously absent (e.g., embryology, genetics, molecular biology, histology/pathology among the basic sciences). even if they are present it may be too expensive to pay local faculty, thus leading to higher tuition costs. some new medical schools have started within existing universities, thus using general science faculty to teach basic health sciences – yet with little or no medical expertise or application. thus, one of the priorities for new medical schools should be to recruit and train nationals to become faculty. another viable option is the use of online courses and other resources.  qualified students. in most lmics, medical school is a 5or 6-year undergraduate degree, so students matriculate directly from secondary (high) school. many have marginal educational 145 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. backgrounds and find adapting to the rigors of medical school difficult, resulting in a relatively high dropout rate. a drop-out rate of 25-50% is commonplace, for instance, in some private medical schools in somaliland. some new medical schools are started quickly to help fill the need for health care training. the plans may be to start first with minimal resources, then add more faculty, physical facilities and clinical training sites as time moves on. in ethiopia, for instance, public directives for rapidly increasing the number of trained physicians have resulted in 25 new public and private medical schools, unfortunately many have very limited resources. this style of “planning” can have negative consequences such as: 1. initial student intake may be very high with a planned attrition rate as high as 50%. 2. a minimal number of faculty engaged before taking in students, with little planning to match the number of students with the number of faculty. 3. minimal (or absent) curriculum plan, and/or a faculty with no experience in curriculum design and implementation. 4. unclear or absent long-term plans for facilities and faculty for clinical training after the basic science years. 5. no clear plans on how to retain national or expatriate faculty. sometimes there is a lack of finances to pay the national faculty on a regular basis. 6. for-profit schools tend to charge high tuition fees to satisfy their investors. unfortunately some christian schools supported by national churches may end up doing the same to support the church. 7. well-meaning mission organizations may not understand the long-term costs associated with running a full-service medical school. while the focus is often on the initial set-up costs, it’s the year-after-year operating budget which is often most challenging to maintain.  secularized curricula: christians working in secular schools will need to contend with the consequences and implications of a secularized curriculum. this may happen even in the context of previously faith-based schools in which the mission and vision have changed over time. in other settings, the commitment to a christian curriculum may be at odds with governmental directives towards a fully secular higher education. moreover, christian medical school curricula are rare and difficult to implement. examples to date include, among others, loma linda university school of medicine 5 in the us, myungsung medical college in addis ababa (ethiopia), université shalom de bunia (drc) 6 and hope africa university in bujumbura (burundi).  availability of paid employment and/or postgraduate training for graduates. this is quite variable in different countries. some of the experiences reported by the workshop participants are described below. 1. in india this is not a major problem. while there are not enough government positions, there are opportunities in the private sector hospitals, independent charities and private practice. immigration to europe and north america has decreased to about 10% of graduates. a significant problem, common to many settings, is having doctors willing to move to rural areas where many jobs go unfilled. 2. china has a large number of medical schools, but the healthcare policy limits employment options. private practice is not allowed, so many graduates cannot find employment, which may affect as many as 60-80% of medical students (jds, personal communication). 3. a few years ago in cameroon, the government approved starting about 15 new medical schools in a very short time, but within 2 years closed all but 3 for lack of qualified students and faculty. 7 146 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. 4. in kenya, there are 6-8 new medical schools which have recently started or are planned to start in the near future. yet when a kenyan physician was asked, the concern was that even at present not all graduates from the two older major medical schools have been able to find paid employment or postgraduate training. 4. this phenomenon is not unique to africa, but has been observed in countries from the middle east to central asia to east asia. when asked, doctors admit they are depending on those not finding paid employment to immigrate to other countries for employment in the medical field. 5. by 2017-2020, it is predicted that there will be no residency positions for foreign medical graduates in the us unless the numbers of residency positions are increased. the question will be whether superior foreign medical graduates will be able to take positions desired by american graduates. 8 recommendations to meet the challenges: opportunities for contribution workshop participants provided both general and specific recommendations. general recommendations 1. it is incumbent for those of us wanting to help to ask the nationals what they see as their needs. a new medical school may not be demographically recommended in an area, yet the desire to create a christian center of excellence in a setting with lower-level secular institutions may be commendable. 2. our key means of assistance may be in “walking with” our spiritual and professional sisters and brothers in lmics through the complex process of “counting the costs” of undergraduate medical education (in terms of workforce, facilities, resources, time commitment) and then establishing a detailed work plan for accomplishing the task. a sample listing of tasks is found in figure 1. figure 1. medical degree program start-up: key steps & tasks domain task key documents needed notes administration college mission & vision mission & vision best derived through a faculty retreat college organogram organogram based on university organogram, if available committee structure college constitution; committee tors based on university constitution staffing staffing plan staffing projections set up minimum and scale-up to ideal staffing policies staffing manual recruitment, dismissal, professional code admissions incremental class sizes typically start with 15-20/year; best start small; limiting factor is clinical exposure admission requirements admissions manual minimum gpa/ high school position, internal exam grade, etc. admissions process admissions committee tor include essay? interview format; normor criterion-referenced 147 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. curriculum curricular philosophy college mission & vision goal: competence; holistic? spiritual? curriculum type syllabus preamble traditional sequential, modular, pbl, hybrid curriculum structure syllabus # years pre-med/pre-clinical/clinical/internship; semester or termbased courses course syllabi each include objectives/contents/format/assessment instructional format non-lecture based formats: group / indiv. projects, debates, slms student assessment assessment principles student manual objective-based; multimodality; formative/summative/external assessment methods student manual clinical assessments osces; iters; sps educational resources infrastructure survey # classrooms; labs; offices lab equipment inventory microscopes; dissection equipment; microbiology library traditional vs. digital?; study space; eplatforms instructional tech models; it for education student affairs counseling professional external/contract counselor student health nurse or physician contact student council, clubs ceremonies, prizes white coat ceremony; cadaver ceremony; best student/teacher awards abbreviations: tor = terms of reference; osce = objective structured clinical examination; iter = in-training evaluation report; sps = standardized patients; mmc = myungsung medical college; herqa = higher education relevance and quality agency (ethiopia) 3. we then need to determine if their expectations of how we can help are realistic in view of our resources and ability to meet them. this is especially true if a new medical school plans to be totally dependent on staffing a school with expatriates in the long-term. 4. this may mean that groups that want to help may need to make hard decisions on which programs are the most viable and concentrate their efforts and resources on those sites that will produce the best doctors. this may also include deciding which sites have the most potential to have a spiritual impact. these decisions will need to be balanced with individuals feeling led by the lord to work in a specific area or with a specific people group. specific recommendations 1. provide support through a medical education office in north america to give curricular support, assessment, instructional methodologies, and help with student affairs. 2. find ways to recruit basic science and clinical faculty who are willing to serve either longor short-term. the most effective faculty will be those willing to serve long-term. 3. identify a core group of individuals who would be willing to serve as consultants for christian mission groups or ngos seeking help to: a. start a new medical school. b. develop locally-appropriate curricula for new schools or for established schools interested in reforming their existent curriculum. c. provide faculty development in adult learning principles, teaching skills, and modern teaching methods (faculty development). d. provide training for prospective missionaries planning to serve in any of these areas. 148 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. 4. create a centralized structure to identify and recruit faculty as well as identify global gaps and needs. it is also necessary to identify and collaborate with organizations or groups already working in these areas to try to minimize duplication of efforts. 5. identify ways to speak into the culture with a christian worldview and ethics, i.e., how to treat patients with love and acknowledge their worth in the eyes of god. this may include small interactive group settings more than lectures, where our faculty can both listen and share their views. an example of such an integrated, longitudinal, whole-person medicine program from myungsung medical college is shown in figure 2. figure 2. mmc whole-person medicine curriculum component year 1 year 2 year 3 year 4 bioethics lectures bi-weekly lectures m1-3 tuesday pm bi-weekly lectures m4-6 wed. pm servant leadership bi-weekly lectures m1-3 tuesday pm bioethics seminars bi-weekly seminars thursday pm community service bi-weekly community service assignments thursday pm worldview course weekly lectures m0 tuesday pm mentorship bi-weekly meetings with mentors in cross-year groups saturday 12:30 – 1:30 pm mmc connect weekly mmc body time (includes community reports, worship, chapel message, and student body activities) saturday am 11-12:30 6. mentor faculty teaching in overseas medical schools, both christian and secular. 7. provide teaching resources such as textbooks, online courses, prepared lectures, videos, webinars, and be ready to do distance education teach via telemedicine and other platforms. generate and share online repositories of copyright-free academic resources. 8. explore innovative lmic-centric training partnerships with hic institutions, similar to the model of the pan-african academy of christian surgeons’ training program in graduate education in lmics. organizing for the way forward 1. most lmics currently have established government standards and requirements for starting new medical schools with which any group wishing to start a new medical school will need to comply. 2. the world federation for medical education has established guidelines, approved by the who. 9 3. it is important for christian medical schools to include a christian worldview in their curricula as much as possible. it is recommended that christian values and ideas in any curriculum be clearly identified and shared. 4. we would recommend that any short-term teaching efforts in a secular setting be done in conjunction with either a full-time expatriate working in the area or with an established medical school. this has the following benefits: a. raises the credibility of the expatriates working in that area; b. provides someone to help make arrangements and logistics for the visit; c. provides someone to help with the language in a non-english speaking setting; 149 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. d. provide someone to follow-up on contacts or relationships developed. 5. identify sites where large international institutions or universities are not already providing personnel and finances for medical schools. there is recently significant interest in global health within the secular community at all levels, so it is essential to be aware of existing efforts and thus avoid or at least minimize costly duplication of efforts. also since smaller, more remote medical schools or hospitals do not have the visibility to attract larger educational institutions from hics, they are usually more appreciative of any efforts to help them and the closer relationships that can be developed. also, newer medical schools usually have younger faculty who are more open to newer teaching methods than faculty from older, established universities. conclusion international undergraduate medical education represents a unique opportunity for cross-cultural mission and holistic development. there are many challenges but also many opportunities in the field. collaboration and networking among christians involved in the field would allow effective development of resources and solutions for fostering kingdom growth through training for equitable health care globally. hopefully, the ideas and recommendations included in this paper will stimulate favorable forward progress. references 1. association of american medical colleges. physician supply and demand through 2025: key findings [internet]. available from: https://www.aamc.org/ 2. campbell j, dussault g, buchan j, pozo-martin f, arias mg, leone c, et al. a universal truth: no health without a workforce. third global forum on human resources for health. recife, brazil. 2013. world health organization. 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[internet] available from: https://medicine.llu.edu/admissions/whyloma-linda-university (cited august 26, 2016) 6. université shalom de bunia [internet] available from: http://www.unishabunia.org/academics/medicine-2/ (cited august 26, 2016) 7. oben, t. medical school bans spark anger. [internet] university world news. 2013 november 15;296 (5) www.universityworldnews.com/article.php 8. traverso g, mcmahon gt. residency training and international medical graduates: coming to america no more. jama 2012;308(21):2193-4 http://dx.doi.org/10.1001/jama.2012.14681 9. accreditation of medical education institutions: report of a technical meeting. [internet] schæffergården, copenhagen, denmark: whowfme task force on accreditation; 2004 october 4-6. available from: www.who.int/hrh/documents/wfme_report.pdf competing interests: none declared. https://www.aamc.org/ http://www.who.int/workforcealliance/knowledge/resources/ghwa_auniversaltruthreport.pdf http://www.who.int/workforcealliance/knowledge/resources/ghwa_auniversaltruthreport.pdf http://dx.doi.org/10.1136/bmj.d7031 https://medicine.llu.edu/admissions/why-loma-linda-university https://medicine.llu.edu/admissions/why-loma-linda-university http://www.unishabunia.org/academics/medicine-2/ http://www.universityworldnews.com/article.php http://dx.doi.org/10.1001/jama.2012.14681 http://www.who.int/hrh/documents/wfme_report.pdf 150 smith, poenaru & phillips nov 2016. christian journal for global health, 3(2): 143-150. correspondence: james d smith, oregan health science university, united states. jamesd.smith@yahoo.com dan poenaru, montreal university health center, canada. dpoenaru@gmail.com j dwight phillips, mayo clinic, united states. jdwightphillips@gmail.com cite this article as: smith dj, poenaru d, phillips jd. fostering international undergraduate medical education. christian journal for global health (nov 2016), 3(2):143-150. © smith dj, poenaru d, phillips jd this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:jamesd.smith@yahoo.com mailto:dpoenaru@gmail.com mailto:jdwightphillips@gmail.com http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ original article sept 2018. christian journal for global health 5(2):29-36. a localized home-based health care delivery model for refugees in jordan salim suleimana, matthew nanceb, daniel w o’neillc a md, mrcpch, jordan b ma, phd candidate, oxford centre for mission studies, jordan c md, ma(th), assistant clinical professor of family medicine, university of connecticut school of medicine, usa abstract inter-professional teams delivering home-based care hold promise as an effective model for vulnerable populations, but examples of good practice are limited. this case study presents the initial evaluation of a contextualized application of home-based medical care initiated from the faith community in jordan toward syrian and iraqi refugees with constrained access to resources. reflexive responses to human need by local churches became the basis for homebased medical outreach. heavily dependent on volunteers, these church-based teams were selected and trained to meet specific needs, inter-professional partnerships were created through networking, and electronic medical records were deployed to facilitate communication and follow-up. the program’s standards of operation are delineated, and a program description is included that clarifies matters regarding volunteer selection, training, faith inspiration, communication, continuity, inter-professional partnerships, and addresses obstacles to care. based on subjective collective observations of team members, the advantages of the model in practice are reported along with lessons learned. these include dignity promotion, contextualization of health in the home, relationship development, inter-faith communication, inter-professional partnerships, and networking with local health professionals of other faiths and ngos. limitations of the model and potential applications in other contexts conclude the case study. keywords: refugees, home based, primary health care, jordan, churches introduction following the outbreak of the syrian war in 2011, hundreds of thousands of refugees began seeking safety in our country of jordan. at times, more than 3,000 individuals were crossing the border every day. after getting screened and receiving background checks, many were allowed to seek refuge in cities and towns across the country as “urban refugees” living in basic and often substandard rented accommodations. as of the writing of this article, there are officially 740,150 refugees in jordan, 657,628 syrian and 66,262 iraqi.1 however, by including unregistered refugees, the government estimates a total of about 1.3 million.2 jordan is a small country of around 10 million, which means that it has the second largest refugee 30 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. population in the world compared to the overall population (20%). eighty percent of refugees live below the poverty line, 51% are children, and 4% are elderly. eighty percent of refugees live in urban areas rather than organized camps. beside significant natural resource limitations and economic constraints, access to services, especially treatment for non-communicable diseases (ncds), is complicated and under-resourced, despite heroic efforts by international aid organizations that tend to prioritize communicable diseases.3 significant mental health conditions were reported in refugee children in low and middle income receiving countries.4 malnutrition was a significant problem among refugees, and anemia was high non-pregnant women and children in the za’atri refugee camp.5 half of syrian refugee households in jordan reported a family member with an ncd (hypertension, arthritis, diabetes, chronic respiratory disease), with a significant minority not receiving care, citing cost as a barrier.6 despite high levels of care-seeking, cost of health services is a large barrier to access for health equity, and care for ncds at the primary care, preventative, and self-care levels have been recommended.7,8 the primary care system of receiving countries can serve as an integral portal to the larger society through screen, manage, assist, refer, team (smart) strategies and collaboration.9 home-based primary care has been utilized for vulnerable refugee populations in the united states, and linguistic communication, cultural safety, and utilization of an inter-professional team has been associated with positive health outcomes.10 the world health organization notes: many people prefer home care to any other option. home is a place of emotional and physical associations, memories and comfort... home care promotes healing. home care allows maximum freedom for the individual, in contrast to institutions, which are regulated environments. home care is personalized — tailored to the specific needs of each individual.11 inter-professional teams delivering home based care to refugees show promise to bridge the health care gap, but more data are needed on effective models.12 urban refugees have faced many unique logistic challenges in seeking aid, which have revealed needs and opportunities for ministry by faith communities. this case study presents a homebased health care delivery model derived from a contextualized local response from the faith community in jordan. a localized aid response jordan has a small but ancient christian minority and many local churches have responded by reaching out to urban refugee families and distributing to them basic bedding, cooking, food, hygiene, medical, and school necessities. these have been funded by foreign and local donations, and the work was carried out by a large number of volunteers (local and foreign). some faith communities have focused on centralized distributions, while a few churches have focused on home visits. instead of having them go to the churches, the church went to them. even though virtually all syrian refugees are muslims, the christian volunteers have been welcomed and have, in many cases, built relationships that are now several years old. the inter-faith understanding of jesus as a healing prophet and the cultural acceptability of praying in his name was an important way to connect with people. frequently on these visits, volunteers encountered medical needs that were not being addressed due to a variety of reasons. as medical professionals, and a part of the christian church where we live, we were among those volunteers. we saw an obvious and great need for health care access and felt compelled to help with the medical needs in any way we could. starting small, visiting as many families as we could, we offered free medical exams, consults, and treatments to the refugees in their homes. we were trying to reach those families who were not able to obtain basic, affordable, humane, 31 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. and effective medical attention. throughout this crisis, governmental and non-governmental bodies such as medair, caritas, operation mercy, and oun were offering medical care to refugees, but were unable to keep up with the demand, leaving a significant gap in the number who could receive adequate care. these ngos only offered centralized care. our focus has been on cases that were untreated or families not adequately served by other resources (figure 1). figure 1. care delivery in the context of the refugees’ dwellings home-based medical outreach standards the idea of home-based medical outreach (hbmo) was born naturally as an extension to the home visits church members in several cities were already making, but it required formation through the following guiding principles: ethical standards even though the care seemed informal, volunteers were committed in writing to a high standard of christian ethics and confidentiality, and medical information was shared only with the patient’s consent. we respected the right of a patient to refuse care or seek a second opinion. informed consent we never took photos without the express permission of the patient and, generally, only did so to take a friendly snapshot with the patient portrayed at their best for honorable purposes. impartiality although an openly christian ministry, we offered our services to anyone regardless of race, religion, gender, nationality, refugee status, or political persuasion. cooperation coordination with churches and other groups working with urban refugees has been critical to reduce duplication of services and provide the most holistic care to patients. competency committed to providing a high level of quality and competent care, we did not hesitate to make referrals when a case was outside our scope of practice. qualitative outcomes the total number of patients served through hbmo was often less than centralized models of medical outreach. we believed that focusing on numbers of patients served was often counterproductive to providing impactful medical, social, and spiritual care. donors like to see numbers, 32 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. however, so we endeavored to define success in terms that demonstrated our commitment to quality holistic care and fruitful relationships. work balance being up close and personal with the living conditions of refugees could leave volunteers prone to discouragement and compassion fatigue, but we practiced healthy self-care in the community. we paid attention to having pastors and counselors on the team for the benefit of the volunteers as well as patients. most of our visits took place for one or two hours in the evenings, and volunteers could give up one or two evenings a week without disrupting their lives or being a burden to their families. this healthy pacing was critical to long-term relationships as well as the sustainability of the model. education emphasis teaching on nutrition, health-promoting behaviors, affordable and available medications, health systems, and the importance of care adherence was a way to empower the refugee population served toward better health outcomes. sustainability short-term volunteers have provided a means of building a donor base but developing long-term volunteers from the community was necessary for success. long-term volunteers who could drive and navigate the city in order to visit refugees or take patients to referral appointments were especially critical, and our team struggled the most to build this capacity. the times when our team had been reduced to only our doctors and short-term volunteers were frustrating, and our capacity was greatly reduced. trust our experience has been that the deepest spiritual impact has come after the medical case is closed but the social relationship and visits had continued. this was ideal work for non-medical volunteers who contributed towards trust-building with the refugees and medical staff. home-based medical outreach methods volunteer selection and training home-based medical outreach was heavily dependent on volunteers. our administrative structure consisted of two doctors, one being a medical director and field operator, as well as counselors with pastoral training who monitored accountability, finances, and fundraising. volunteers were assigned tasks according to their skills and availability. the tasks involved interaction with refugee families through regular visits and medical follow up. volunteers did not need to have a medical background but could be trained to perform a simple medical assessment. nurses and nurse practitioners were involved, and female volunteers participated when caring for female patients. ideally, each volunteer was assigned a few families with whom they could build a relationship through regular visits. volunteers needed to have christ-like bedside manners, maintain confidentiality, have humility, and be able to follow through with medical follow-up whenever indicated. they were expected to be able to offer spiritual care and assist the medical personnel with tasks such as medication delivery, checking blood pressure, and transport to specialists or diagnostic labs. faith inspiration the biblical pattern of caring for the foreigner and the poor is a strong motivator for volunteer action (ex 23:9; lev 19:34; num 35; heb 13:2-3). jesus’ model of care was pursued in each outreach. this consisted of entering their chaos, asking questions, listening intently to their story, holding their story, affirming their humanity, identifying and utilizing existing resources, meeting felt needs, pointing out other needs, networking in community, and holding out hope for a better future. jesus’ words in luke 10: 5 & 9 are inspiring and instructive: “when you enter a house, first say, ‘peace to this house.’... heal the sick who are there and tell them, ‘the kingdom of god has come near to you.’” 33 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. record-keeping, consent, and communication when families or individual subjects are identified, their medical and personal information was logged into a password-protected online database built specifically for field work. this allowed for review and update of patient information during visits and medical follow ups and interprovider communication. consent followed the social norms, since the social visit component of the encounter dominated. the fact that the refugees accepted team members into their homes was considered implied consent. integrated care at the community level using home-based care models with information technology support has been shown to be effective for care delivery.13 documentation is extremely important in any medical work or ministry, both for effective care coordination and effective reporting to donors. confidential patient information was only accessible to healthcare providers involved in the medical outreach. continuity of care while we often responded to acute cases, many of our patients suffered from chronic conditions (ncds). caring for chronic cases allowed frequent visits to build relationships and foster a continuity of care. most new patients came via referrals from churches or existing patients. initial assessment and triage was performed through a phone call or a quick home visit. the urgency of care needs was determined based on this assessment. we were not always able to respond to acute medical issues in the home; so in such cases, the patient was instructed to visit the nearest acute care facility. the team stepped in to help cover the cost. often times, we transported or met the patient at the appropriate facility and stayed with them when feasible until treatment was administered, following jesus’ instructions in the parable of the good samaritan in luke 10:30-37. medical and holistic care continued as long as necessary. even when, at times, spiritual care was not welcomed, medical care was offered as long as the patient had no reliable sources to continue to obtain it. medical cases were closed, and follow-up was discontinued when appropriate. the social relationship could remain active at the discretion of the volunteers and the willingness of the refugees (prov 25:17). inter-professional partnerships hbmo has thrived on fruitful partnerships with other healthcare providers and laboratories, many of whom offered their services free of charge or at a reduced fee. these valuable partnerships were created through personal connections and networking. this aspect of hbmo has been surprisingly positive. the decision to focus on building capacity for home visits rather than a fully capable clinic forced us to seek out local specialists and diagnostic labs. working with these providers gave us continual opportunity to explain who we were, how and why our church was aiding refugees. our need of the services of local providers and allied health professionals has given them opportunities to serve and give. by bringing patients to them, they could participate in our work without the time commitment or the burden of leaving their practices or offices. we were often making these types of referrals to dentists, ophthalmologists, cardiologists, surgeons, and imaging centers. we established a relationship with a local laboratory that allowed us to collect blood and urine samples during home visits and deliver to the lab for testing. we were sensitive not to overload any one community provider and diverted patients to others in order to not wear out our welcome. when we made referrals to another provider, our volunteers often accompanied the patient to help with transportation and made sure they received any medicines or medical devices that had been prescribed to them. connections with the work of other ngos partially helped fill gaps for the non-medical needs of those refugees. addressing obstacles to care hbmo also addressed other limitations urban refugees faced. going to the patients relieved them of the burden of paying for transportation. even small amounts of money needed to travel within our 34 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. cities were too much for many families. most of the aid available to refugees was in the capital city demanding even more costly travel. another significant obstacle was childcare; the prospect of waiting for hours to be seen at a clinic while caring for small children could easily deter families from having minor conditions treated. many refugee families were proud people from middle-class backgrounds, so they often seemed ashamed to publicly seek free healthcare. these obstacles to care meant that preventative or early treatment was foregone, raising the likelihood of subsequent major issues. observed advantages of home-based medical outreach through a system of face-to-face feedback and follow-up phone calls from local pastors, the team observed that this approach had many advantages. • personal medical history and case assessment were obtained in a relaxed environment within the context of a social visit. • direct assessment of the social and economic situation of the family. • contextualized observation of the interaction and behavior of children with their caregivers. • time for clinical instruction for adherence by patients with treatment plans. • face-to-face communication and trustbuilding, so that families felt safe to share their stories and struggles with us. • an excellent environment to share the love of christ and provide spiritual and emotional care following biblical patterns. • improved access to other relatives and neighbors with health issues. • socially and legally acceptable model for outreach, especially for those refugees whose access to healthcare was significantly challenged. lessons learned we found that hbmo was a medically effective and culturally appropriate health care delivery model. in the middle eastern culture, home visits are regarded as a highly-esteemed way to build relationships and connections. visiting your neighbors is much more common than in the west. it conveys warmth, acceptance, respect, and friendship. around the world, arab culture is renowned for hospitality, and we have found it important to give refugee families opportunities to practice hospitality on us. even the poorest of families can manage a cup of tea or coffee and some crackers. our volunteers were often invited to share a meal in the patient’s home. even though refugees were under tremendous stress because of their displacement and conflict-related trauma, opportunities to practice hospitality offered them honor and a sense of normalcy. in this setting, the exchange of medical care from us and hospitality from them contributed towards equalizing the power dynamic (figure 2). this was important for maintaining and restoring dignity and also for opening the doors for effective spiritual care. figure 2. objective medical assessments over tea. coordination with churches and other groups working with urban refugees was critical to reduce duplication of services and provide the most holistic care to patients. focusing on the number of patients 35 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. served was often counterproductive to providing impactful medical, social, and spiritual care. we defined success to donors in terms that demonstrated our commitment to quality holistic care. healthy pacing of volunteer hours and pastoral care to workers was critical to long-term relationships as well as the sustainability of the model. short-term, volunteer, church-based clinics were helpful motivators for connection with refugee populations, but long-term volunteers who could navigate the cities were more difficult to retain. limitations observations from this study were subjective, but consistent. outcomes measured were based on subjective feedback to the team members and was not quantified through survey forms or structured interviews of recipients or partners. this could be an approach for further research into the outcomes of this model applied. the program itself had some limitations in the numbers of families reached, longterm volunteer retention, and primary care focus (unable to offer specialized care). we could not offer chronic care for longer than several months, often due to the constant movement of refugees which undermined follow-up. there was an inability to address every need. conclusions preliminary observations of home-based medical outreaches designed to fill a significant gap in health services to displaced urban populations in jordan showed some advantages of this model, but several challenges. further studies designed to measure its health-related outcomes are warranted. these would help to further develop program design, to scale for implementation in other cities, and to apply to refugee contexts in other host countries. references 1. unhcr fact sheet. jordan. february 2018. available from: https://reliefweb.int/sites/reliefweb.int/files/resources/ factsheetjordanfebruary2018-final_0.pdf 2. mulki h [prime minister]. jordan reached its maximum capacity due to the syrian refugee crisis, says pm. petra. 5 april 2018. available from: http://www.petra.gov.jo/public_news/nws_newsdet ails.aspx?lang=2&site_id=1&newsid=296480&cati d=13 3. hassan amara a, mohamed aljunid s. noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need. global health. 2014 apr 3;10:24. https://doi.org/10.1186/1744-8603-10-24 4. reed rv, fazel m, jones l, panter-brick c, stein a. mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors. lancet. 2012;379:250–65. https://doi.org/10.1016/s0140-6736(11)60050-0 5. moazzem hossain sm, leidman e, kingori j, al harun a, bilukha oo. nutritional situation among syrian refugees hosted in iraq, jordan, and lebanon: cross sectional surveys. confl health. 2016 nov 16;10:26. https://doi.org/10.1186/s13031-016-0093-6 6. doocy s, lyles e, roberton t, akhu-zaheya l, oweis a, burnham g. prevalence and care-seeking for chronic diseases among syrian refugees in jordan. bmc public health. 2015;15:1097. http://doi.org/10.1186/s12889-015-2429-3 7. doocy s, lyles e, akhu-zaheya l, burton a, burnham g. health service access and utilization among syrian refugees in jordan. int j equity health. 2016 jul 13;15:108. https://doi.org/10.1186/s12939016-0399-4 8. doocy s, lyles e, akhu-zaheya l, oweis a, al ward n, burton a. health service utilization among syrian refugees with chronic health conditions in jordan. plos one. 2016 apr;11(4): e0150088.13. https://doi.org/10.1371/journal.pone.0150088 9. olayiwola jn, raffoul m. saving women, saving families: an ecological approach to optimizing the health of women refugees with s.m.a.r.t primary care. aims public health. 2016;3(2):357-74. https://doi.org/10.3934/publichealth.2016.2.357 10. nies ma, febles c, fanning k, tavernier ss. a conceptual model for home based primary care of older refugees. j immigrant minority health. 2018;20:485. 2018. https://doi.org/10.1007/s10903017-0610-8 https://reliefweb.int/sites/reliefweb.int/files/resources/factsheetjordanfebruary2018-final_0.pdf https://reliefweb.int/sites/reliefweb.int/files/resources/factsheetjordanfebruary2018-final_0.pdf http://www.petra.gov.jo/public_news/nws_newsdetails.aspx?lang=2&site_id=1&newsid=296480&catid=13 http://www.petra.gov.jo/public_news/nws_newsdetails.aspx?lang=2&site_id=1&newsid=296480&catid=13 http://www.petra.gov.jo/public_news/nws_newsdetails.aspx?lang=2&site_id=1&newsid=296480&catid=13 https://doi.org/10.1186/1744-8603-10-24 https://doi.org/10.1016/s0140-6736(11)60050-0 https://doi.org/10.1186/s13031-016-0093-6 https://doi.org/10.1186/s12939-016-0399-4 https://doi.org/10.1186/s12939-016-0399-4 https://doi.org/10.1371/journal.pone.0150088 https://doi.org/10.3934/publichealth.2016.2.357 https://doi.org/10.1007/s10903-017-0610-8 https://doi.org/10.1007/s10903-017-0610-8 36 suleiman, nance, o’neill sept 2018. christian journal for global health 5(2):29-36. 11. tarricone r,tsouros ad, eds. home care in europe: the solid facts. world health organization. 2008. p. vii. available from: http://www.euro.who.int/__data/assets/pdf_file/0005/ 96467/e91884.pdf 12. nies ma, lim wya, fanning k, tavanier s. importance of interprofessional healthcare for vulnerable refugee populations. j immigrant minority health.2016;18:941. https://doi.org/10.1007/s10903016-0424-0 13. petrakou a. integrated care in the daily work: coordination beyond organisational boundaries. int j integr care. 2009 jul-sep;9:e87. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2748 180/ peer reviewed: submitted 31 may 2018, accepted 15 aug 2018, published 22 sept 2018. competing interests: none declared. acknowledgements: the faithful volunteers and project donors along with our faithful lord. correspondence: salim suleiman (pseudonym), jordan. alexjo321@airpost.net cite this article as: suleiman s, nance m, o’neill dw. a localized home-based health care delivery model for refugees in jordan. christian journal for global health. sep 2018; 5(2):29-36. © suleiman s, nance m, o’neill dw. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.euro.who.int/__data/assets/pdf_file/0005/96467/e91884.pdf http://www.euro.who.int/__data/assets/pdf_file/0005/96467/e91884.pdf https://doi.org/10.1007/s10903-016-0424-0 https://doi.org/10.1007/s10903-016-0424-0 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2748180/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2748180/ mailto:alexjo321@airpost.net http://creativecommons.org/licenses/by/4.0/ original article june 2014. christian journal for global health, 1(1):26-33. calling, conflict and consecration: the testament of ida scudder of vellore reena mary george a a mbbs, md(rt), ma(cs), professor of palliative medicine, christian medical college, vellore, india abstract how does the hand of god grasp a hesitant human hand to reach out to a world that needs health and wholeness? this article describes how one night, a young ida scudder experienced a painful and life changing encounter with god. through her first person account and her personal parable, it traces the conflict, surrender, fruitfulness and breaking points that followed on a journey that led from a one-room dispensary to the christian medical college, vellore. for those who feel prompted to serve in health care, it is a testimony of the power of a vocational call, and the provision of god in the face of human inadequacy. introduction some of the foundational initiatives in christian health care had their origins not in a policy decision but in a vocational call and an act of obedience. among the pioneers who came to india were john scudder, the world’s first protestant medical missionary, clara swain, the first woman medical missionary, and mary glowrey, the world’s first physician-nun and the founder of the catholic health association of india. all three were already qualified physicians, and for all three, the call to missionary work came through a written text. john scudder was moved by a pamphlet about millions who had not heard the gospel. 1 clara swain came in response to a letter about the health needs of women in the indian zenanas. 2 mary glowrey, a practicing doctor in melbourne, read a brochure about work being done in india and became a nun in order to go out as a missionary. 3 the call of ida scudder of vellore (fig.1), however, came to a young woman who had resolved never to be a missionary or a doctor. an encounter compelled her to make a life changing decision overnight. she lived out that commitment for the next seventy years of her life. the immediacy of ida’s encounter has some parallels to the calls in christian history of abraham, moses, saul of tarsus, and francis of assisi. 4 (genesis12:1, exodus 3:1-14, acts 9:1-15). they met god in unusual circumstances, were overcome by fear and awe, but surrendered, obeyed, and were empowered to lead movements that had a lasting impact. fig. 1. ida sophia scudder 27 george june 2014. christian journal for global health, 1(1):26-33. ida scudder’s call also bears studying because there are first person accounts, spoken and written, describing the events that happened. 5,6 contemporaneous biographers and colleagues have narrated the story of her life and work. 6,7 not published, however, is ”the monk’s story,” 8 handwritten by ida scudder and accessed recently amongst her papers. this is ida’s own parable about the meaning and impact of her encounter with god. i have juxtaposed, below, ida’s description of the events of her call and “the monk’s story,” the allegory of the spiritual struggle within. 8 they are presented here not as an academic analysis but as steps in the unfolding of a vocation for those who might wonder:  does god still encounter people today?  can god work with human resistance and weakness?  is it possible for the nature of a call to change? the formation in 1870, the year ida scudder was born, clara swain, the world’s first woman medical missionary arrived in bareilly, india. many were skeptical: …the native women in india are quite shrewd enough to pin their faith to the colours of the male doctors, native or european. excepting a few strongminded european ladies in madras, and perhaps in bombay, there is not the faintest demand for female doctors… if these good and wise ladies would turn their attention to missionary enterprise, they might prove useful. but in medicine, their efforts can only result, as has been the case here, in the production of an inferior article for which there is literally no necessity or demand in india. 9 ida was born into a family where many of the men were doctors. her grandfather, john scudder, and his sons had founded the american arcot mission west of madras in south india. 10 they worked as evangelists and itinerant surgeons setting up churches, schools, seminaries, orphanages, and a few dispensaries. despite the early deaths of spouses and children, the work of the mission grew. john scudder’s son, silas scudder, left his medical practice in america to begin the mission’s first hospital in ranipet, the town of ida’s birth. it was the only hospital in the region. administrative and clinical pressures and ill health led to silas’s death at the age of 44. the next doctor who took charge of the hospital died, a short while later, of hydrophobia (rabies). 10 ida’s parents continued working in india. at the age of six, ida witnessed the ravages of a famine that left three million dead. images of dead bodies on the road and of handing out rationed food to emaciated children remained in her memory when her family went on furlough to america. ida was resentful that despite what they had endured, her parents chose to return to their work in south india. 7, 10 the rebellious teenager was offered a place in northfield seminary, a private secondary school founded by the evangelist, dwight l moody, in massachusetts. 11 happy years spent with close friends on a beautiful campus on the banks of the connecticut river confirmed ida’s conviction that america was where she belonged. she stated that she would never become a missionary or work in india. after northfield, she planned to enter wellesley college. 6,7 the contrast between the poverty and suffering ida had witnessed as a child in india, and the green, prosperous america of her student years is described at the beginning of ‘the monk’s story.’ there is a beautiful story told of a young monk. he was placed in a village at the foot of a beautiful mountain, to work. before he had been there very long he found the village was full of sickness and sorrow, sadness and death. after working there for some months the monk felt he could no longer endure it. he therefore packed his belongings and moved up to the top of the mountain with its cool sweet air. the monk daily read 28 george june 2014. christian journal for global health, 1(1):26-33. his bible and prayed and communed with god. all about him was perfect peace and joy. 8 unexpectedly, in 1890, ida was called to india for a short while to help her ailing mother. determined to return, ida sailed for india and joined her parents on the mission compound in tindivanam, south india. 7 it was there one night she received a call. the call suddenly in his trance the monk saw a figure coming up his garden path. and as he looked he said in an awed voice, ‘“it is the lord. my master. “he prostrated himself at his feet. ‘yes,’ said the master, ‘it is i. i have come for you. i have need of thee. i want you to return to the village you have left and go back and work for them. 8 in ida’s words, one night in the mission bungalow: 6 as i sat alone at my desk in my room in the little bungalow, i heard steps coming up to the verandah and looking up i saw a very tall and fine-looking brahmin gentleman. i asked him what i could do for him, and he said his little wife, a mere child, was in labor and having a very difficult time and the untrained barbers’ wives had said that they could do nothing for her, and asked if i would go and help her. i told him that i knew absolutely nothing about midwifery cases but that my father was a doctor and that when he returned from a call he would gladly come and help. the man drew himself up and said, “your father come into my caste home and take care of my wife! she had better die than have anything like that happen.” later, i took him over to my father’s study and together we pleaded with him and i told him that i would do everything in my power to help his wife, with my father if he would only let us come i would be an assistant! still, he refused. father also urged him, but he went away, apparently very unhappy because i could not help. i went to my desk very much stirred by that first encounter. after a time i heard steps again on the verandah and jumped up, hoping that the man had returned to take my father and me, but instead of seeing the brahmin gentlemen, i saw a mohammedan who had come to see me, and i was horrified to hear the same plea from him. his wife was dying, a mere child, and would i come and help? again, i said i knew nothing about midwifery cases. i took him to my father, and we both reasoned with him and i said that i would go with my father who was a doctor, and do what i could to help. a scornful answer made my heart sad. he utterly refused saying that no man outside his family had ever looked upon the face of his wife. “she had better die than have a man come into the house,” he said. again, my father and i urged him to allow us to come, but again he refused repeating that she had better die than have a strange man look upon her face; and he left. i went back to my room with my heart so burdened that i hardly knew how to overcome it. after some time of thinking and trying to get my mind back onto my book, i again heard footsteps, and, running to the door, looked out to see if the second man had come back, but again i was more than horrified to have the same plea coming from a third man, a high-caste hindu. he refused just as the others had done, and vanished in the darkness. 6 the conflict i could not sleep that night—it was too terrible. within the very touch of my hand were three young girls dying because there was no woman to help them. i spent much of the night in anguish and 29 george june 2014. christian journal for global health, 1(1):26-33. prayer. i did not want to spend my life in india. my friends were begging me to return to the joyous opportunities of a young girl in america, and i somehow felt that i could not give that up. 6 the monk said, “i cannot return. it is so beautiful here. so much sunshine and beauty and love. i feel so close to you and god here. the sin, the dirt, the foulness are so great. i cannot return to it all”, and he prostrated himself at his master’s feet. 8 i went to bed in the early morning after praying much for guidance. i think that was the first time i ever met god face to face, and all that time it seemed that he was calling me into this work. early in the morning i heard the ‘tom-tom’ beating in the village and it struck terror in my heart, for it was a death message. i sent our servant, who had come up early, to the village to find out the fate of these three women, and he came back saying that all of them had died during the night. as a funeral passed our house during the morning, it made me very unhappy. i could not bear to think of these young girls as dead. again i shut myself in my room and thought very seriously about the condition of the indian women. 6 the surrender …and after much thought and prayer, i went to my father and mother and told them that i must go home and study medicine, and come back to india to help such women. 6 the consecration the monk’s story continues: the master stooping over him, lifted him up and looking into his face said, “my son i have need of thee down there. come let us go together to the village where the need is so great. learn to love.” and the master vanished. after long prayer the monk arose. going into his little hut, he gathered up his belongings. and saying farewell to all that had been so beautiful, so lovely, he went back to the village. and he found it needed him more than it needed him before. but he gave himself utterly to serving those people who needed him so sorely.8 stages on a journey beginnings ida went to medical school in philadelphia and cornell. towards the end of her training, louisa hart, working in ranipet, pointed out the need for a hospital for women and children in vellore. efforts at fundraising were disappointing until a week before ida was to set sail, robert schell gifted the entire amount she needed to build the hospital. ida reached vellore on 1 st january 1900, starting internship by observing and assisting her father in medical work. his sudden death in april left ida bereft of father and mentor and helpless to cope. but a few weeks later, she began with the little she had: a few months of experience, a 10x12 foot room in the mission bungalow for a dispensary, the cook’s wife as an unskilled assistant, and a horse buggy to visit patients at home. small beginnings and the trust of patients led to more: two beds in the guest room, a few huts for inpatients, (fig.2) and in 1902, the forty-bed mary taber schell hospital, (fig.3) supported by the reformed church of america. 6,7 fig. 2. hospital beds on the mission compound, 1901-02 30 george june 2014. christian journal for global health, 1(1):26-33. fig. 3. mary taber schell hospital for women and children, vellore, 1902 co-workers and trainees: innovation and collaboration to meet needs as the schell hospital grew, it needed more staff. (fig. 4) a course in compounding was started in 1905. delia houghton was invited to join as nursing superintendent and start a “lower grade” nursing school. after long years of being the only doctor facing an impossible load of maternity, surgical, and general cases, ida realized that she needed to start a medical school for indian women. it was an audacious idea with one doctor, forty beds, and no classrooms. but interdenominational commitment towards a union missionary medical school for women and the support of the british government enabled her to begin the lmp (licentiate medical practitioner) course for assistant surgeons. ida selected her first batch of eighteen girls and began in rented classrooms on aug 12, 1918. in the first government exams, ida’s protégés made her proud by securing the best results in the madras presidency (also known as the madras province). 6,7 fig. 4. surgical care for women by women stability, buildings, and traditions an interdenominational fundraising drive by women in america and britain raised funds for the medical school. a teaching hospital was built by 1928, and by 1932, a beautiful residential college campus arose on the outskirts of the town. here, ida tried to capture the magic of her years in northfield; students and staff lived, studied, played, and prayed together. traditions of worship and celebration from those early years continue to enrich student life to this day. 6,7 (fig. 5) fig. 5. women medical students carry the jasmine chain on graduation day, 1932 a crisis and the inadequacy of old ways by 1937, the women’s medical school was in its twentieth year. that year brought a government ruling that the assistant surgeons course was to be abolished. schools that could not upgrade to a university degree would be closed. the ruling was intended to raise the standards of medical training, but it did not make allowance for the scarcity of human and material resources. since the early 1930s, vellore had hoped to upgrade to an mbbs course, but the economic impact of the depression prevented that. similar constraints had forced the christian medical association of india (cmai) to postpone their plans to build the first university level christian medical college for men and women in allahabad. 12,13,14 the government did not extend the deadline, and the school had to stop taking new students in 1938. the option of partnering with the cmai to create a single co-educational college in vellore was considered and put aside. (fig. 6) ida’s supporters and ida, herself, believed that would be a betrayal of the original calling to provide women doctors for women. they were confi31 george june 2014. christian journal for global health, 1(1):26-33. dent that as they had done in the past, they would again find the necessary resources. fig. 6. the question of coeducation 1938 to 1947 however, by 1941 only thirty-one students in the final year of the assistant surgeons course remained. once the student body, left the school might never open again. 10 in an effort to prevent this, the limited resources available were used to expand the preclinical teaching facilities and permission was obtained to start a premedical course. in 1941, ida scudder sailed for the usa to raise money to save the school, double the number of hospital beds, and to find twelve new professors with higher teaching qualifications. 7 god’s way: cast the net on the other side these efforts were unsuccessful. the first batch of women who had joined in 1942 for the premedical part of university mbbs course had to be sent to government hospitals in madras for clinical training, as vellore did not have the requisite number of beds, laboratories, or trained faculty. fundraising again in her seventies, weary ida meditated often on john 21, believing resources would somehow become available. “the disciples went fishing, worked all night but caught nothing sad, hopeless, tired, discouraged, well-nigh desperate. at the break of day, jesus stood on the shore. ‘throw your nets on the other side.” 15 the staff working in india urged ida to take up the cmai‘s offer to work together for co-education. 14 old allies in the usa remained opposed. 7 at this impasse, ida realized that god wanted her to go beyond her original call. the closed door to women’s education, the open door to co-education, was the signpost to the other side. a near breakdown became the breakthrough. in 1943, she assented. the christian medical association of india and vellore coordinated efforts, and recognition for clinical training for the mbbs course was obtained in 1945. in 1947, as india’s first christian mbbs college, the institution opened its doors to co-education. (fig. 7) it also started the country’s first university course in nursing. 13,14,16,17 fig. 7. the college chapel breaking and remaking these ups and downs may resonate with the experiences of many who have journeyed with god. as they obeyed, they received prompting and provision, one step at a time. threads came together transcending boundaries of time and space. the work grew. then, when things were flourishing, unexpected shattering events taught them, through breaking and remaking, that god’s ways were not their ways. (jeremiah 18:4). they were called to depend, not to be limited by past experience and boundaries, but to remain open to god’s greater purpose. the impact it was up gradation to mbbs, coeducation, and the arrival of faculty like robert cochrane, john carman, paul brand, edward gault and others from india and abroad that enabled vellore to develop postgraduate courses, higher specialties, and research. it moved from being a modest hospital for women and children to a premier teaching hospital of independent india. the hospital that had begun as a one room clinic became the first in india to perform open heart surgery, neuro32 george june 2014. christian journal for global health, 1(1):26-33. surgery, renal transplants, and bone marrow transplants. equally, it led the way in neglected areas such as leprosy work, community health, rehabilitation, and mental illness. nursing and medical schools of high repute, a hospital that sees 6000 patients a day, campuses scattered over many hundreds of acres, and alumni around the globe carry on this legacy. 18 (figs. 8, 9). ida was privileged in her lifetime to see the fruit of her obedience. her parable continues: a change came over the village. sin in time gave way to right living. the sorrow and suffering were replaced. all, all was changed. because one consecrated young man gave himself to working with the master for those who needed him. schools, churches, hospitals were organized and christ dwells among them, through his faithful loving service to his loving master. 8 ida never imagined what her first ‘yes’ would lead to. when she looked back at her journey she marveled at how god’s indwelling presence had led her, one step at a time: “i took only one step at a time, the step god showed me.” 19 the message ida’s parable ends with the commission: “our master may be preparing a place for you here in india or somewhere. the world is in need of loving workers today. may his voice come to you in a clear loving call — i have need of thee, my child.” 8 may those who hear that voice find gladness and serenity in ida’s discovery that, “when god has told you what to do, he has already told you, you can.” 8 fig. 8. the two-thousand bedded teaching hospital today fig. 9. a painting depicting the christian medical college, vellore 33 george june 2014. christian journal for global health, 1(1):26-33. references 1. waterbury jb. memoir of the rev. john scudder, m.d. thirty six years missionary in india. new york: harper and brothers publishers; 1870. 2. hoskins r. clara a swain, m.d: first medical missionary to the women of the orient. [updated november 88 2004; cited 2014 may 1]. available from http://www.gutenberg.net ebook #14017 3. glowrey, mary (1887-1957). [updated 2009; cited 2014 may 1]. in: trove. available from http://nla.gov.au/nla.party-742091 4. habig ma, editor. the testament of st francis. in: st francis of assisi, writings and early biographies: english omnibus of the sources for the life of st francis. chicago: franciscan herald press; 1983. p.1. 5. scudder i. glimpses of my life and work in india by dr ida scudder [updated 2012 aug 15; cited 2014 jan 26] available from: http://www.youtube.com/watch?v=dt4bt7rdxtc 6. jeffrey p. ida s scudder of vellore. jubilee edition, mysore: wesley press and publishing house; 1951. [narrative of the call quoted from pages 2627]. 7. wilson, dc. dr ida: passing on the torch of life. usa: friendship press; 1976. 8. scudder is. the monk’s story [handwritten, undated document], quoted with permission [ida scudder papers, collection mc 205 series 1v. schlesinger library radcliffe institute for advanced study, harvard university]. boston. 9. west c. medical women: a statement and an argument .london: j. a. churchill; 1878, p.17. 10. scudder dj. a thousand years in thy sight. the scudder association. new york: vantage press; 1984. 11. history of nmh [cited 2014 jan 26] available from:http://www.nmhschool.org/about-nmh-history 12. minutes of the meeting of the executive committee of the national christian council jan 1936. nagpur: the national christian council of india, burma and ceylon; 1936. 13. brouwer rc. the varieties of religious experience in an indian medical missionary: belle chone oliver. touchstone; may 2005; 23: 41-45. 14. georgia j. legacy and challenge: the story of dr ida b scudder. mcnaughton & gunn; 1994. 15. scudder is. notebook entry on 20 feb 1942, cmc vellore archives. 16. oliver bc. appeal for medical literature. canadian medical association journal. jul 1945; 53:78. 17. proceedings of the ninth meeting of the national christian council. nagpur: office of the national christian council; 1944. 18. home of a healing god. [updated mar 13, 2010; cited 2014 jan 28] available from : http://www.youtube.com/watch?v=hddkjk4pnwy 19. scudder is, speech in the late 1940s, soon after university recognition for mbbs was obtained, at a public meeting in tindivanam, the place where she had received her call over half a century earlier. cited by inbanathan ae in the souvenir, jubilee celebrations, aug 12, 1960, p 141. this article was peer reviewed. competing interests: none declared. correspondence: dr. reena mary george, the archives, christian medical college, vellore, india 632004. reena.vellore@gmail.com cite this article as: george, rm. calling, conflict and consecration: the testament of ida scudder of vellore. christian journal for global health (august 2014), 1(1):26-33. © george, rm this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://nla.gov.au/nla.party-742091 http://www.youtube.com/watch?v=dt4bt7rdxtc http://www.nmhschool.org/about-nmh-history http://www.youtube.com/watch?v=hddkjk4pnwy mailto:reena.vellore@gmail.com mailto:reena.vellore@gmail.com http://creativecommons.org/licenses/by/4.0/ original article nov 2016. christian journal for global health, 3(2):49-59. developing and measuring healthcare capacity and quality in burundi: lifenet international’s horizontal conversion franchise model michael f brooks a , maggie ehrenfried b a communications officer, lifenet international, united states b pt, dpt, development officer, lifenet international, united states abstract in a departure from traditional “vertical” healthcare interventions in low-resource settings that work to combat a single specific health issue, lifenet international (ln) uses a horizontal conversion franchise to develop and measure healthcare capacity and quality in primarily faith-based health centers in east africa. through a comprehensive franchise package of medical training, management training, pharmaceutical supply, and growth financing, ln is able to leverage existing resources and respond to a greater number of the obstacles preventing facilities from providing quality care. through its quality score card, ln measures improvements in quality of care within its network. this tool has measured consistent and significant improvements in quality of care following ln partnership. together, these services improve quality of care at east african primary care facilities in ways that issuespecific, “vertical” interventions cannot. introduction in 2009, a us entrepreneur and franchise ceo began researching means of improving east africa’s pharmaceutical supply chain. he and his research team, however, quickly discovered that the most important missing component in the health care delivery supply chain was further upstream at the point of diagnosis and consultation. through 3 years of continued research, trials, and pilots, the team launched lifenet international’s (ln) integrated franchise model, designed to build capacity and quality among primarily faith-based community health facilities in east africa, which provide roughly 50% of healthcare in the region and 12% in burundi. 1,2 as a model, the integrated ln franchise model was a departure from most international health interventions in burundi and the broader region of east africa. the purpose of this study is to highlight the difference between these models and inspect the impact ln’s horizontal model has had on healthcare quality in burundi. the fundamental differences between these opposing models are briefly discussed in the following definitions. definitions: vertical vs. horizontal models in the context of international development, a “vertical” approach “may be considered to be 50 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. disease-specific programs, the ‘traditional’ means by which governments, ngo’s, international bodies, and donors work in many countries, partly as a means of limiting the problems of working through under-resourced health systems.” 1 a vertical model, therefore, is one that addresses a single issue or a specific need with a single, defined response. examples include organizations working against malaria by distributing mosquito nets or overcoming lack of access to drinking water by drilling wells. promoting family planning through condom distribution is another vertical response that remains popular today. frequently found in underdeveloped countries struggling with poverty and epidemics, vertical models are easier to pursue and advance in relative autonomy from local general health systems and other government structures, which are often poorly managed, under resourced, and suffering from limited human resources. 2 for the vertical program, this has the benefit of focusing funding and avoiding complications with extensive integration of local structures. while these programs have seen success within a narrower goal framework, they can contribute to broader health issues, including the reduction of coordination with general health structures, skewing priorities from national priorities to funder priorities, diverting limited human resources from general and local health services, and creating inefficiencies through duplicate parallel operations. 3 horizontal models, in contrast, involve the broader health system of general services, including local primary care and its structures. horizontal approaches integrate a wider range of solutions each designed to respond to a particular factor within a given issue. examples of more horizontal models include anti-poverty campaigns that coordinate work with established government and private institutions, including a diverse set of responses to the various underlying factors directly linked to poverty. most ngos operate in between the theoretical definitions of vertical and horizontal models. historically, however, ngos tend towards a vertical model structure due to the complexities that increase as the number of services offered increases, in spite of the unintended consequences to the general horizontal systems. one of the most relevant unintended consequences was visible most recently in the lack of horizontal development, integration, and coordination in the response to west africa’s 2014 ebola outbreak. this insufficiency in horizontal structures has been identified as a leading cause preventing effective responses to west africa’s 2014 ebola outbreak. 4 materials and methods the model the ln franchise model was built upon three years of research on the burundi healthcare delivery system. this research identified key issues at all levels of healthcare delivery, most specifically at the level of consultation, diagnosis, and treatment. based on these findings, the team recommended a systems-level approach for strengthening the underlying weaknesses instead of working vertically on one issue. ln’s replicable, asset-light model designed for health system strengthening in response to identified weaknesses was based directly upon this recommendation. findings by the team on the ground were consistent with contemporary publications beginning to investigate health systems strengthening, vertical vs. horizontal interventions, and their impact across a wide variety of health issues. 5,6,7,8,9, 10 ln’s team identified a conversion franchise model as the best fit for strengthening healthcare systems as it provides scalable access to existing facilities and their operating structures in a way that meets needs both at the individual health centers as well as regional heath coordination needs. conversion franchises have proven successful across a wide range of for-profit business applications, from fast food to software solutions, allowing existing business to partner with a larger organization and benefit from access to centralized resources and branding. in a healthcare context, ln 51 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. is able to bring these same benefits to existing health structures in a way that has been recognized by the world health organization’s special programme for research and training in tropical diseases as an innovation selected for research and international recognition. 11 the final result in designing ln’s model was the integrated franchise model built on four program verticals: medical training, management training, pharmaceutical supply, and growth financing. ln medical training operates at the frontlines of local healthcare systems by delivering medical training directly to primary care nurses. this approach stresses knowledge transfer, behavior change, and local ownership. ln medical education experts work closely with ln’s local nurse trainers, who then train staff at partner facilities once every month. the ln curriculum is designed for the local context in alignment with the priorities of the local ministries of health, as well as the international community’s millennium development goals and post-2015 development agenda. the lesson plans cover best practices for addressing maternal, neonatal, and child health, hiv/aids, malaria, reproductive health, and more. ln’s management training program trains managerial staff at franchise partner health facilities in financial management and accounting, pharmacy and human resource management, key data analysis, and planning and budgeting. these skills help health centers avoid common stock-out problems, manage debt, and improve their financial sustainability. through ln’s pharmaceutical supply program, ln connects rural partner health centers to local and regional wholesalers, delivering medicines directly to facilities. before launching the program, ln research discovered that health center nurses were often purchasing medicines themselves, spending days at a time to travel to the capital cities by public transportation in order to buy whatever they could before returning. this cost them valuable time when they could have been providing care to patients. in addition to saving health center staffs time, ln’s supply program also dramatically decreases the occurrence of stock-outs in partner pharmacies and increases the quality and variety of the medicines they offer. in countries with non-existent or ineffective quality assurance programs for imported or locally produced pharmaceuticals, ln tests medicines using its own mini-lab, working in coordination with other distributors to create a quality assurance apparatus operated by local personnel, ensuring the quality of pharmaceuticals distributed through the ln network. filling a gap in local capital markets, ln’s growth financing loan program increases the scope of services health centers offer and the revenue they generate. by providing small to mid-sized loans to ln partners who have demonstrated good money management, ln finances projects that expand facilities’ capacity and services. partners are eligible to apply for loans once they have achieved ln’s quality standards on key financial management lessons in the management training program. ln’s “rent-to-own” program, operated under the aegis of growth financing, allows health centers to pay a small fraction of the market value of an item of medical equipment — such as an ultrasound machine or a glucometer — and rent the item from ln, eventually purchasing the item through the monthly installments. once qualified for equipment financing by achieving financial management quality benchmarks, partner health centers can select equipment from a list according to their ability to repay. because ln pairs equipment placement with ongoing medical training and check-ins, no equipment goes unused. health centers generate more revenue when they offer expanded services made possible by additional equipment, which helps them improve their financial sustainability and stability. in 2015, ln sold 53 pieces of equipment to partner health centers in burundi, generating over $16,000 in new revenue for these facilities over the course of the year. 52 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. quality score card ln measures the impact of its horizontal conversion franchise model over time through its quality score card (qsc) evaluation tool. this tool is designed to measure both medical and management quality and was developed by ln nursing, public health, and development specialists, drawing on local ministry of health standards, the usaid/smiling sun health services “quality and monitoring supervision clinic preparedness guide,” the ifc self-assessment guide for health care organizations from the joint commission international, the management sciences for health financial management assessment tool, the columbia university access project health center assessment tool, and other similar sources. 12,13,14,15,16,17 directly aligned with the ln training curriculum, the medical and management qscs measure standards set by the local ministries of health and then measure important additional items to quantify staff adherence to ln-taught best practices in healthcare delivery and management. at the beginning of ln partnership, each health facility is evaluated by a ln monitoring and evaluation specialist. these specialists are drawn from program staff in the medical and management training teams, including experienced ln trainers as well as medical and management training program managers. the baseline evaluation score serves both as a control for ln’s impact as well as a guide for the focus of the training and mentorship for each medical and management module. ln monitors the implementation of the work plan through 1-year or 2-year contracts signed with partner health facilities. contracts are signed by the ln country director, the health facility manager, and the leadership of the church or larger body to which the health facility belongs. regular training and mentorship reports from monthly site visits facilitate ln data collection. each ln medical and management trainer writes a training report on every monthly visit. this report serves to confirm that each health facility is benefiting from regular monthly trainings and is progressing through the curriculum. it also serves to highlight particular challenges to be addressed or successes to be acknowledged. at the end of each completed six-month medical and management module, health facility partners are re-evaluated with the qsc. the evaluation is conducted by one of ln’s monitoring and evaluation specialists. in order to ensure objectivity, the monitoring and evaluation specialist is never a regular trainer at the site s/he is evaluating. these scores are measured against the baseline score to measure the impact of ln intervention. with the implementation of these quality improvement and measurement tools, ln began working towards its goal to transform quality of care for underserved populations in east africa. results in 2012, ln implemented its conversion franchise model with its first cohort (group of health centers beginning partnership with ln in the same month). through 2013, ln steadily increased the number of health centers within its network (figure 1). while adding additional partnerships, ln terminated partnerships with some existing partner facilities that did not attend or otherwise participate in scheduled trainings, most noticeably in q2 2012 and q3 2013. this helped focus program interventions where facility leadership and staff were motivated and interested in leveraging the ln franchise package for improvements in quality of care. along with a growing number of partner facilities, the number of patient visits in the franchise network (figure 2) and the quality of care delivered within the network (figure 3) also grew. gains made by new cohorts followed similar patterns of growth and improvement. by the end of 2013, the network had grown from 10 to 41 franchise partners, delivering double the quality of care for over 60,000 patient visits per month. 53 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. figure 1: number of health cen ters within the ln n etwork figure 2: number of patient visits in the ln network* * the decrease in numbers after q1 2014 is due to a restructuring in patient visit data collection that reduced redundancies. health centers report information and statistics that must be sorted to ensure that one patient receiving multiple services from the health center is not counted multiple times. 54 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. figure 3: percent increase in quality of care beginning in 2014, ln implemented an updated quality score card (qsc). although similar to the original, it added multiple new levels of detail and precision. the most substantial change was the separation of management quality-related data points from the medical quality data points, creating separate medical and management qscs in order to independently monitor ln’s separate medical training and management training programs. the number of health centers within the ln franchise network in burundi continued to grow to 50 in q3 2014, before reaching 60 partner centers by the end of 2015. (figure 1) the number of patient visits within this growing network has grown consistently (figure 2). in 2014, however, ln improved the way in which patient-visits were counted, reducing redundancies for patients that received separate treatments for different conditions during the same visit. this improvement in data collection is the driver behind the decrease in patient visits numbers during 2014. since the qsc update in 2014, ln no longer measures progress by cohort. rather, ln measures progress within the ln curriculum. improvements as a percent increase remained consistent, however, across both designations of measurement (cohort vs. progress in ln curriculum). quality of care improvement has also remained consistent in both medical and management portions of the qsc (figures 4 and 5). since 2012, baseline qsc scores have been low in every area of care at all partner health centers. within the first quarters of program implementation, however, partner health centers began to show significant improvement. 55 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. figure 4: 2015 medical baseline and follow-up qscs, by module† figure 5: 2015 management baseline and follow-up qscs, by module ‡ † module 1 in the ln medical curriculum trains medical staffs in everyday tasks including sanitation, consultation basics, infection prevention, and other core elements of primary care delivery. module ii covers primary care techniques specific to maternal health ‡ module 1 in the ln management training curriculum trains management staffs in professional ethics, financial management, and pharmacy management. module ii continues with additional lessons on financial management, pharmacy management, and human resource management best practices 56 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. by comparing ln qsc score changes over time against burundi ministry of health (moh) score changes over the same time (figure 6), ln can help control for internal testing bias. here, ln’s qsc results remained extremely close to the burundi moh’s own quality evaluations over the same period. this corroborates ln measurements and reflects the heavy emphasis ln places on aligning training curriculum with moh priorities. the burundi moh quality evaluation tool is embedded into the ln qsc. roughly 50% of ln qsc metrics come from the moh quality evaluation tool. the half of the ln qsc that is drawn independently from the moh quality evaluation tool adds layers of specificity and detail that are not present in the government tool. this enables ln evaluations to track quality changes in levels of greater detail that is not possible in the moh tool. because 50% of the ln qsc corresponds directly to the moh evaluation tool, there should be a correlation between improvements at facilities when measured by both tools over similar time periods during ln intervention. divergences introduced by the dissimilar 50% in the ln qsc, differences in evaluator scoring, and other differentiating factors should introduce noticeable differences between the two measurement tools. with an average divergence of 5.63% in the preintervention measurements and 4.91% in the postintervention measurements, these divergences are smaller than expected. differences between scores diverge by as much as 19.20% pre-intervention and 14.45% post-intervention, which are closer to what was originally expected. the extreme similarity in score averages (differences of only 1.60% pre intervention and 0.63% post-intervention) are likely more attributable to coincidence than to the 50% correlation between scoring tools and methodologies. once full 2014 data becomes available, the difference between moh and ln scoring will again be comparable and allow for more accurate analysis of results. figure 6: ln qsc scores vs. burundi moh scores (2013) province pre-intervention: average moh score pre-intervention: ln qsc average score post-intervention: average moh score post-intervention: ln qsc average score buja mairie 60.61 60.37 71.55 76.58 buja rural 65.70 59.30 84.18 80.70 bururi 46.47 65.67 77.52 80.17 cibitoke 70.03 64.96 81.91 79.01 gitega 64.70 63.30 81.73 82.47 kayanza 73.46 72.15 83.78 84.47 kirundo 64.10 58.61 79.67 74.38 makamba 64.39 68.41 78.97 81.79 muramvya 54.77 51.34 74.11 59.66 muyinga 73.06 72.23 83.29 76.18 mwaro 52.76 60.76 75.65 83.00 rutana 67.81 79.97 79.01 85.39 avg 63.16 64.76 79.28 78.65 57 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. discussion ln’s horizontal model has been successful in improving quality of care within its network of primarily faith-based health centers. by integrating multiple responses to the numerous barriers to quality care, ln addresses not only the medical conditions of poor care but also the underlying factors including financial management, sustainability, and access to pharmaceuticals and equipment. this intervention style avoids the issues associated with vertical models. by training workers in the general health system instead of redistributing them according to vertical priorities, ln interventions strengthen local systems instead of weakening them. by aligning training curriculums with moh priorities, ln avoids skewing intervention priorities away from national health agendas. this also avoids contributing to poor communications and coordination with general health structures. and, by equipping management staff to improve reporting, ln improves national statistics and other records supplied by health centers to the centralized government health systems. the greatest impact factors for this horizontal approach are its comprehensive impact, its scalability, and its adaptability. by working through medical and management training, pharmaceutical supply, and financing programs, ln is able to affect change at every level of health center operations, raising the level of all aspects of health care delivery. the conversion franchise model allows quick scalability without compromising impact. with a core curriculum in place, the model is adaptable to areas with similar health systems and struggles. since launching in burundi, ln has successfully expanded its franchise to uganda and the democratic republic of the congo, making adjustments in its curriculum for each country to align with its specific health needs and moh priorities. although a horizontal model allows for the most comprehensive, wide-reaching impact at the primary care facility level, it also creates demands and challenges not present in vertical models. with the expansion of intervention areas across different specialties (e.g., medical, health management, credit and financing, import/export, and pharmaceuticals), horizontally oriented organizations like ln must incorporate specialists that ensure the correct operation of each program as well as its proper integration with the others. by maintaining a sufficiently skilled staff, however, this challenge is reduced and programs work well in coordination with each other. one major challenge upon entry for ln was communicating the model to health centers in a way that created interest and buy-in. with no offers of per-diems or other immediate financial incentives, facilities were less interested. once trainings began and the facilities saw the benefits of training and partnership, however, their hesitancy was replaced with ongoing interest and, mostly by word of mouth, they communicated their good experiences to other facilities that, in turn, became interested in ln partnership without ln having to work to “sell” or “pitch” the partnership and franchise model. ln continues to mine and evaluate data in order to measure impact and assess the effectiveness of current programs. current data suggest that ln’s integrated horizontal model is effective in improving quality of care in burundi. data from new operations in uganda and the drc will enable direct contrast and comparison between changes in quality of care from country to country, permitting new analysis for the transferability of the model across countries in the region. in burundi, and potentially across the region, the ln horizontal model is able to address diverse barriers to quality care that would not be possible to address in a vertical model. references 1. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock, f, et al. understanding the roles 58 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. the lancet. 2015;386(10005):1765-75. http://dx.doi.org/10.1016/50140-6736(15)60251-3 2. woodward d, smith rd; who. global public goods and health: concepts and issues. available from: http://www.who.int/trade/distance_learning/gpgh/gpgh1/ en/index11.html 3. elzinga g. vertical–horizontal synergy of the health workforce; who. available from: http://www.who.int/bulletin/volumes/83/4/editorial10405 /en/ 4. primary health care performance initiative [methodology note]. available from: http://www.phcperformanceinitiative.org/sites/default/fil es/phcpi methodology note_0.pdf published 2015 sept. 5. woodward d, smith rd; who. global public goods and health: concepts and issues. available from: http://www.who.int/trade/distance_learning/gpgh/gpgh1/ en/index11.html 6. knippenberg r, lawn j, darmstadt g, begkoyian g, fogstad h, walelign n, et al. systematic scaling up of neonatal care in countries. the lancet. 2005;365(9464):1087-98. http://dx.doi.org/10.1016/s0140-6736(05)74233-1 7. rosenfield a, min cj, freedman lp. making motherhood safe in developing countries. n engl j med. 2007;356(14):1395-7. http://dx.doi.org/10.1056/nejmp078026 8. béhague dp, storeng kt. collapsing the vertical– horizontal divide: an ethnographic study of evidencebased policymaking in maternal health. am j public health. 2008;98(4):644-9. http://dx.doi.org/10.2105/ajph,2007.123117 9. kieny m-p, evans db, schmetsa g, kadandalea s. health-system resilience: reflections on the ebola crisis in western africa. health-system resilience: reflections on the ebola crisis in western africa. available from: http://www.who.int/bulletin/volumes/92/12/14149278.pdf 10. who. toolkit for assessing health-system capacity for crisis management. available from: http://www.euro.who.int/__data/assets/pdf_file/0008/157 886/e96187.pdf 11. kieny m-p. ebola and health systems: now is the time for change. world health organization. 2014 dec 12. available from: http://www.who.int/mediacentre/commentaries/healthsystems-ebola/en/ 12. who. 24 healthcare delivery innovations selected for research and international recognition. 2015 june 3. available from: http://www.who.int/tdr/news/2015/25_healthcare_deliver y_innovations/en/ 13. usaid/smiling sun health services. quality & monitoring supervision clinic preparedness guide. 2010 january. 14. management sciences for health. the financial management assessment tool. 2015. 15. mango's financial management health check: how healthy is your ngo? 2005;2.0 16. access project, columbia university. questionnaire for evaluation of management capabilities in health centers. 17. international finance corporation. a self-assessment guide for health care organizations: march 2015. peer reviewed competing interests: none declared. http://dx.doi.org/10.1016/50140-6736(15)60251-3 http://www.who.int/trade/distance_learning/gpgh/gpgh1/en/index11.html http://www.who.int/trade/distance_learning/gpgh/gpgh1/en/index11.html http://www.who.int/bulletin/volumes/83/4/editorial10405/en/ http://www.who.int/bulletin/volumes/83/4/editorial10405/en/ http://www.phcperformanceinitiative.org/sites/default/files/phcpi%20methodology%20note_0.pdf http://www.phcperformanceinitiative.org/sites/default/files/phcpi%20methodology%20note_0.pdf http://www.who.int/trade/distance_learning/gpgh/gpgh1/en/index11.html http://www.who.int/trade/distance_learning/gpgh/gpgh1/en/index11.html http://dx.doi.org/10.1016/s0140-6736(05)74233-1 http://dx.doi.org/10.1056/nejmp078026 http://dx.doi.org/10.2105/ajph,2007.123117 http://www.who.int/bulletin/volumes/92/12/14-149278.pdf http://www.who.int/bulletin/volumes/92/12/14-149278.pdf http://www.euro.who.int/__data/assets/pdf_file/0008/157886/e96187.pdf http://www.euro.who.int/__data/assets/pdf_file/0008/157886/e96187.pdf http://www.who.int/mediacentre/commentaries/health-systems-ebola/en/ http://www.who.int/mediacentre/commentaries/health-systems-ebola/en/ http://www.who.int/tdr/news/2015/25_healthcare_delivery_innovations/en/ http://www.who.int/tdr/news/2015/25_healthcare_delivery_innovations/en/ 59 brooks & ehrenfried nov 2016. christian journal for global health, 3(2):49-59. correspondence: michael f brooks, lifenet international, united states. mbrooks@lninternational.org maggie ehrenfried, lifenet international, united states. mehrenfried@lninternational.org cite this article as: brooks fm, ehrenfried m. developing and measuring healthcare capacity and quality in burundi: lifenet international’s horizontal conversion franchise model. christian journal for global health (nov 2016), 3(2): 49-59. © brooks fm, ehrenfried m. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:mbrooks@lninternational.org mailto:mehrenfried@lninternational.org http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ original article nov 2018. christian journal for global health 5(3):12-22 training a christian public health workforce: a qualitative study of christian public health training programs jason paltzera a mph, phd, grand canyon university, university of wisconsin-madison population health institute, usa abstract objective: the objective of this qualitative pilot study was to identify opportunities and challenges christian public health training programs experience when it comes to equipping public health students to work within christian health mission organizations. methods: a sample of seven out of seventeen (41 percent response rate) primarily american christian public health institutions completed an online survey. thematic analysis was conducted to identify major themes in the following areas: values specific to a christian worldview, competencies focused on integrating a christian worldview, challenges to integrating a christian worldview, and training available to students interested in christian health missions. results: values focused on christ-like humility in serving god and others, discipleship, respecting human dignity in the image of god, and collaborative community partnership. more than half of the respondents identified the interrelationship between culture, religion, spirituality, and health as the primary competency integrating a christian worldview. global health was identified as the second competency followed by understanding the history and philosophy behind global health and missions. identified challenges include faith of students and faculty, limited availability of christian public health textbooks, and secularization of concepts such as poverty and development. conclusion: the holistic nature of public health is conducive to integrating a christian worldview into program content. the results show that christian public health institutions have biblical values and integrate a christian worldview in understanding the interrelationship between culture, religion, spirituality, and health primarily through the lens of global health. programs experience significant challenges to embedding a christian perspective into other content areas. opportunities for integrating competencies with a christian worldview include offering a certificate in global health/development ministry, teaching methods for engaging individuals and groups in holistic health discussions, and incorporating spiritual metrics and instruments into program evaluation courses to measure the influence of faith, hope, and discipleship alongside physical and social health metrics. key words: public health, training, christian, worldview, universities. 13 paltzer nov 2018. christian journal for global health 5(3):12-22 introduction christian health organizations, ministries, and churches leverage the discipline of public health to foster long-term improvements in community health.1,2 there is a growing recognition among donors and secular health and development organizations that faith-based organizations (fbos) and local churches are critical to achieving and sustaining global development goals.2 effective partnerships based on mutual respect and shared risk will become increasingly important as health disparities among the most vulnerable continue to grow. secular organizations and donors appreciate the reach and trust faith-based communities bring to a partnership while providing funds and technical support to expand the services faith-based communities provide.3-5 it is important for faith communities and local churches to clearly define goals based on their role in the community as spiritual leaders. faith-based organizations have the responsibility to recognize the foundation of spirituality in improving community health and integrate it into public health programs. faith and spirituality are not supplemental but integral and central elements of health. partnerships with the public sector can artificially dichotomize the holistic nature of health and well-being into separate components of the physical and spiritual. partnerships between fbos and the public sector are important as communities move to increase their capacities to improve health. benn recognizes that a critical part of these partnerships is the individuals responsible for facilitating the terms of agreement and expectations of each partner.6 he goes on to state that faith communities need to maintain their role as advocates and facilitators of inclusion in the community and not only be leveraged for their presence in the community as service providers.6 in the book, for the love of god: principles and practice of compassion in missions, steps for developing a healthy partnership with the local church are described.7 such partnerships require christian public health leaders that can effectively communicate the mission of the faith-based entity to maintain its role in the community. given this understanding, it is important for christian public health training programs to emphasize the spiritual determinants of health and to train public health practitioners to integrate these components effectively into such partnerships. o’neill commented on the gap existing between the development and faith communities.8 this translates into a gap in the public health workforce and their understanding of christian principles supporting fbos effectively in secular partnerships. to address this gap, christian public health institutions and programs will need to prepare students to have a common language that integrates public health and faith for effective communication, be accountable to the discipline of public health as well as the values of the local church, and build collaborative partnerships with the local church that prioritize the church’s perspective. three competencies and skills to address this gap include stronger evidence of the role of spiritual beliefs and faith in development; understanding the perspectives of the practitioner, church, and community; and clear communication regarding the intended goals for effective change.8 olivier also commented on the specific gap in academic programs in recognizing the importance of faith-based organizations and health centers in public health.9 she goes on to state there is a unique set of competencies required for faith-based health practitioners but limited opportunities to obtain this training.9 most public health and development practitioners learn in the field and eventually come to a recognition of integral mission and participatory holistic health programming that values the process and relationship over short-term projects and interventions. the projects and interventions are important to achieve outcomes but only when conducted on a strong foundation of community trust and cohesion often established by the religious and faith-based institutions in the community.10 these elements of development are essential if 14 paltzer nov 2018. christian journal for global health 5(3):12-22 sustainability and social justice are the long-term goals. methods the public health as mission initiative of the global che network consists of several christian public health practitioners interested in understanding the role of public health in global health mission efforts (https://www.chenetwork.org/ publichealth.php). christian public health training programs are uniquely equipped to train the next generation of public health leaders tasked with the responsibility of building effective partnerships. the purpose of this qualitative, pilot study was to understand how christian public health training programs leverage their foundation on christian beliefs and values to equip students with skills to strengthen public health ministry opportunities. a convenient sample of seventeen christian public and community health training institutions were identified through personal communication and the public health as mission initiative. a majority of the institutions (76 percent) were located in the united states and included large evangelical universities as well as smaller christian colleges. inclusion criteria included 1. a statement recognizing the institution as christian; 2. courses conducted in public or community health leading to a public health-related degree or certificate; 3. contact information available through the institution’s website or network contacts. an electronic survey (see appendix a) link was sent to one program leader (program director, lead, or faculty member) at each institution with one followup reminder email sent one week later. fourteen institutions were based in the united states, three in asia, and one in africa. the response rate was 41 percent (n=7 completed responses) with six of the institutions based in the united states. the sample represented institutions from various denominations and ranged from small colleges to large universities. the survey involved the following domains: 1. definition of public health; 2. values that integrate a christian worldview; 3. program competencies that integrate a christian worldview; 4. challenges to integrating a christian worldview; and 5. christian short-term mission or service-learning training. qualitative responses were coded and categorized by the author into themes to identify major themes in each domain. the term, christian worldview, was not specifically defined in this study but is an area of important study as a person’s worldview influences the adoption of a particular development approach and process.11 generally speaking, an individual’s worldview includes the set of beliefs and assumptions that guide one’s interaction with the physical environment and the supernatural world. a christian worldview is based on creation, the fall of mankind, the reconciliation work of christ, and mankind’s restoration with god. all content questions focused on program-level characteristics, and any contact information was provided voluntarily. results among the institutions that responded, six offered a master’s degree, three offered a doctorate, two offered a bachelor’s degree, and one offered a certificate in public health. the themes in each domain were coded by the author. in some cases, a single response included more than one theme. an institution could contribute to each theme only once. figure 1 shows the topics used in defining the term “public health” as applied in the specific programs. the top three themes focused on community (home, workplace, and the environment), health promotion, and inclusivity especially health disparities among vulnerable populations. https://www.chenetwork.org/ https://www.chenetwork.org/publichealth.php 15 paltzer nov 2018. christian journal for global health 5(3):12-22 figure 1. themes in defining public health (percent; n=7) figure 2 shows the second domain of program values that incorporate a christian worldview. in general, the values cover three broad areas of loving god and others (humbly serving god and others), identity (human dignity in the image of god), and discipleship (faith, spirituality, character based on christ). humble service, especially for the disadvantaged, was the dominant value. additional values included cultural competence leading to effective community engagement/partnership and approaching health holistically. figure 2. program values that represent a christian worldview (percent; n=7) wholeness/holistic, 28.6 policies, regulations, programs, 28.6 inclusive population health including vulnerable populations, 42.9 health promotion, 57.1 community including homes, work places, and environment., 57.1 0 10 20 30 40 50 60 percent understanding "whole" health, 14.3 cultural competence for effective community engagement/partnership, 28.6 human dignity (image of god), 42.9 faith, spirituality, character based on christ loving god, 42.9 humbly serving god by serving others, especially the disadvantaged, 85.7 0 10 20 30 40 50 60 70 80 90 percent 16 paltzer nov 2018. christian journal for global health 5(3):12-22 the third domain (figure 3) of program competencies that integrate a christian worldview gave institutions the opportunity to list five different competencies as well as corresponding assessment strategies. each institution could contribute once to each theme even if multiple statements referenced that theme. more than half (57 percent) stated that understanding the interrelationship between culture, religion, spirituality, and health was a core competency. the same percentage also stated global health practice and leadership was a core competency that integrated a christian worldview. program development and evaluation were also mentioned that integrated a christian worldview but details were not offered as to how this was done or assessed. understanding a process for collaboration and partnership and the larger geopolitical landscape were highlighted as additional competencies that integrated a christian worldview. this included understanding the history of christian missions and how early health mission efforts influenced the current landscape of public health. servant leadership and bible knowledge regarding creation, the fall, reconciliation, and restoration undergirded the final theme of christian bioethics as significant competencies that integrated a christian worldview. the respondents did not provide specific assessment strategies for these competencies and is an area for future research. figure 3. current program competencies that integrate a christian worldview (percent; n=7) the fourth domain (figure 4) identified challenges in integrating a christian worldview into the program and curriculum. institutions were able to identify up to three challenges. the first two challenges focused on the belief system of the students. weak beliefs and faith of christian bioethics, 28.6 bible knowledge and creation, 28.6 servant leadership, 28.6 geo-political landscape and policy, 42.9 collaboration and partnership, 42.9 program development and evaluation, 42.9 global health practice and leadership, 57.1 interrelationship between culture, religion, spirituality, and health, 57.1 0 10 20 30 40 50 60 percent 17 paltzer nov 2018. christian journal for global health 5(3):12-22 students, as well as non-believing students, can lead to the secularization of programs based on previous public health courses and experience. this challenge can be compounded by the overall lack of public health textbooks that integrate and appreciate a faithbased perspective of public health. the faith of faculty was also identified as a challenge. minimal understanding of the socio-geo-political definition of poverty, limited discipleship opportunities through an online modality, and competing program accreditation requirements were identified as additional challenges. figure 4. challenges to integrating a christian worldview into a public health curriculum (percent; n=7) the final domain (figure 5) asked about training requirements or opportunities offered by the institution for students interested in christian health mission service learning experiences. more than half (57 percent) of the institutions did not offer formal or specific training for the students. some offered opportunities through the internship or practicum experience, which could have included health mission models such as community health evangelism. one institution identified global health seminars offered through the university’s global health institute as training opportunities but these were not required. competing program accreditation requirements, 14.3 limtied discipleship opportunities through an online modality, 14.3 minimal understanding of the socio-geo-political components of poverty, 14.3 limited biblical knowledge of faculty, 28.6 lack of a faith-based persepctive in public health textbooks, 28.6 limited biblical knowledge of students including non-believing students, 42.9 secularization of program from prior public health classes , 42.9 0 10 20 30 40 50 percent 18 paltzer nov 2018. christian journal for global health 5(3):12-22 figure 5. training for christian short-term mission trips or service learning (percent, n=7) discussion the purpose of the qualitative study was to answer the questions, “how do christian public health programs integrate a christian worldview to prepare students for global health mission service?” and “what challenges do they face integrating a christian worldview?” developing a strong christian public health workforce that understands the importance of holistic or integral health through participatory community-church partnerships is essential to strengthen the impact of the local church in community health. whole-person health and development require an appreciation for and knowledge about the psychosocial and spiritual in addition to the physical and environmental factors influencing health and wellbeing.12 overall, the results show that the christian public health training programs sampled appreciated the emphasis on community and holistic health when it came to defining public health. however, the relatively low priority of holistic health in defining public health represents a potential gap to strengthen the emphasis on whole-person care within public health training. connecting these themes with the values highlights the importance of relationships as central for understanding poverty and health. myers states, “the nature of poverty is fundamentally relational and its cause is fundamentally spiritual.”13 the relational includes our relationship with god, self, others, and creation. the values provide the scaffolding to hang the program competencies. some of the competencies, such as program development and evaluation or understanding the geopolitical landscape, might not mention a christian worldview but integrating a christian worldview into these areas might be enhanced by adopting this definition of poverty. for example, including spiritual metrics and instruments in a program evaluation course could highlight the role of hope or other spiritual characteristics as key program components. other competencies such as the interrelationship between culture, religion, spirituality, and health or servant leadership rely on a specific christian worldview in that these require a biblical view of mankind and a belief that individuals are created with an internal desire for sustained holistic health and well-being.14 understanding the interrelationship between culture, religion, spirituality, and health also requires a discussion of a specific object of faith. relying on a false concept of spiritual or supernatural can cause harm just as a negative cultural practice can cause harm. myers discusses observations of jayakumar christian in stating, “... powerlessness is reinforced by what he calls inadequacies in worldview. writing within a hindu context, christian points to the disempowering idea of karma which teaches the poor that their current state is a just response to their former life.”13 understanding the multiple determinants of health is necessary as well as how these determinants promote health rather than hinder it. spirituality and religion tend to be recognized as important but rarely explored in a health curriculum given the diversity in beliefs and negative global health institute seminars, 14.3 internship/practicum course, 28.6 no formal or specific training, 57.1 0 10 20 30 40 50 60 percent 19 paltzer nov 2018. christian journal for global health 5(3):12-22 perceptions of “paternalistic and welfare” approaches historically used by churches.15 public health practitioners working in christian health and mission organizations play an important role in integrating the element of worldview while moving toward the centrality of the christian worldview regarding holistic health. this necessity leads to some of the challenges identified by christian public health training programs in integrating a christian worldview. public health programs within christian institutions include students from diverse beliefs. teaching on the interrelationships of culture, religion, spirituality, and health requires sensitivity and an openness to respectful dialogue while upholding the importance of the christian worldview. the public health content in many textbooks avoid discussing or even downplay the spiritual determinants of health. the strength of faith among students and faculty along with limited options for public health textbooks that teach from a christian worldview create an opportunity to strengthen the connection between the values of christian programs and public health competencies. resources such as the best practices for global health missions website (www.bpghm.org) provide a comprehensive toolbox of secular and faith-based best practices across multiple health topics to assist faculty members in integrating a christian worldview with core public health competencies. the results of the study identified specific areas for christian public health training programs to improve the integration of a christian worldview and how that worldview informed partnership development and holistic public health practice. the responses provided suggested opportunities (box 1) to strengthen the integration of the christian worldview and principles to equip students to effectively facilitate partnerships that honored the role of the faith community to holistically improve community health. box 1. opportunities for training a christian public health workforce limitations of this study included the small, convenient sample of institutions primarily based in the united states, limiting the power and generalizability of the results as they may not represent the larger population of christian public or community health training programs in the united states or globally. responses were coded by one individual leading to potential bias in the analysis. the strengths of the study included a satisfactory response rate of 41 percent with program types including certificate to doctorate programs. the survey maintained anonymity unless the respondent voluntarily shared contact information for future follow-up. 1. provide a certificate in global missions within a public health program to strengthen the biblical knowledge and application among students interested in pursuing a career in christian health ministry. 2. include spiritual metrics and instruments as viable opportunities for evaluating the role of faith and spirituality in improving community health. 3. encourage christian public health faculty and graduate students to collaborate on writing textbooks that support a faith-based approach to public health. 4. train for community engagement by modeling participatory tools for adult-based facilitation and teaching skills that are sensitive to communities with low literacy levels. 5. offer a course, workshop, or seminar on biblical concepts that support holistic health as a practice and mindset. this could also provide the opportunity for students to engage with faculty members who have experience with cross-cultural faith-based public health programs and partnerships. 6. engage christian global health practitioners to share “friendship-based” or “life-based” case studies that represent the holistic side of public health alongside formal public health services and incorporate these case studies into a student-led seminar experience. http://www.bpghm.org/ 20 paltzer nov 2018. christian journal for global health 5(3):12-22 conclusion christian public health training institutions include a christian worldview in educating public health students but primarily do so through a global health focus. the gaps identified in this study offer opportunities for strengthening the integration of a christian worldview into the curriculum of christian public health training programs. next steps could include conducting key informant interviews with public health program leaders and faculty to further identify assessment strategies for holistic health competencies throughout the program. interviews could also address how public health programs are preparing students for emerging topics such as universal healthcare from a christian perspective. future research should investigate needs from global faith-based health and mission organizations in their capacity to employ public health practitioners as ministry workers and leaders thereby increasing the demand for such specialized training. there is an opportunity for christian public health training programs and health organizations to identify competencies that equip students to integrate the spiritual determinants of health into holistic public health practice. balancing a faith-based health organization or a local church’s evangelical mission with christ-like compassion for people in the community is essential. christian public health training programs are in a unique position to strengthen this mission workforce and provide professional development for those currently in the field in order to effectively initiate whole-person care and community health services. references 1. bopp m, fallon ea. health and wellness programming in faith-based organizations: a description of a nationwide sample. health promot pract. 2013;14(1):122-31. https://doi.org/10.1177/1524839912446478. 2. ochillo ma, van teijlingen e, hand m. influence of faith-based organizations on hiv prevention strategies: a systematic review. afr health sci. 2017;17(3):753-61. https://doi.org/10.4314/ahs.v17i3.18 3. schmid b, thomas e, olivier j, cochrane jr. the contribution of religious entities to health in subsaharan africa. study commissioned by b & m gates foundation. may 2008. unpublished report. arhap. available from: https://s3.amazonaws.com/berkleycenter/08arhapgatescontributionreligioussubsa haranafrica.pdf 4. whyle e, olivier j. models of engagement between the state and the faith sector in sub-saharan africa — a systematic review. dev pract. 2017;27(5):68497.https://doi.org/10.1080/09614524.2017.1327030. 5. widmer m, betran ap, merialdi m, requejo j, karpf t. the role of faith-based organizations in maternal and newborn health care in africa. obstet gynecol int j. 2011;114:218-22. https://doi.org/10.1016/j.ijgo.2011.03.015 6. benn c. guest introduction: faith and health in development contexts. dev pract. 2017; 27(5):5759. https://doi.org/10.1080/09614524.2017.1330875. 7. paltzer j. the local church and faith-based organizations. in: ireland j, editor. for the love of god: principles and practices of compassion in missions. eugene, or: wipf & stock; 2017. p. 23043. 8. o’neill dw. what works? evidence on the role of faith in poverty reduction. christ j global heal. mar 2017;4(1):55-9. https://doi.org/10.15566/cjgh.v4i1.158 9. olivier j. guest editor conclusion: research agendasetting for faith and health in development — where to now? dev pract. 2017;27(5):775-81. https://doi.org/10.1080/09614524.2017.1332164. 10. rivera jd, nickels ae. social capital, community resilience, and faith-based organizations in disaster recovery: a case study of mary queen in vietnam catholic church. risk, hazards, crisis pub policy. 2014; 5(2):178-211. https://doi.org/10.1002/rhc3.12050 11. beddoe r, constanza r, farley j, garza e, kent j, kubiszewski i, et al. overcoming systemic roadblocks to sustainability: the evolutionary redesign of worldviews, institutions, and technologies. pnas. 2009;106(8):2483-89. https://doi.org/10.1073/pnas.0812570106 https://doi.org/10.1177/1524839912446478 https://doi.org/10.4314/ahs.v17i3.18 https://s3.amazonaws.com/berkley-center/08arhapgatescontributionreligioussubsaharanafrica.pdf https://s3.amazonaws.com/berkley-center/08arhapgatescontributionreligioussubsaharanafrica.pdf https://s3.amazonaws.com/berkley-center/08arhapgatescontributionreligioussubsaharanafrica.pdf https://doi.org/10.1080/09614524.2017.1327030 https://doi.org/10.1016/j.ijgo.2011.03.015 https://doi.org/10.1080/09614524.2017.1330875 https://doi.org/10.15566/cjgh.v4i1.158 https://doi.org/10.1080/09614524.2017.1332164 https://doi.org/10.1002/rhc3.12050 21 paltzer nov 2018. christian journal for global health 5(3):12-22 12. long kng, paterson g, bhattacharji s. wholeperson health and development: two south indian initiatives. dev pract. 2017;27(5):760-5. https://doi.org/10.1080/09614524.2017.1329401. 13. myers bl. walking with the poor: principles and practice of transformational development. new york: orbis. 2011. p. 15. 14. motz a. transforming worldviews for effective community development. william carey internat devel j. 2014;3(1). available from: http://www.wciujournal.org/journal/volume-3-issue1-transformational-development-part-2 15. james r. handle with care: engaging with faithbased organizations in development. dev pract. 2011;21(1):109-17. https://doi.org/10.1080/09614524.2011.530231 peer reviewed: submitted 20 june 2018, accepted 21 aug 2018, published 8 nov 2018 competing interests: none declared. acknowledgments: thanks to the gcn public health as mission members for providing their feedback and helpful critique of the results. correspondence: jason paltzer, grand canyon university, university of wisconsin-madison population health institute. jpaltzer1@gmail.com cite this article as: paltzer j. training a christian public health workforce: a qualitative study of christian public health training programs. christian journal for global health. nov 2018; 5(3):12-22 https://doi.org/10.15566/cjgh.v5i3.228 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1080/09614524.2017.1329401 http://www.wciujournal.org/journal/volume-3-issue-1-transformational-development-part-2 http://www.wciujournal.org/journal/volume-3-issue-1-transformational-development-part-2 https://doi.org/10.1080/09614524.2011.530231 mailto:jpaltzer1@gmail.com https://doi.org/10.15566/cjgh.v5i3.228 http://creativecommons.org/licenses/by/4.0/ 22 paltzer nov 2018. christian journal for global health 5(3):12-22 appendix a public health as mission – a survey to measure christian characteristics and competencies within public christian health training programs thank you for taking time to complete the survey regarding unique characteristics and competencies of christian public health training programs. the purpose of this survey is to create a resource to support the development of public health competencies that integrate a christian worldview and emphasize the role of public health in christian missions, outreach, and evangelism. your responses will remain confidential and results will be aggregated and compiled into a final report for dissemination. by volunteering to complete this survey, you are providing your consent to having your information included in the aggregated results. you can stop the survey at any time. if you have questions regarding any aspect of the survey, contact dr. jason paltzer at jason.paltzer@gcu.edu. thank you in advance for contributing to this important movement in building on the strengths of public health to advance global health missions and ministry for god’s kingdom. dr. jason paltzer 1. type of program a. certificate b. diploma c. bachelors d. masters e. doctorate f. other 2. definition: based on your experience and primary discipline, what is public health/community health? 3. describe the values of your program and how they integrate a christian perspective or worldview. (include your mission statement if appropriate.) 4. describe up to five competencies in your program that integrate a christian worldview. (is the competency assessed with an assignment? which course contains this competency?) 5. describe specific courses that have christian missions as the primary topic or focus area. 6. describe key challenges in integrating a christian worldview into your public health training program. 7. how many hours of training do you provide to students in preparation for going on short-term health mission trips? 8. if you would be interested in participating in a network to work with christian health field staff requesting support to evaluate their programs through a holistic christian perspective, please provide your name and contact information: mailto:jason.paltzer@gcu.edu editorial nov 2017. christian journal for global health 4(3) addressing palliative care in low-and middle-income countries this is the ninth issue of the christian journal for global health and features responses to our call for papers relating to christians and the global palliative care movement. this is an auspicious year for palliative care, being the 50 th anniversary of the establishment of st. christopher’s hospice in london by dame cicely saunders. then, in september, the comprehensive report of the lancet commission of palliative care was released. this 64-page guide includes a section that outlines the huge inequality in access to palliative care and appropriate pain relief in lmics compared to hics. interestingly the commission report also outlines the importance of clergy and fbos in palliative care but then concludes, perhaps unsatisfactorily, that little is known about their involvement and more research is required. accordingly, the lancet findings speak to the niche for this edition of the cjgh which focuses on the christian response to palliative care in lmic settings (p44). 1 with an estimated 21.2 billion severe healthrelated suffering days per year globally, 80% of which occur in lmics, the opportunities to serve this neglected disease burden are great. christians have an honorable history of contributing to the compassionate care of the dying in the less developed areas of the world as epitomized by saint theresa’s work in kolkata. in that tradition, five submissions in this issue describe how palliative care is being carried forward in three continents. eileen o’shea et al describe a faith-centered effort to develop leadership in palliative care nursing at fairfield university in connecticut, usa. clearly nurses are at the center of the delivery of palliative care and through the kanarek center for palliative care nursing education students experience a core curriculum steeped in christian ethics, communication, philosophy, theology, humanities, math, and science. daniel munday and ruth powys reflect on the work of christian missions in nepal in supporting palliative care and the particular challenges of cultural sensitivity, rural residence, the cost of end-of-life care, and changes in family life. eleanor foster introduces a participatory community-based approach which has been integrated with palliative care service in kenya. one issue that surfaces in the care of the dying is resuscitation. not many hospitals in lmics are equipped to offer intensive cardiac resuscitation, but those that begin to do so may face unique challenges. in his submission, death in a mission hospital, james richie gives an account of what initiating a program of advanced cardiac resuscitation turned out to entail for a rural kenyan mission hospital. its leaders were moved to define and educate their staff on a christian understanding of death and advanced directives. this process, of course, brings up the need to understand local customs and beliefs regarding death. in a related guest editorial ian campbell muses on what an understanding of local culture can mean in a series of probing and challenging questions that are relevant not just to dying but to the communication of the gospel more broadly. reena george also offers a poetic reflection on death and communion. even when a particular issue centers around a theme like palliative care or medical education, the editors continue to welcome submissions on a variety of subjects. although faith-based efforts in healthcare in lmics have a long and venerable history, there is a general sense that these efforts have not been sufficiently acknowledged or credited by governments and world bodies. in an effort to provide a quantitative estimate of fbo contributhttp://journal.cjgh.org/index.php/cjgh/article/view/192 http://journal.cjgh.org/index.php/cjgh/article/view/194 http://journal.cjgh.org/index.php/cjgh/article/view/194 http://journal.cjgh.org/index.php/cjgh/article/view/189 http://journal.cjgh.org/index.php/cjgh/article/view/199 http://journal.cjgh.org/index.php/cjgh/article/view/195 2 nov 2017. christian journal for global health 4(3) ions, alfredo fort analyzes publicly available databases from the health care sector in kenya. fbos were responsible for somewhat less overall health presence than expected, but scored high in most measures of quality by international development standards. sustaining a missionary presence in lmic, of course, requires people, particularly long-term local and expatriate staff. john mcvay, christopher place, and david stevens describe the results of two surveys of would-be or current cross-cultural medical missionaries to ascertain factors facilitating their stays on the field and/or obstacles to their going in the first place. in particular, mentorship, teamwork, and fellowship were found to be important, which has relevance for recruitment and retention. the editors are pleased to publish a delightful essay on anatomy lessons by professor reena george and shefali mathew, which highlights the way god speaks through creation (ps 19:1-4) if we would listen intently to the design of the human body. helen fernandes and her colleagues have studied inclusion of people with mental illness (for which they prefer the term psychosocial disability) in three lmic countries: india, nepal and afghanistan. they highlight the roles of community and government in improving access and provision for these individuals. also, on the subject of mental illness, daniel o’neill has reviewed a new book on an increasingly major global non-communicable disease: dementia, which shows how christian principles and practices contribute to dignity, meaning, and quality personal care giving. our july 2017 issue was focused on family planning, but not all the ethical issues and controversies were able to be expressed there. monique chireau wubbenhorst and jeffery wubbenhorst contribute a provocative essay on whether evangelical christian organizations should support international family planning. using a historical, public health, obstetrical, and theological framework, they urge caution to avoid a “contraceptive mentality” which can be influenced by secular family planning organizations and promoters which almost always consider elective abortion an important part of meeting global health and development goals. not everyone will agree with their argument, that contraception and abortion are inextricably linked. on the other hand, the authors’ well thought out suggestions and principles for christian involvement in family planning should be considered. paige cunningham and michael sleasman from the center for bioethics and human dignity weigh into the ethical considerations for promotion of family planning in developing countries. references 1. knaul fm, farmer pe, krakauer el, et al. alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the lancet commission report. 2017 oct 13. http://dx.doi.org/10.1016/s0140-6736(17)32513-8 the full palliative care commission available from: http://www.thelancet.com/commissions/palliative-care http://journal.cjgh.org/index.php/cjgh/article/view/191 http://journal.cjgh.org/index.php/cjgh/article/view/178 http://journal.cjgh.org/index.php/cjgh/issue/view/17 http://journal.cjgh.org/index.php/cjgh/issue/view/17 http://journal.cjgh.org/index.php/cjgh/article/view/172 http://journal.cjgh.org/index.php/cjgh/article/view/200 http://journal.cjgh.org/index.php/cjgh/article/view/184 http://journal.cjgh.org/index.php/cjgh/article/view/184 http://dx.doi.org/10.1016/s0140-6736(17)32513-8 http://www.thelancet.com/commissions/palliative-care original article nov 2016. christian journal for global health, 3(2): 18-26. evaluation of the effectiveness of a community health worker training course in india nicole butcher a , adeline sitther b , jachin velavan c , elizabeth john d , mary chandra thomas e , nathan grills f a bsc. miph, research assistant, the nossal institute for global health, australia b mbbs, clhtc course coordinator, distance education department, christian medical college, vellore, india c mbbs, dnb (family medicine), mrcgp(int), pgdde, coordinator, department of distance education, christian medical college, vellore, india d m.sc (nsg), masters in dist edu (made), senior nurse educator, distance education department, christian medical college, vellore, india e mbbs, mph, external faculty, distance education department, christian medical college, vellore, india f public health physician (fafphm), senior researcher, the nossal institute for global health, australia abstract community health workers (chws) have long played a key role in delivering healthcare in rural and remote populations, through primary care, prevention, and education. numerous mechanisms of training and supporting chws have been implemented, and the world health organization (who) has outlined recommendations for the programmatic and financial aspects of chw programs. this study evaluated the outcomes of a chw training program in india whereby community development workers from faith-based organisations have been trained since 2011 to extend health promotion, education, and basic services to rural, remote, and poor communities across the country. triangulation of quantitative and qualitative data and course information was conducted, and analysis pointed to the effectiveness of the trainees in their respective work locations. outcomes were noted in these areas: health promotion (trainees had gained skills and confidence to implement health promotion interventions); first aid and primary care (graduates were treating common conditions in the community); beneficiary diversity (rural and poor beneficiaries were frequently cited as well as trainees and their families); and, spiritual health (the nurture of person was an important part of conducting chw activities). the consistency of the data across these areas suggests that the training course is effective in its delivery, its contribution to the expansion of healthcare coverage, and its potential for impact across india. 19 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. introduction from alma-ata 1 to the present universal health coverage paradigm, 2 community health workers (chws) have consistently played a key role in pursuing “health for all,” particularly for rural and disadvantaged communities. known in various contexts by a host of names — community health volunteer, lay leader, physician assistant, multipurpose health worker, or other — chws are typically members of their community who provide a “reasonable level of healthcare to underserved populations.” 3 models of training, supervision, and development of chws have varied over time and differ between contexts. irrespective of the context, the quality of training largely determines the quality and effectiveness of the particular chw program. as such, multiple models of training have been developed to promote effective chws and programs. 3-6 india has a poor record of ensuring access to affordable services for poor and geographically isolated populations. 7 with a population of 1.34 billion, 8 and 67% living in rural areas, 9 a model of disseminated chws is essential to provide accessible healthcare. realising this, in 2008, the national health mission of india capitalised on the existing chw model in conceiving of and implementing the accredited social health activists (asha) program. 7 these governmentsupported community health workers have helped make progress towards improving health coverage in india, though non-government health and development workers help bolster the government systems, particularly in rural and remote areas. from 2011 to 2014, the christian medical college of vellore conducted a needs assessment among 770 community lay leaders in rural and remote locations across india and analysed 100 of them by regional randomisation. it assessed health indicators in the lay leaders’ workplaces, including proximity of health facilities, availability of doctors, health-seeking behaviours in the community, accessibility of maternal health services, maternal mortality, vaccination, and payment mechanisms. the results quickly established grounds for training respondent candidates to become community health workers, to address the poor health indicators, and thus, the community lay leaders health training certificate (clhtc) course was designed and launched in 2011. taking an intentionally holistic approach to health and wellbeing —, i.e., addressing the spiritual, emotional, and social, as well as the physical — the course seeks to enhance efforts to respond to the high burden of largely preventable and often easily treatable disease. trainees are church leaders, staff of non-government/faith-based organisations (ngo/fbo), and other volunteers serving rural and underserved areas. they receive the necessary knowledge, skills, and attitudes to serve additionally as basic community health workers. eligibility criteria for trainees are as follows: (1) twelfth standard equivalent education level or completion of a two-year theological degree, (2) commitment to serve people in the remote areas, and (3) residence in remote areas where access to and quality of medical facilities are poor. master trainers are cmc nursing staff. regional trainers are mission hospital nurses. now in its fifth year of operation, the course trains over two hundred lay leaders each year, equipping each of them to serve around ten villages and three village schools. their role is to provide basic health care to villages, to conduct school health programs, and to share their knowledge and skills with those in the villages. this study aims to evaluate the early effectiveness of the clhtc training program in equipping “lay leaders” to serve — in addition to their ongoing work — as chws in india inherently supplement the work of existing/other chws. the study assesses the ways in which course graduates contribute to a sustainable and trained community health workforce serving rural and poor communities. 20 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. materials and methods an evaluation of the clhtc course was conducted by means of triangulating (1) a quantitative survey of 269 graduates from the 2014 and 2015 cohorts, (2) course data on numbers completing the course, and (3) qualitative questioning on the course effectiveness. there was a 78% survey response rate amongst the 344 trainees who attended the graduation/refresher training, representing 38% of all trainees who have so far completed the course. the survey of course graduates was carried out at the graduation and refresher events at cmc vellore in south india and at kacchwa hospital in north india. trainers at cmc vellore designed the survey; the questionnaire had 29 questions and was issued to participants present at the refresher training. each question was projected on a powerpoint slide and explained by the cmc vellore facilitator. participants responded in handwriting on individual paper response forms. thematic analysis, corroborated by two researchers, was undertaken on the qualitative data to arrive at themes regarding the impact of the course on trainees and their communities. simple descriptive analysis was undertaken on the quantitative survey data to supplement the qualitative data. ethics approval was not required under the common rule, as this was an evaluation of an existing program and de-identified survey data was being gathered. results course structure and completion numbers completion of the course entailed attendance three times at one of 23 training sites for 22 days and studying ten lessons that contained several modules each (figure 1). between contact programs, participants had course work to complete in their normal work setting. a total of 708 candidates have completed the course across 23 training centres (table 1). figure 1. clhtc contact program outline contact program 1 contact program 2 contact program 3  basic concepts of health and primary care (6 modules)  communication & knowing your body (4 modules)  a healthy home & community (6 modules)  common illnesses – part 1 (4 modules)  common illnesses – part 2 – and screening (9+1 modules)  first aid (5 modules)  health of the mother & child (6 modules)  common illnesses – part 3 (9 modules)  chronic illnesses (4 modules)  caring for the individual & community (8 modules) table 1. clhtc graduates from 2012 to 2015 year of completion graduates training centres 2012 112 10 centres 2013 178 15 centres 2014 163 19 centres 2015 255 23 centres total 708 23 centres 21 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. the graduates surveyed were working in 27 states and territories around india, plus nepal (1 respondent) and myanmar (2) (figure 2). the working locations of five respondents were unknown (“unk”). figure 2. geographic distribution of respondents every two years, a refresher course is conducted over two days at cmc vellore and kacchwa hospital. attendance is optional and on-site expenses are covered (food, accommodation). the cmc vellore clhtc records show that around three in four graduates have attended the two events since inauguration. respondent demographics the survey respondents work across 27 states in india, except the two working in myanmar and one in nepal. they had an average age of 35 years, ranging between 18 and 58 years. two-thirds (65%) were male, two-thirds (65%) were full-time ministry workers, and the remainder were of various professions and occupations, including among others teaching or working with children. less than 10% (n=20) had received prior health or medical training. course outcomes thematic analysis of the qualitative responses concerning how completion of the course had affected the ability of trainees to conduct health assessments or provide health care and connect with their community revealed four main outcome categories. the quantitative data supported the themes and sub-themes presented below (with the exception of spiritual health) and have been integrated into the following presentation of the thematic data analysis. 1. trainees gain skills and confidence to provide health promotion interventions first, the interviews and surveys revealed that trainees had been equipped to undertake prevention and health promotion and, by extension, raise awareness and prevent diseases. nearly all (96%) of the respondents said that after the training they “understood the importance of health communication and the ways to communicate health messages.” over half the respondents (58%) reported “doing preventive work” more than once per month, and one-quarter on a once-monthly basis. particular areas where prevention and promotion activities were reported as being undertaken were women’s health and ncds. 1 3 4 27 14 1 1 12 2 1 1 20 1 5 24 2 2 4 1 31 2 1 2 15 3 5 5 34 19 25 0 5 10 15 20 25 30 35 40 a n d h ra p ra d e sh a ru n a ch a l p ra d e sh a ss a m b ih a r c h h a tt is g a rh d a d ra & n a g a r h a ve li d e lh i g u ja ra t h a ry a n a h im a ch a l p ra d e sh ja m m u & k a sh m ir jh a rk h a n d k e ra la m a d h y a p ra d e sh m a h a ra sh tr a m iz o ra m m y a n m a r n a g a la n d n e p a l o d is h a p u n ja b r a ja st h a n s ik k im t a m il n a d u t e la n g a n a t ri p u ra u n k u tt a r p ra d e sh u tt a ra k h a n d w e st b e n g a l 22 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. concerning health education in the villages where they served, respondents s163 and n13 said, recently i was able to teach 200-250 women and girls about the care of pregnancy, puberty care, marriage, self-examination. everyone got use of it even experienced women who came from hyderabad. (s163) after this course i explained to the people in my village the various ways in which diseases spread and how we can prevent them . . . [w]e used to get a lot of diseases in the village. now we have understood the reasons for the same and are able to prevent them. (n13) the trainees also reported being involved in various screening programs and, thus, promoting early detection, referral, and treatment of diseases such as diabetes. this was evident in individual cases, in workplaces, and community groups: we found a pregnant woman to be anaemic while visiting a village. we gave her health education about pregnancy. she delivered the baby safely. (s2) as we are doing children ministry, now i can do screening for all the children who are coming for the children’s camp. now we can teach to our [children] whatever i learnt in this training. (s165) since malto people live in the hills, they don’t get medical help easily because of the hospital distance. once when checked, more than 70% of the people were affected with anaemia. i gave health education on diet — green leaves, vegetables, nuts, and peas. after two months, when we checked again, there was a good improvement in them. (s-unk-1) 2. teaching diagnostic skills enables chws to provide needed treatment second, the course has equipped the trainees to respond to a variety of illnesses through first aid, making clinical diagnoses of and managing certain common simple illnesses, and making appropriate referrals. nearly all (97%) of trainees reported being either confident or very confident to be able to carry out healthcare tasks such as checking blood pressure and administering first aid. respondents n47, s118 and n12 commented: i help more people by these tools. one time, someone got bitten by a snake. then i took him to [the] doctors and saved his life. (n47) a boy met with an accident and was bleeding profusely. i placed his leg in a higher position and pressed it, thereby preventing more loss of blood. (s118) this training has been very useful in my ministry. diabetes is a disease very prevalent in my place of work. out of ten people that i checked, three people were suspected to have diabetes, and i referred them to herbertpur hospital. now they are undergoing treatment for the same. (n12) in line with trainees’ responses to illness and disease, tuberculosis and diarrhoea were raised repeatedly in stories of trainees having intervened and made a difference in their communities. respondent n2 reports about a student who got infected with tb, saying, “he became so discouraged to even tell his parents. i helped him get dots treatment fully. now [he’s] fully healed.” by educating his community about diarrhoea, respondent s12 saw pleasing results in one family’s life: i taught about diarrhoea. how to prevent and make ors. our believers are using ors so now they [are] alert. [for] two years one child had diarrhoea. [for] two days he could not able to walk. his mother prepared ors and gave [it to him]. then he got up and started to play. respondent n67 has been able to make a dramatic difference in the life of one woman who had been suffering from diarrhoea several times monthly for the past seven to eight years. he/she taught her household about water safety: i went to their house to find out the issue and realised that they used to drink water from a vessel in which they dipped their tumblers with dirty hands to take water. i taught them that it is wrong. from then, the woman has stopped having diarrhoea. (n67) 23 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. most respondents (89%) reported strong agreement with the statement, “the training on practical skills and other sessions were beneficial for our actual role in the field,” and many were enthused by the outcomes they experienced personally through application of their new knowledge and skills. respondent s95 testified: it is very helpful to me. once i recognised a patient who had rheumatic fever. when he went to the doctor, the doctor declared he is a patient of rheumatic fever. then doctor started treatment and slowly that person got well. it was very exciting to me. (s95) concerning medication, around two-thirds (69%) of respondents give medicines “sometimes,” and equal parts of the remaining third do so never or often. a number of the participants added comments about giving medicines to those in their villages (according to the instructed protocols). 3. clhtc reaches a diversity of beneficiaries, in particular the rural and poor third, respondents reported how clhtc was benefiting their own families, churches and communities, and, in particular, populations in rural and disadvantaged areas. two-thirds (69%) of respondents apply their knowledge and skills in an opportunistic manner, one-third (33%) in their church, and around half (53%) at organised health promotion events. a focus on helping the poor and marginalised was evident through the qualitative responses: i live in a very poor area so this training is very helpful for me and my community. i used [it] for awareness programs. (s28) treated and prayed for kalpna who was ill and belonged to a poor family. (s3) abundantly helped in my ministries. especially our rural and semi-rural areas where [there is] no medical opportunity. (s42) . . . [i] help the people working in a remote area. it [clhtc] helps me to teach them about clean environment, making toilet for the people. (s59) we stay in a remote area with many tribals. . . in my field, many are tb and pneumonia patients. we visit them and find symptoms and take them to medical (services). also we find skin problems. we advise them and give some medicine. (s75) most (97%) respondents said that they are either confident or very confident to teach village health volunteers in their area. several trainees explained how they are playing an active role in knowledge and skills multiplication and using a community development approach: taught health education with practical lessons (e.g., ors) to our home (hostel) children and they in turn teach their families. (n2) in the place where we work there were a lot of deaths. we sat together with the community and came to the conclusion that it was due to the drinking of liquor. we taught the villagers the ill effects of drinking [alcohol] and now slowly people are giving up the habit and are happy. (n7) 4. spiritual health is an important component of healthcare finally, most respondents mentioned the importance of the spiritual aspect of the health work they carried out. in part, this relates to improved relationships: 88% of graduates have gained increased acceptance in their workplaces: clhtc helped me build relationships with my family, village and society and thereby encouraged people and took the church forward. it help me to communicate with people easily. (s70) there were families in the village who would not listen or invite us but now they are inviting and listening and learning. (n9) it also refers to the avenue graduates have gained to minister to people’s spiritual needs as part of treating their physical condition: i am the pastor of a church. whenever i visit believers, if they have any headache, viral fever, [or] body pain, i give them some medicines and pray to god for their healing. not only among the believers, but also with non-believers i do give and have been praying for them. (n36) 24 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. in addition, the trained workers help counter mysticism and medical illiteracy through educating villagers: before i joined the course i used to only teach from the bible. i didn’t have any information about the diseases and used to say that it’s from the devil, pray for the disease and send the patient away. but now after i’ve done the training i can examine the patient and teach him/her about the disease and treat whatever is possible. (n11) discussion respondents were virtually unanimous in their testament to the effectiveness of the course, affirming that clhtc benefited their knowledge, skills, and confidence levels. it had moreover caused the strengthening of relationships between graduates and their communities, an observation that corroborates who’s statement that chws “can go beyond the provision of care and foster community-based action.” 2 the results also showed evidence of improveing graduates’ own health and that of their families. although trainees were not the intended direct beneficiaries, it is appropriate and advantageous for families working in rural and remote areas with little access to healthcare. that is, they need to be able to maintain their health, self-diagnose, and know when to seek further medical attention. this course might contribute incidentally, therefore, to the longevity of these workers staying in rural areas. it is noted that cmc vellore does not deliver this course in order to establish a chw program, per se, but to produce health worker graduates for remote locations across india. as such, this isolated investment in chws may not optimise synergies of chw programs across india as per the who’s recommendations, 2 and some of the operational elements of a chw program are lacking, 5 e.g., individual performance evaluation, and information management. however, the “hub and spokes” model of the course — whereby cmc links clhtc graduates to the local hospital/training site — allows for a certain degree of support and monitoring. also, course graduates have reported in both quantitative and qualitative responses that they make referrals to medical services, through which the treating practitioners can partially gauge the quality of first-aid treatment and response. with respect to information management and monitoring of outcomes, it would be valuable to repeat the study that was conducted as a needs analysis to observe changes to indicators that were reported when training was established. some indicators of referrals and drug administration (and other, including spiritual) could be incorporated to provide additional insight into the impact of graduates serving as chws. for example, a validated and standardised survey could be completed by the trainees (or a representative sample) at enrolment (time=1), at completion of the course (time=2), and at a specified period after completion of the course (time =3). indeed, as the number of trainees increases and the course expands, there is a growing need for systematised and comparable data collection from the trainers, trainees, and field sites. this is necessary to facilitate improvements to the course as well as gather quantitative measures of the impact of the course on health indicators. concerning the training curriculum, who stresses the importance of developing trainee competencies, such that the trainee graduates with experience in a blend of promotive, preventive, therapeutic, and rehabilitative services. 4 the data gathered here suggest that the clhtc course has achieved this mix in the training and has effectively equipped workers with promotive, preventive, and therapeutic community health skills. it should be considered if this training might be relevant for other similar lowand middle-income settings. to this end, the trainees from myanmar and nepal have already successfully completed the course. however, as recommended by the who, 4 training would need to emphasise applicability of the 25 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. knowledge and its relevance to the social context of the learner. concerning the trainees proper, two-thirds of the survey respondents were male, whereas in other chw training courses in india, and indeed internationally, female trainees are typically greater in number. asha workers, for example, are exclusively females. these gender-based findings reflect the minimum education requirement for entry to the course, but may also reflect the fact that many full-time ministry workers based in rural india are men. as it happens, training males who are working in rural, poor, and hard-to-reach areas may be an appropriate strategy for reaching those very beneficiaries. finally, noting that 72% of respondents came from faith-related occupations, it is not surprising that the qualitative results had a strongly spiritual focus. nevertheless, it suggests that the training equipped them to think and function with a holistic or integral approach, which is also contextually appropriate insofar as the indian patient commonly expects to receive both the medicine (dawa) and the blessing (duwa) from an encounter with a health practitioner. limitations both the qualitative and quantitative questions in this survey asked the trainee to self-report the change in their knowledge and practices. as such, the results do not provide an objective understanding of graduates’ proficiency of knowledge or skills before or after the course. also social desirability bias is a relevant concern given the strong relationships with the training institution, as indicated in the qualitative data. however, the survey forms were designed for anonymous and individual completion in order to minimise pressure on respondents from peers and/or staff to give a positive response. similarly, the survey did not ascertain the level of trainees’ exposure to health-related incidences or assistance in health-related matters (prevention, education, referral, etc.) prior to the course. ideally, a baseline would have been undertaken to gain an understanding of trainees’ prior health knowledge and practices. however, it is assumed that such health-related knowledge and actions were minimal given that most trainees reported having no prior health or medical training. again, the quality of healthcare provided by the graduates cannot be determined from this study. however, these candidates have passed three sets of formal exams set by cmc vellore that has ranked as india’s second leading medical college for maintaining high standards in teaching, assessment, and certification of graduates. 10 finally, the sample only included those who graduated and attended refresher training sessions. this may have created some selection bias towards enthusiastic and well-performing trainees. however, this would be limited, given that the sample represented over one-third (38%) of those who had ever completed the course. conclusion a large workforce is needed to meet india’s health needs. as trained health personnel are unwilling to move to the villages of india, the clhtc health worker training course demonstrates potential to train thousands of community health workers to work in disadvantaged rural/remote areas. this well-designed training program conducted by a premier institute, focused on knowledge, skills, and attitudes, using alreadyestablished regional centres based in rural india, and employing nurses based in these centres as trainers, is drawing out ngo/fbo workers to make a significant contribution to the health and wellbeing (including the spiritual health) of particularly disadvantaged populations. these trainees who already live among the poor and are committed to their wellbeing are increasing the accessibility of healthcare services and, thus, hold the potential to substantially reduce incidences of illness and disease. 26 butcher, sitther, velavan, john, thomas & grills nov 2016. christian journal for global health, 3(2): 18-26. references 1. world health organization. alma ata declaration. geneva: world health organization. 1978. 2. tulenko k, mgedal s, afzal mm, frymus d, oshin a, pate m, et al. community health workers for universal health-care coverage: from fragmentation to synergy. bulletin of the world health organization. 2013;91:847-52. http://dx.doi.org/10.2471/blt.13.118745 3. lehmann u, sanders d. community health workers: what do we know about them. the state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers geneva: world health organization. 2007:1-42. 4. bhutta za, lassi zs, pariyo g, huicho l. global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. global health workforce alliance. 2010;1:249-61. 5. crigler l, hill k, furth r, bjerregaard d. community health worker assessment and improvement matrix (chw aim): a toolkit for improving chw programs and services. bethesda, md: usaid. 2011. 6. rosato m, laverack g, grabman lh, tripathy p, nair n, mwansambo c, et al. community participation: lessons for maternal, newborn, and child health. the lancet. 2008;372(9642):962-71. http://dx.doi.org/10.1016/s0140-6736(08)61406-3 7. patel v, parikh r, nandraj s, balasubramaniam p, narayan k, paul vk, et al. assuring health coverage for all in india. the lancet. 2015;386(10011):242235. http://dx.doi.org/10.1016/s0140-6736(15)009551 8. india online pages. population of india 2016 [10/09/2016]. available from: http://www.indiaonlinepages.com/population/indiacurrent-population.html 9. world bank. world bank data set: rural population (% of total population) 2015 [10/09/2016]. world bank staff estimates based on united nations, world urbanization prospects]. available from: http://data.worldbank.org/indicator/sp.rur.totl.z s?year_high_desc=true 10. india today. india today best medical colleges 2016 [10/09/2016]. available from: http://indiatoday.intoday.in/bestcolleges/2016/ranks.j sp?st=medicine&lmt=1&y=2016 peer reviewed competing interests: none declared. acknowledgments: the authors would like to thank ben ebenezer and arun zechariah for their help with questionnaire translation and delivery. correspondence: nicole butcher, the nossal institute for global health, australia. butcher.nicole@gmail.com cite this article as: butcher n, sitther a, velavan j, john e, thomas mc, grills n. evaluation of the effectiveness of a community health worker training course in india. christian journal for global health (nov 2016), 3(2):18-26. © butcher n, sitther a, velavan j, john e, thomas mc, grills n. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.2471/blt.13.118745 http://dx.doi.org/10.1016/s0140-6736(08)61406-3 http://dx.doi.org/10.1016/s0140-6736(15)00955-1 http://dx.doi.org/10.1016/s0140-6736(15)00955-1 http://www.indiaonlinepages.com/population/india-current-population.html http://www.indiaonlinepages.com/population/india-current-population.html http://data.worldbank.org/indicator/sp.rur.totl.zs?year_high_desc=true http://data.worldbank.org/indicator/sp.rur.totl.zs?year_high_desc=true http://indiatoday.intoday.in/bestcolleges/2016/ranks.jsp?st=medicine&lmt=1&y=2016 http://indiatoday.intoday.in/bestcolleges/2016/ranks.jsp?st=medicine&lmt=1&y=2016 mailto:butcher.nicole@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ 50 jahre nach tübingen: auf der suche nach dem proprium christlicher ge-sundheitsdienste im 21 original article may 2016. christian journal for global health, 3(1): 25-35. future of christian health services – an economic perspective steffen flessa a a phd, professor, department of health care management, university of greifswald, germany abstract although christian health services have a proud history of healing and compassion especially in developing countries, their future is affected by secular changes in the financing and provision of health care services. however, the nature of life as it is evolving in modern society promises a need for the capacity to deal with increasing dynamics, complexity and uncertainty. in these circumstances the potential capacity of christians in their institutions and churches to provide unconditional reliability suggests a new opportunity. the components of unconditional reliability and how they affect the portfolio of christian health services is explained. effective christian health services will require appropriate analysis of their portfolios. introduction christian health care services can be proud of their history: millions of people healed, suffering reduced, and contributions made to political, social, and economic development, particularly in developing countries. 1 however, as early as 1964, the “healing ministry in the mission of the church” was challenged 2 with the realization that a doctor-oriented “healingfactory” was not in line with the christian call for shalom, wholeness, and community-orientation. 3, 4 the christian medical commission, founded in 1967 in tübingen, germany, propagated a community-based concept of christian healing. this concept had a strong influence on the development of the primary health care philosophy that became known as the declaration of alma ata, created by the world health organization (who) in 1978. 5, 6 at that time, leaders of mission organizations and diaconal institutions argued about the characteristics and quality of christian health care services, but not at all about its relevance or future. in the past, it had always been clear that they were needed and that no alternative existed. in many places of the world, christian institutions had a monopoly on modern health care, i.e., without church-run hospitals, dispensaries, and preventive services, the population had no access to modern health care at all. today, the situation has changed. in particular, the poor seek fast and easily accessible health care from private providers in cities, and even in the rural areas of poor counties, there is frequently competition with private practitioners. 7 the argument “if we are not there – nobody is there” has changed to “if we are not there – others will provide the services”. this is in particular true for developed countries where the majority of the population is covered by health insurance, but it is also true for more and more developing countries. thus, we have to ask whether christian health care services will have or should have a future. since private and government providers offer professional and accessible health care 26 flessa may 2016. christian journal for global health, 3(1): 25-35. services, a new discussion of the distinctiveness and the rationale of future existence of christian health care services is called for. cum grano salis: is there still a need for christian health care services? do they have a future? this paper addresses these questions from an economic perspective, i.e., it covers only one dimension of the reality. however, as many christian health care providers offer their services in a competitive market, economics is a tremendously important dimension for the future of these providers. the following section analyzes the properties of modern societies and concludes that “unconditional reliability” – as the distinctive feature of christian health care services – is still of high relevance. it goes beyond “technicalfunctional” healing and constitutes a resource for the future. next, we analyze the portfolio of christian health care services in order to determine the most appropriate service program of these institutions. the paper closes with some conclusions. unconditional reliability in modern society in order to understand the role and future of christian health care services we have to understand their role in a competitive health care market. generally, a market justifies and supports the existence of a market element if it produces a value for the entire population. consequently, we have to ask what value christian health care services produce that is unique or at least more likely to be efficiently produced by these providers than by any other. in order to determine the relevant value of christian health care providers for the society and economy we have to reflect on the characteristics of modern societies. modern societies and the life of individuals are characterized by continuous change. as figure 1 shows, old system regimes are disturbed by perturbations and become unstable. these perturbations can be internal or external, technical, organizational, or societal innovations. if the perturbation is strong enough, the system evolves into a crisis until it reaches a “point of no return,” the bifurcation point. here, it is obvious that nothing will remain as it was, but it is not clear how the new system regime will look. ideally, the system reaches a new steady state at a higher energy level. figure 1. system regimes 8 energy level old regime diachronic regime new regime time new equilibrium bifurcation pertubation old equilibrium the length of the stable steady-state equilibrium between two diachronic regimes determines the stress on society and individuals. as figure 2 indicates, the time can be very long (zone i). in the middle ages, for instance, rules, technologies, and social strata remained constant 27 flessa may 2016. christian journal for global health, 3(1): 25-35. sometimes for generations. during the industrial era (zone ii), the number of changes and crises markedly increased. however, the synchronic phases remained long enough so that a complete stabilization (“freezing”) of organizations, societies, and individual lives became possible. consequently, stabile meta-structures such as strong organizations, rules, and hierarchies were possible and required. however, if the frequency of changes and crises increases even more, the synchronic phases will become so short that no steady state will be possible. as soon as a system comes out of a crisis, the next perturbation is waiting. thus, no fixed rules are possible; instead, ad-hoc decisions and structures are required. decisions have to be made in the microstructure (on the grass root level), but need multiple information inputs, so that networks become extremely important (zone iii). finally, this can lead to a situation where phases and directions cannot be distinguished (zone iv). new major perturbations appear before a new macro structure can be established, and the system falls into destructive chaos. 9 over the last fifty years, we see that the number of perturbations, changes and crises, are steadily increasing. rieckmann analyzes these developments and points out that modern societies are characterized by three features summarized in the term “dynaxity”: complexity, dynamics, and uncertainty. 9, 10 complexity means that the number of elements in a system, the number of relevant environmental systems, and the number of relations between elements in the system or between systems and the environment are increasing. in the 1960s, for instance, most markets were local. providers were mainly “standalone” institutions connected primarily with their catchment population and the local government. modern business units and individuals, however, have a tremendous number of interdependencies with highly mobile clients, globalized suppliers, civil society, worldwide competitors, customer rights organizations, lawyers, tax consultants, international ngos, etc. . . the complexity has markedly increased. dynamics can be expressed by the speed of the development of new elements and new relationships in a system. a system is dynamic if it not only develops new relationships with other organizations but if the time interval between the creation of new relationships becomes shorter and shorter. at the same time, old foundations deteriorate, and there seem to be no more safe harbors on which society and individuals can rely. regulations, customers, supplier relationships, and traditions change as rapidly as knowledge. the consequence of this is that the predictability of changes in time becomes more difficult, i.e., uncertainty increases. this either means that possible conditions of the environment are completely unknown or that their realization can only be assessed by likelihood. nothing is certain any more, stochastics is the art of the future, and decision-theory is mainly dealing with uncertainty. enterprises, other organizations, societies, and individuals are left with high risk in all activities and life in general. figure 2. dynaxity11 28 flessa may 2016. christian journal for global health, 3(1): 25-35. complexity time chaotic zone zone iii = post-modern phase zone ii = industrial phase zone i = pre-industrial phase dynaxity zone iii as the description of a post-modern society and economy makes high requirements on the individual. 12, 13 one must be able and willing to understand highly complex systems, to accommodate rapid changes, and to take risks under extreme uncertainty. the 21 st century places a high demand on one’s personality. individuals and society require a resource that gives them the capability of dealing with this complexity, dynamics, and uncertainty. which resource could make them willing to take the risks of modern life and prevent the drift towards destructive chaos in the presence of complexity, dynamics, and uncertainty? obviously, this is only possible if central areas of human lives are protected by unconditional reliability. 14 thus, modern society and economy call for unconditional reliability as a resource of modern life. this unconditional reliability has different dimensions. the physical dimension requires unconditional protection of the human body by reliable health care services. only if people can be sure that their physical needs will be attended to under all conditions of life will they be able to take the risks of life. a young man willing to become an entrepreneur must know that there will be a comprehensive basic health care package available for him, even if risks materialize and he goes bankrupt with a fortune of debts. consequently, reliable health care services for every member of the society, a core of universal health coverage, are not a luxury but a resource of unconditional reliability in a modern world. christian health care services contribute to this unconditional reliability as a feature of the society the world can rely on that will offer care whatever happens. unconditional reliability also has a social dimension. dynaxity zone iii is full of networks and relationships – but people have the longing to be more than a business partner in a network. they want to be loved and respected irrespective of their personal success. nobody can “survive” and invest himself fully into a network economy or society unless he can fully rely on sources of respect for his dignity and of love for him as an individual even if he fails in life. consequently, reliable health care services, where the dignity of human beings is respected under all conditions, are not a luxury, but a resource of unconditional reliability. christian health care services have the unique calling to make this respect and love perceivable irrespective of their clients’ success or failure in life or their ability to pay. finally, unconditional reliability also has a spiritual dimension. human beings seek meaning, and this includes phases of sickness and dying. 15 every human needs the time and space to discover the meaning of suffering and dying without fear, accompanied by relatives and friends and without terrible pain. people cannot dare to invest their lives into the modern economy and face all the risks of dynaxity zone iii unless they can believe that there is spiritual support in the crucial 29 flessa may 2016. christian journal for global health, 3(1): 25-35. situations of life. christian health care services have the unique opportunity to provide this support, help the seeker, and provide answers that offer reliability beyond this life. in a nut-shell, one can conclude that individuals, the economy, and the society have to be assured they can rely on functional, humanitarian, and “warm” health care services. otherwise, they cannot risk full dedication of their lives and work in zone iii in a post-modern society. christian health care produces a crucial value in dynaxity zone iii: unconditional reliability in all dimensions of life. the consequence is trust as the “moral capital” of human life, economics, and societal development. 16 it is the trust in one’s capability, in others, in the social system, and in god that is so crucial for our future. without trust, society and economy will collapse. 17 but the economy cannot produce this trust. instead, trustworthiness must be experienced in families, friendship, churches, and health care services. 18 an economy and society in dynaxity zone iii induces stress on the “flexible man“ that can be survived only with a firm foundation of unconditional reliability. 19, 20 unless we want to risk a trust crisis, we need this firm foundation. 21 christian health care services can produce this utmost important value: trust based on unconditional reliability. however, the production of trust based on unconditional reliability in christian health care organizations is not by default. in other words: we must make wise decisions in our portfolios and processes in order to guarantee that christian services can fulfil this demand. in the next section, we will analyze the conditions of this function of christian health care providers for the society. portfolio and process management it is obvious that the physical dimension of unconditional reliability does not necessarily have to be fulfilled by christian services. government and private for-profit enterprises are capable of performing this function as well. only if the supply of services provided by these competitors is insufficient do christian health care services provide a value that would not exist without them. the social dimension is frequently addressed by professional quality management. respect for the dignity of human beings is not unique to christian services. consequently, we have to analyze the portfolio of christian health care services to determine where they must engage themselves to have a unique value for the society. the analysis of service portfolios is a standard of business administration that has to be adapted for this analysis. 22 the most well-known system for commercial industries is the so-called “bcgmatrix” that was introduced in 1968 by boston consulting group. 23 it assumes that any enterprise (including church-run hospitals) has a portfolio of service. some products have growing turn-over and are in growing markets, others persist on shrinking markets and have declining sales. some products produce a lot of cash flow, and others need cash flow to grow. the bcgmatrix gives strategies to determine the products in which to invest. 30 flessa may 2016. christian journal for global health, 3(1): 25-35. figure 3. bcg-matrix 23 market growth p.a. [%] poor dogs cash cows stars question marks relative market share 30 times 1 times 0.1 times -4 % 0% 7 % 18 % as figure 3 shows, the axes of the matrix are “relative market share” (relative in comparison to the biggest competitor) and “market growth”. it contains four fields with four strategy norms:  poor dogs: low relative market share, low market growth. strategy: give up.  question marks: low relative market share, high market growth. strategy: further research, promising candidates should be developed further.  stars: high relative market share, high market growth. strategy: further investment to maintain success.  cash cows: high relative market share, low market growth. strategy: no more investment, use cash flow to support question marks. christian health care services cannot base their portfolio decisions on the bcg-matrix. this is due to the fact that these nonprofitorganizations do not seek profit but want to fulfil their lord’s command of love by caring for the sick and needy. consequently, the dimensions have to be adjusted. schellberg developed a portfolio matrix for nonprofit-organizations and recommended the dimensions “ethical mission” and “refinancing.” 24 flessa and westphal applied this concept to diaconal institutions and used the dimensions of “diaconal mission” and “refinancing.” 25 the first expresses the priority within a christian goal system, the latter the possibility to break-even within the existing financing mechanisms. a service is usually of low diaconal priority if the christian service provider offers exactly the same services like everybody else. figure 4 shows the respective portfolio-matrix. 31 flessa may 2016. christian journal for global health, 3(1): 25-35. figure 4. portfolio-matrix of diaconal institutions 25 diaconic mission cash cows stars touch stones refinancing high low low high goiter as before, four strategy norms can be derived:  touchstones: these services can only be offered with a financial deficit, but they have a high diaconal priority. these services are usually innovative so that there is hardly any competitor on the market. at the same time they are not yet financed by (health) insurances or the government. strategy: investment and development.  stars: these services are completely refinanced by fees or government subsidy. they have a high diaconal priority. strategy: further investment.  cash cows: these services are completely refinanced by fees or government subsidy, but they have a low diaconal priority. strategy: these services should be used to produce cash flow for the development of touchstone services.  goiter: these services can only be offered with a financial deficit. at the same time they have a low diaconal priority. strategy: give-up. it is crucial to analyze the service program of christian health care services in order to determine to which field of the matrix they should be assigned. figure 5 exhibits a decision-chart for the portfolio analysis. in a first step, we analyze the competitiveness, i.e. we analyze whether christian health care providers are monopolists or have total or partial competition. if no other provider offers the services (such as it was for generations in rural sub-saharan africa), the christian provider must give a high priority to this service. if there is competition, we have to analyze whether the alternative supply is sufficient in quantity and quality to satisfy the needs of the population. it can be shown that nonprofit organizations will have — without other changes — a tendency to produce a higher quantity of services as they try to achieve their output maximum which is still recovering their cost while a for-profit provider would maximize its profit margin. 26 under the condition of an sshaped production function, this is less than the quantity of nonprofit organizations. health care markets are structurally imperfect, i.e., customers cannot easily assess the quality of services, and the number of service providers is limited. 27 under this condition, the market does not necessarily guarantee that the produced quantity is sufficient to satisfy all basic needs, including basic health care. supply provided by government and for-profit organizations can be insufficient so that christian 32 flessa may 2016. christian journal for global health, 3(1): 25-35. services should consider supporting the population with additional supplies. here, christian services are competitors on the market, but their existence is crucial. however, even if the supply is insufficient, it can be that there is no need for christian providers to fill the gap. instead, we have to conduct a second step in analysis and appraise whether the needs justify christian engagement. for instance, there might be a tremendous demand for jewelry, but this does not call for christian provision. only if the physical existence or the dignity of human beings are threatened will christians be urged to intervene. in all other cases, we can leave the satisfaction of needs to the free market or just accept that not all needs on this earth have to be satisfied. nevertheless, the situation is different if the spiritual dimension is considered as decisionrelevant. generally, all services and commodities have different utility dimensions. if we can separate these dimensions (e.g., physical and spiritual dimension), different providers can provide the services. for instance, a private forprofit hospital can do the operation, and the spiritual care can be taken by a pastor outside a christian institution. however, if the spiritual dimension cannot be separated from the physical, christian health care providers have a high incentive to fulfil even the physical needs of their clients. in this case, it makes sense to have a christian health care provider and not just christians “visiting” other providers for spiritual care. this requires that the personnel be capable and willing to perform not only technicalfunctional tasks, but also offer spiritual services (e.g., prayer with the patient) by one and the same person (una persona). figure 5. portfolio analysis 28 start competition? yes no basic needs? yes high priority no spiritual dimension? high priority yes no spiritual dimension? high priority yes low priority no low priority cash flow >0? cash flow >0? yes star no touchstone yes cash cow no goiter end cash flow >0? yes cash cow no goiter based on figure 5, we can distinguish categories of christian health care services and attach the service program to the portfoliomatrix. 28 services that address existential needs 33 flessa may 2016. christian journal for global health, 3(1): 25-35. and that are not sufficiently provided by the competitors have a high priority. services where spiritual and physical dimensions cannot be separated also have a high priority, even if other competitors suffice to satisfy the physical needs. all services that can be provided by others in the very same way should have a low priority. at the same time, we have to see that christian health care providers could have elements in their portfolio that have a low priority, but produce cash flows to subsidize high-priority fields. these cash cows are necessary to finance touchstones with high priority but low financing. services which neither produce positive cash flow nor have a high priority are as useless as a goiter and should be taken out of the portfolio at once. services that can be fully refinanced and have a high priority are stars. figure 4 shows the respective portfolio matrix. 25 christian health care providers are asked to analyze their portfolios to realize whether they produce the value of unconditional reliability in each quadrant of the matrix. without doubt, the ideal producer of trust is the touchstone: people realize that christians are aware of the current (health) problems and provide solutions irrespective of financing. christians take their own funds – cash flow from cash cows or donations – to offer services seen as relevant and needed. almost all christian health care services were touchstones at the time of their inauguration. and until today, many christian institutions are touchstones, in particular, in rural sub-saharan africa and asia. here, it is decided whether christian love and solidarity is really more than just a tradition. and here, it is determined whether the world perceives that it can rely on christianity. it is obvious that this calls for christian solidarity, i.e. richer christians within one country and worldwide are called to support the touchstones with their giving. at least in countries with universal health coverage (like in most european countries), we have become accustomed to the assumption that diaconal work is financed by fees or government contributions. however, financing touchstones — in particular in absence of cash cows — will require additional financing. if we assume that the social situation is dynamic (i.e., that new needs will arise) and that not all needs can be covered by the government of a social insurance, this is also a call for a new reflection on financial stewardship for each christian and the church as a whole. the development of social security frequently makes stars (which are of high priority and are fully financed) out of touchstones. however, full financing induces competition. the christian provider will lose his monopoly, and unless he manages to stress the spiritual component, the original touchstone will soon become a cash cow. the amalgamation of physical and spiritual dimensions will produce unconditional reliability for the society. every human being can rely on christian health care services to not only treat his body but also support him on his journey of finding meaningful answers for the important questions of life. the search for meaning in life, suffering, and dying are not only luxuries for the rich and successful minorities, but are integrated into christian health care services. in the worst case, the cash cow cannot compete with private for-profit providers and runs again into the loss-zone. at the end of the cycle, a service remains that neither has a christian priority nor produces cash flow for re-financing touchstones. in other words: christian health care services must “live above the line” by focusing on services with a high priority: either by providing services in places where nobody else wants to work or by closely linking the spiritual and the physical dimension of health. the latter is definitely an issue of process management, i.e., the future of christian health care services and their role in producing ultimate reliability as a source of trust for the society and economy depending on the dedication of the christian health care staff. conclusions based on this analysis, we can conclude that christian health care services can only be different and fulfil their function of producing uncondition34 flessa may 2016. christian journal for global health, 3(1): 25-35. al reliability if the spiritual dimension of healing is strengthened. therefore, we have to ask whether the reality of christian health care institutions globally reflects the reality of the “congregation as the healing body of christ” or our spirituality is reduced to an ethics committee — just as it exists in all governmental and private for-profit hospitals. the fulfillment of the original function of christian health care providers requires a spirituality that is interwoven in daily processes within these institutions. this is primarily not a question of quality management but of staff who are personally deeply grounded in the truth of the gospel and have a relationship with the living god. the spiritual dimension of health care requires spiritual co-workers. their love, dedication, faith, and trust determine whether christian health care providers really make a difference. this also requires spiritual leaders. their spiritual life, motivation, and ability to have a vision, to motivate others, and to earn their trust determine the foundation of spirituality in christian health services. and, it determines whether co-workers can make christian health care services distinguishable and whether there is still a need for christian health care services in the future. this paper started with the statement that we will only address the economic dimension of christian health care. everybody who runs a christian hospital or program knows how much our church work is “in this world” with all its limitations and complexities. at the same time, we have shown that the functionality and sustainability of our services increasingly depend on the christian spirituality of our staff and leadership. thus, the visible and the invisible church are both to be reflected in our work. finding the right balance between market and godliness, between economic constraints and the indefinite resources of god remains a challenge. however, it is not an academic 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correspondence: professor dr. steffen fleßa, universität greifswald, friedrich-loeffler-straße 70 17487 greifswald, deutschland. steffen.flessa@uni-greifswald.de cite this article as: flessa, s. future of christian health services – an economic perspective. christian journal for global health (may 2016), 3(1):25-35. © flessa, s. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.14315/vf-2014-59-1-38 mailto:steffen.flessa@uni-greifswald.de http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ original article nov 2014. christian journal for global health, 1(2):19-28. evaluation of jamaican knowledge of diabetes and health beliefs melody l. hartzler a , aleda m.h. chen b , bethany l. murphy c , sarah j. rodewald d a, pharmd, asisstant professor of pharmacy practice, cedarville university school of pharmacy b pharmd, ms, phd, vice chair and assistant professor of pharmacy practice, cedarville university school of pharmacy c pharm d, assistant professor of pharmacy practice, union university school of pharmacy d bsn, registered nurse, miami valley hospital, dayton, ohio abstract background & aims: the international diabetes federation (idf) estimated that over 382 million people worldwide were affected by diabetes in 2013. the caribbean region consistently is above the global average in regard to diabetes prevalence. specifically, in jamaica, researchers have found that the management of diabetes is not consistent with international guidelines, and in caribbean culture, there are additional health beliefs that may need to be addressed. the purpose of this study is to (1) evaluate patient diabetes-related knowledge and health beliefs and (2) determine the association between diabetes-related knowledge and health beliefs in rural jamaica. methods: rural jamaican patients with diabetes (n=48, mean age = 55.16±15.08) were asked to complete questionnaires for cross-sectional examination of knowledge and health beliefs during a medical mission trip to the parish of st. elizabeth in jamaica. participants were asked to verbally complete the spoken knowledge in low literacy in diabetes scale (skilld, 10 items) and health belief model-11 (hbm-11, 11 items), as well as a demographic instrument. analyses were performed in spss v. 20.0. descriptive statistics were performed for all items. spearman or pearson correlations, as appropriate, were utilized to assess associations. differences in hbm subscales by demographic characteristics were assessed using paired t-tests. results: participants had poor knowledge of diabetes, particularly regarding signs and symptoms of hyper/hypoglycemia, importance of foot and eye exams, fasting blood glucose levels, and long-term diabetes complications. knowledge deficits were associated with educational attainment, as many participants had only completed primary school. most participants indicated they were ready to take action regarding their health, but they perceived there were significant barriers to doing so. also, older adults were more likely to believe that they could control their diabetes. there were no other differences in knowledge or health beliefs based on demographic characteristics. 20 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. conclusions: among this population of rural jamaican patients, general knowledge regarding diabetes remains low, but patients want to take action regarding their diabetes. these results indicate a continued need to develop programs to provide diabetes-related education to patients living in rural jamaica, as patients are ready to improve their management of diabetes. introduction diabetes is not only highly prevalent in the united states but worldwide. the international diabetes federation (idf) estimated that over 382 million people worldwide were affected by diabetes in 2013. 1 idf anticipates that in less than 25 years that number will climb beyond 592 million. eighty-percent of the total number of patients affected are living in low and middle income countries and suggest this is a worrying indication for the future impact of diabetes to global development. 1 in regard to mortality, diabetes accounts of 13.5% of all deaths among adults in the north american and caribbean region; while this includes the united states and canada, the prevalence of diabetes in the caribbean islands is consistently above the global average. 1 in 2013, the national prevalence for diabetes in jamaica was estimated at 10.59%. 1 in addition, a recent crosssectional study of jamaican adolescents found that one-third had more than three risk factors for type 2 diabetes, with adolescent girls having more risk than boys. 2 researchers have also found that the management of diabetes in jamaica is not consistent with international guidelines. 3 traditionally, jamaican patients have relied on the physician for diabetes information and self-management recommendations. 4 however, research has found patients’ adherence, attitude, beliefs, and knowledge about diabetes may affect diabetes self-management. 5 improved adherence has been linked to patients who have a higher level of confidence in their ability to follow medical recommendations. 6 also, culture and language may influence patients’ health beliefs, attitudes, and health literacy, which may then affect diabetes management. 5 it is important to identify factors that influence patients’ self-management, particularly patients’ health beliefs, to provide a comprehensive treatment and education plan for diabetes. the barrier analysis model 7 provides a framework by which to identify and address “behavioral determinants associated with a particular behavior so that more effective behavior change communication messages and support activities (e.g., changing social norms) can be developed.” in the 7 steps of this method, community health team members move from defining and developing questions to collecting and analyzing results to using the results to improve care. the health belief model (hbm) is recognized as a key framework within the barrier analysis model 7 for understanding patient psychological readiness to take positive health actions. the model is based on the theory that perception of reality, instead of reality itself, determines whether individuals take action. 8 the overall hbm theory recognizes that for an individual to take action to avoid disease, he or she has to believe (1) (s)he is susceptible to it, (2) the presence of disease would have at least a moderate impact on a component of his/her life, and (3) that taking a certain action would be beneficial to improving disease risk or disease progression and would not include overcoming important psychological barriers such as cost, convenience, etc. 8 knowledge itself may not be sufficient to promote adherence. patient beliefs are strong motivators of their behavior; thus, it is imperative practitioners understand a patient’s beliefs, especially when 21 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. caring for patients whose beliefs may be very different than their own. specifically, in caribbean culture, there are additional health beliefs that are different than typical us-based diabetes management practices and may need to be addressed. a widely used practice of treating with nonprescription and folk remedies for diabetes is found in many caribbean cultures including st. vincent and jamaica. 4,9 wint et al. conducted a descriptive study to determine the extent of knowledge, motivation, and barriers to lifestyle changes for control of diabetes in jamaica. 4 a few of the barriers to making positive lifestyle changes included: lack of self-monitoring of blood glucose, lack of perceived risk of complications, overweight or obese status, inadequate knowledge, little motivation, non-compliance, use of bush teas, and belief that diabetes can be cured. jamaican patients also wanted more diabetesrelated education and explanations of diabetes-related complications. 4 many of these barriers, such as lack of education about the chronic nature of diabetes and use of natural remedies, need to be addressed during diabetes educational efforts in jamaica. integrating longitudinal lay educator personnel in communities has led to improvements in hemoglobin a1c (a1c); 10 however, longitudinal diabetes education is not always feasible in rural or underserved areas in jamaica. the parish of st. elizabeth is a rural area of jamaica that often receives additional health care support from united states medical mission organizations. without medical mission teams, many of the patients in this area would go without physician medical care. these organizations have recently shifted their goals from only providing short-term medical teams to finding partners on the ground in the country to continue to carry on work after they have gone home. assessing knowledge and barriers to care on the mission field will best allow mission organizations to address educational barriers while in the country and continue to develop local partnerships and train lay personnel to further address educational barriers after leaving. this study was conducted to better understand patient health beliefs about diabetes in the parish of st. elizabeth in order to develop proper education and programming to meet their shortand long-term needs, as recommended by the barrier analysis model. 7 research objectives 1. to evaluate rural jamaican patient diabetes-related knowledge and health beliefs. 2. to determine the association between diabetes-related knowledge and health beliefs in rural jamaican patients with diabetes. . materials and methods research design this cross-sectional, exploratory study using a convenience sample was conducted during a medical mission trip to the st. elizabeth parish of jamaica from february 6 to 10 th , 2012. a team researcher had previously been on a short-term medical mission trip to st. elizabeth and identified that there were barriers to diabetes education and care. based on her experience, and after performing an extensive literature search, the study objectives and corresponding survey instruments were identified (steps 1-3 in barrier analysis). 7 survey instruments were verbally-administered by an investigator (pharmacist, nurse, or student pharmacist) after verbal consent was obtained (steps 4-5 in barrier analysis). 7 after completing the instruments, participants were invited to attend a 30minute diabetes education session led by one of the investigators. all patients were given the opportunity to attend the educational session regardless of study participation. sample the sample consisted of patients who were at least 18 years of age with type 1 or type 2 diabetes, lived in st. elizabeth parish 22 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. in jamaica, and came to the medical mission clinic for treatment. all participation was voluntary; patients were asked to participate if they had a diagnosis of diabetes. data collection institutional review board approval was obtained by cedarville university prior to data collection. this project was conducted at the “final step” of the clinic. at that point, patients had been seen by the medical provider and were waiting for their medications. study investigators identified, approached, and asked individuals who met study criteria to participate. if they declined, they were informed about and invited to the diabetes education class. if they agreed, researchers verbally administered three surveys: a demographic survey, spoken knowledge in low literacy in diabetes scale (skilld), 11 health belief model-11 (hbm-11). 12 once the surveys were completed, study investigators invited participants to attend a diabetes education class. all investigators completed a 1-hour training session going over the information presented during the class to ensure consistency in education. investigators utilized the international diabetes federation as well as the american diabetes association standards of care to create the patient education and included the following concepts: types of diabetes, diabetes complications, prescription and herbal treatments for diabetes, exercise, signs and symptoms of hyper/hypoglycemia, and diabetic foot care. 13 instruments demographic instrument the demographic instrument was comprised of questions regarding participant age, sex, education level, race, height, weight, blood pressure, prior diabetes education, diabetes treatment (diet, exercise, insulin, tablets, other remedies), duration of diabetes, and source of information about diabetes. spoken knowledge in low literacy in diabetes scale (skilld) 11 the skilld is a 10-item scale designed to measure knowledge of diabetes in patients with low literacy. the 10 openended items relate to the signs and symptoms of hyper/hypoglycemia, treatment of hypoglycemia, foot and eye exams, normal fasting blood glucose and hemoglobin a1c, exercise, and long-term complications. each question is worth one point, with a maximum score of 10. higher scores indicate greater knowledge of diabetes. participants were read the full question and given 10-15 seconds to respond. if the participant responded correctly, then a point was awarded. if the answer was incomplete, incorrect, or not known, then no points were awarded. the skilld is found to be valid and reliable for use in low healthliterate patients (cronbach’s alpha = 0.72; r=0.22, p=0.007 for literacy level). health belief model-11 (hbm-11) 12 the hbm-11 is an 11-item scale designed to measure patient psychological readiness to take positive action in diabetes. this scale is theoretically-based on the health belief model and includes perceived susceptibility/seriousness of the health condition (in this case, diabetes) and benefits of and barriers to taking action. within the scale, 4 items relate to perceived seriousness, 3 items to benefits of taking action, and 4 items to barriers to taking action. participants are asked to rate their level of agreement with statements using a 5-point likert-type scale (1=strongly disagree, 5=strongly agree). negatively-worded items were reverse scored. scores range from 11 to 55, with higher scores indicating a readiness to take positive diabetes health actions. the hbm11 is both valid and reliable and has been successfully utilized in low health-literate patients. 12,14 data analysis all data were analyzed using ibm spss v. 20.0 for windows (armonk, new york) (step 6 of barrier analysis). 7 an a 23 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. priori level of p=0.05 was used for statistical significance. descriptive statistics were used to assess participant information, including frequencies for categorical variables, means for continuous variables, and medians for likert-type data (individual items and total hbm-11 score). spearman or pearson correlations, as appropriate, were utilized to assess associations. paired t-tests were used to examine differences in hbm-11 subscale by demographic characteristics. results a total of 48 patients completed the questionnaires. participants were mostly female, had a primary school education, and had been diagnosed with diabetes in the last 10 years (see table 1). table 1. demographic information the average diabetes-related knowledge (skilld score) of participants was 3.8 out of 10 possible points, and participant mean score on the hbm was 38.28 out of a possible maximum score of 55. no question on the signs and symptoms of high/low blood glucose, foot/eye exams, fasting blood glucose levels, and long-term complications was answered correctly by more than 25 participants. only one participant gave a correct answer regarding normal hemoglobin a1c levels (see table 2). table 2. participant diabetes knowledge, as measured by the spoken knowledge in low literacy in diabetes (skilld) scale question answered correctly treatment of low blood sugar 30/48 exercise length and frequency 28/48 recommended frequency of foot checks 25/48 importance of foot checks 23/48 long-term complications of diabetes 18/48 signs/symptoms of high blood sugar 17/48 frequency of eye exams and importance 16/48 normal fasting blood glucose 14/48 signs/symptoms of low blood sugar 6/48 normal hemoglobin a1c 1/48 participants believed they could control their diabetes (median response = strongly agree) but indicated that adhering to diet regimens was challenging (median response = agree) (see table 3). there was a statistically-significant, positive association between educational attainment and diabetes knowledge (r=0.32, p=0.03, see table 4). also, there was a significant positive association between age and item 6 on the hbm-11 scale (benefit to taking action: i believe i can control my diabetes; r=0.36, p=0.01). there were no other significant associations between demographic characteristics, even when collapsed into binary variables, and diabetes knowledge total score and individual items, readiness to demographic n or mean±sd female 32/43 age 55.16±15.08 education none 4/47 primary education 29/47 secondary education 12/47 tertiary education 2/47 length of time with diabetes <5 years 15/46 5-10 years 14/46 10-20 years 13/46 >20 years 4/46 received prior diabetes education 32/46 diabetes treatment tablets only 37/47 insulin and tablets 6/47 insulin only 2/47 diet and/or exercise only 2/47 local remedies for diabetes 19/47 bush tea 10/19 cinnamon leaf 3/19 other, not specified 6/19 weight (kg) 78.44±17.69 systolic blood pressure 143.37±22.64 diastolic blood pressure 83.86±13.89 skilld score 3.79±2.26 hbm-11 score 38.28±5.63 24 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. take action, or any of the hbm-11 constructs (seriousness, benefits, barriers) or individual items (p>0.05). participant diabetes knowledge and readiness to take action were not associated (r=0.10, p=0.52). table 3. participant readiness to take action, as measured by the health belief model-11 (hbm-11) scale 4 items relate to perceived seriousness, 3 items to benefits of taking action, and 4 items to barriers to taking action. question m e d ia n s c o re s tr o n g ly d is a g re e a n d d is a g re e u n d e c id e d a g re e a n d s tr o n g ly a g re e perceived seriousness/susceptibility q5. i believe i will always need my diabetes diet and insulin/pills. 4 (agree) 3 1 43 q3. my diabetes will have a bad effect on my future health. 4 (agree) 6 5 35 q4. my diabetes will cause me to be sick a lot. 4 (agree) 15 1 31 q2. my diabetes is no problem to me as long as i feel all right.* 4 (agree) 12 1 34 benefits of taking action q6. i believe i can control my diabetes. 5 (strongly agree) 3 0 44 q1. i believe that my diet and insulin/pills will prevent diseases (complications) related to diabetes. 4 (agree) 2 0 45 q7. i believe that my diet and insulin will control my diabetes. 4 (agree) 2 1 44 barriers to taking action q8. i would have to change too many habits to follow my diet.* 4 (agree) 17 1 28 q9. it has been difficult following the diet prescribed for me.* 4 (agree) 16 1 30 q11. taking my insulin/pills interferes with my normal daily activities.* 4 (agree) 22 0 25 q10. i cannot understand everything i’ve been told about my diet.* 3 (undecided) 23 2 22 *reverse-score result shown, as it was utilized for the final hbm-11 score table 4. associations of diabetes knowledge (skilld score) and readiness to take action (hbm-11 score) with demographic characteristics readiness to take action (hbm-11) diabetes knowledge (skilld) n correlation p n correlation p age 45 -0.04 a 0.78 45 -0.08 0.60 gender 43 -0.08 b 0.60 43 0.09 0.58 education 47 0.01 b 0.94 47 0.32 0.03 length of time with diabetes 46 0.07 b 0.63 46 0.14 0.35 a pearson correlation b spearman correlation discussion general knowledge of survey participants, based on the skilld test, was found to be low. over half of participants knew how to treat low blood sugar, about exercise recommendations, and how often to check their feet. however, only a few patients knew the symptoms of low blood sugar, and only one patient knew what their normal hemoglobin a1c should be. overall, knowledge of signs and symptoms and normal values were low. this can lead to challenges for patients in managing blood glucose and dealing with hyperand hypoglycemic episodes, and educators should assist with their patients in dealing with these chal25 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. lenges. further examination of the hbm-11 scores indicate that while participants tended to agree with statements regarding perceived susceptibility and benefits of taking action, they also agreed that they experienced barriers to action. given the context of the barrier analysis model and that the final steps are to analyze and use the results, 7 it is important to examine these findings in context of the literature. for example, these findings reflect previous surveys of jamaican individuals that suggest a continued need for diabetes-related education. 4 indeed, examining the broader context of the literature suggests that many patients with low health literacy, irrespective of cultural group or geographic location, lack diabetes-based knowledge. 14,15 lower educational attainment has consistently been found to be related to lower health literacy and less disease-based knowledge. 16,17 the participants in this study were similar, as lower educational attainment was associated with less knowledge. however, in spite of this low overall knowledge regarding diabetes, greater knowledge regarding diabetes was not associated with an increased readiness to make changes related to the disease. knowledge simply is not enough to induce change. other researchers have found that regardless of literacy level or knowledge, patients can perceive disease severity, see the positives, and overcome barriers associated with therapy adherence. 14 likewise, participants in this study perceived that their disease was serious and possessed an overall readiness to take action regarding their diabetes. however, these participants perceived that barriers to action were significant and may have been unsure as to whether these aspects could be overcome. patients perceiving that barriers to action are too high, typically, have poorer diabetes self-management. 18,19 education for patients with diabetes, irrespective of geographic location, may need to focus on how to overcome barriers. one of the greatest barriers seemed to be dietary changes, which is consistent with the literature. 18,19 however, participants did see the benefits of a proper diet, combined with use of pills and/or insulin, in leading to better control of diabetes and preventing complications. the international diabetes federation (idf) advocates nutritional therapy and physical activity to prevent and manage type 2 diabetes but recognizes that these measures are only effective in a small percentage of diabetics due to difficulties with adherence and physiological conditions requiring pharmaceutical intervention. 20 indeed, duff and colleagues studied self-care and diabetes management adherence in jamaicans and found that only 45% were compliant with their medications and only 56.4% to the recommended diet. 21 similar barriers of dietary and medication adherence were reported in our participants as well. instead, many participants surveyed reported using bush teas for diabetes control. bush teas, such as cerasee, are frequently utilized among jamaicans to lower blood glucose levels. 3 there have been limited studies, in animal models alone, demonstrating their efficacy 22 and may, instead of being efficacious, be contaminated with toxins and produce unwanted side effects. 23 until further information is available, patient beliefs about bush teas need to be assessed, and patients need to be informed of risks and benefits of consumption. educational programs in rural jamaica would be beneficial if used to improve disease-related knowledge among individuals with diabetes as well as focusing on how to overcome barriers to positive action. since increases in disease-related knowledge have been linked to improvement in selfmanagement of diabetes 6 and because it appears that many jamaicans are ready and willing to take steps to manage their diabetes, programs to equip individuals with the tools to do so must be developed. particularly, these tools should address overcoming the 26 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. barriers to taking effective action but will need to be expanded to more thoroughly address all the complexities that undergird patient decision-making. the high prevalence of diabetes in jamaica 1 and the lack of accessibility to healthcare services for many rural patients further increase the challenges of identifying barriers to self-care management and determining solutions. while addressing the components identified in this study during short-term mission trips may be beneficial, longer term solutions also are necessary, yet outside the scope of this study. however, other researchers, such as less and colleagues, suggest training individuals in the community to provide education training and reinforcement. 10 this type of programmatic development could be considered by missions organizations. limitations to this study include a potential for self-selection bias, since participation in the survey was voluntary. additionally, the sample size was small and consisted mostly of women. knowledge scores had a large variability, which makes inferential analyses challenging. finally, this study serves only to highlight the need for future education of this group of people and does not assess the impact of the educational session provided. future studies should assess varying techniques of providing patient education to jamaican individuals to determine the most effective method. conclusions this study of rural jamaican individuals indicates that while knowledge of disease is important and often less than desired, patients understand the seriousness of diabetes and the benefits of making changes. however, the challenges of making changes proved to be a noteworthy barrier. results of these surveys can be used to encourage more indepth assessments of patient barriers to selfmanagement using the barrier analysis method and development of future educational initiatives that provide individuals with both the knowledge and tools needed to begin self-management of diabetes, ultimately improving diabetes-related outcomes in jamaica. this project was conducted on the mission field, where a team of us-based health care providers served this region by providing primary care services. this team returns to the same location every year, and this information gives the team and future teams a great foundation to continue to evaluate patient needs and challenges as well as for preparing diabetes education materials and continuing to empower this population to make changes in their behaviors to improve the diabetes epidemic in jamaica. references 1. international diabetes federation (idf) diabetes atlas-sixth edition [internet]. brussels (belgium): international diabetes federation; [updated 2013 cited 3 march 2014]. available from: http://www.idf.org/diabetesatlas (p. 9, 11, 62, 120). 2. barrett sc, huffman fg, johnson p, campa a, mangus m, ragoobirsingh d. a cross-sectional study of jamaican adolescents’ risk for type 2 diabetes and cardiovascular diseases. bmj open. 2013;3:e002817. http://dx.doi.org/10.1136/bmjopen2013-002817 3. wilks rj, sergeant la, gulliford mc, reid me, forrester te. management of diabetes mellitus in three settings in jamaica. pan am j public health. 2001;9(2):65-72. http://dx.doi.org/10.1590/s102049892001001100001 4. wint yb, duff em, mcfarlane-anderson n, o'connor a, bailey ey, wright-pascoe ra. knowledge, motivation and barriers to diabetes control in adults in jamaica. west indian med j. 2006; 55 (5):330-3. 5. nam s, chesla c, stotts na, kroon l, janson sl. barriers to diabetes management: patient and provider factors. diabetes res clin pract. 2011;93(1):1-9. http://dx.doi.org/10.1016/j.diabres.2011.02.002 6. gherman a, schnur j, montgomery g, sassu r, veresiu i, david d. how are adherent people more likely to think? a meta-analysis of health beliefs and http://www.idf.org/diabetesatlas http://dx.doi.org/10.1136/bmjopen-2013-002817 http://dx.doi.org/10.1136/bmjopen-2013-002817 http://dx.doi.org/10.1590/s1020-49892001001100001  http://dx.doi.org/10.1590/s1020-49892001001100001  http://dx.doi.org/10.1016/j.diabres.2011.02.002 27 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. diabetes self-care. diabetes educ. 2011;37(3):392408. http://dx.doi.org/10.1177/0145721711403012 7. barrier analysis model. [internet]. washington dc (united states): food for the hungry;[updated 2004 cited august 2014] available from: http://barrieranalysis.fhi.net/ 8. rosenstock im. historical origins of the health belief model. health educ behav. 1974;2(4):328-35. http://dx.doi.org/10.1177/109019817400200403 9. moss mc, mcdowell jrs. rural vincentians' (caribbean) beliefs about the usage of non prescribable medicines for treating type 2 diabetes. diabet med. 2005;22(11):1492-6. http://dx.doi.org/10.1111/j.1464-5491.2005.01676.x 10. less la, ragoobirsingh d, morrison ey, boyne ms, anderson-johnson p. the jamaican lay facilitators program: a positive impact on glycemic control. diabetes manage. 2011;1(2):167-73. 11. rothman rl, malone r, bryant b, wolfe c, padgett p, dewalt da, et al. the spoken knowledge in low literacy in diabetes scale. diabetes educ. 2005; 31(2):215-24. http://dx.doi.org/10.1177/0145721705275002 12. hurley ac. the health belief model: evaluation of a diabetes scale. diabetes educ. 1990;16 (1):44-8. 13. standards of medical care in diabetes—2012. diabetes care 2012; 35(supplement 1):s11s63. http://dx.doi.org/10.2337/dc12-s011 14. powell ck, hill eg, clancy de. the relationship between health literacy and diabetes knowledge and readiness to take health actions. diabetes educ. 2007; 33(1):144-51. http://dx.doi,org/10.1177/0145721706297452 15. berkman nd, sheridan sl, donahue ke, halpern dj, viera a, crotty k, et al. executive summary: health literacy interventions and outcomes: an updated systematic review. rockville, md: agency for healthcare research and quality;2011. 16. williams mv, baker dw, parker rm, nurss jr. relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension and diabetes. arch intern med. 1998;158(2):166-72. 17. institute of medicine. health literacy: a prescription to end confusion. national academy of sciences; 2004. 18. aljasem li, peyrot m, wissow l, rubin rr. the impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. diabetes educ. 2001;27(3): 393-404. http://dx.doi.org/10.1177/014572170102700309 19. ayele k, tesfa b, abebe l, tilahun t, girma e. self care behavior among patients with diabetes in harari, eastern ethiopia: the health belief model perspective. plos one. 2012;7(4): e35515. http://dx.doi.org/10.1371/journal.pone.0035515 20. global guidelines for type 2 diabetes [internet]. brussels (belgium): international diabetes federation; 2012 [cited 24 jan 2013]. available from: http://www.idf.org/global-guideline-type-2-diabetes2012 21. duff e, o’connor a, mcfarlane-anderson n, wint y, bailey e, wright-pascoe r. self-care, compliance and glycaemic control in jamaican adults with diabetes mellitus. w indian med j. 2006; 55(4):232-6. 22. bailey c, day c, turner s, leatherdale b. cerasee, a traditional treatment for diabetes. studies in normal and streptozotocin diabetic mice. diabetes res. 1985;2(2): 81-4. 23. allen d. 'bush' tea danger: cerassie, ganja tea, aloe vera among potentially harmful home remedies [internet]. kingston (jamaica): jamaica observer; 2012 mar 29 [updated 2012 mar 29, cited 29 jan 13]. available from: http://www.jamaicaobserver.com/news/-bush-teadanger_11141393 peer reviewed competing interests: none declared. acknowledgements: cedarville university school of pharmacy; medical ministry international; william john van schepen, pharmd candidate 2016. http://dx.doi.org/10.1177/0145721711403012 http://barrieranalysis.fhi.net/ http://dx.doi.org/10.1177/109019817400200403 http://dx.doi.org/10.1111/j.1464-5491.2005.01676.x http://dx.doi.org/10.1177/0145721705275002 http://dx.doi.org/10.2337/dc12-s011 http://dx.doi,org/10.1177/0145721706297452 http://dx.doi.org/10.1177/014572170102700309 http://dx.doi.org/10.1371/journal.pone.0035515 http://www.idf.org/global-guideline-type-2-diabetes-2012 http://www.idf.org/global-guideline-type-2-diabetes-2012 http://www.idf.org/global-guideline-type-2-diabetes-2012 http://www.jamaicaobserver.com/news/-bush-tea-danger_11141393 http://www.jamaicaobserver.com/news/-bush-tea-danger_11141393 28 hartzler, chen, murphy & rodewald nov 2014. christian journal for global health, 1(2):19-28. correspondence: melody l. hartzler, cedarville university school of pharmacy, 251 n. main st. cedarville, oh 45314, usa mhartzler@cedarville.edu cite this article as: hartzler, ml, amh chen, bl murphy, sj rodewald. evaluation of jamaican knowledge of diabetes and health beliefs. christian journal for global health (november 2014), 1(2):19-28. http://dx.doi.org/10.15566/cjgh.v1i2.13 © hartzler, ml, et al. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:mhartzler@cedarville.edu http://dx.doi.org/10.15566/cjgh.v1i2.13 http://creativecommons.org/licenses/by/3.0/ family planning and reproductive health supply stockouts: problems and remedies for faith-based health facilities in africa www.cjgh.org july 2017 | 19 original article christian journal for global health | family planning and reproductive health supply stockouts: problems and remedies for faith-based health facilities in africa amy m. metzgera and mona bormetb a mph, consultant, christian connections for international health b mph, program director, christian connections for international health abstract background and aims: faith-based organizations (fbos) provide a substantial portion of the health care services in many african countries. fbo facilities do consider family planning and reproductive health services as essential to reducing maternal and child mortality, and to the growth of healthy families. many health facilities, however, struggle to maintain adequate stocks of reproductive health (rh) supplies because of the various rh supply chains and funding sources, which often operate separately from other medicines and supplies. the purpose of this study is to identify the types of supply chain systems used by african faith-based health facilities to acquire reproductive health products (clotrimazole, combined oral contraceptive pills, contraceptive implants, cyclebeads®, emergency contraception, erythromycin, female condoms, injectable contraceptives, intra-uterine contraceptive devices, magnesium sulfate, male condoms, methyldopa, misoprostol, nifedpine, oxytocin, and progestin-only pills), to describe their problems and challenges, and to identify possible corrective actions. methods: through email surveys, phone interviews, and on-site visits, we studied the supply chains of 46 faith-based health facilities in 13 african countries. sixteen rh commodities, including contraceptives, were selected as indicators. results: of the 46 facilities surveyed, 55 percent faced stockouts of one or more products in the three months prior to the survey. stockouts were less common for contraceptives than for other rh products. significant strengths of the fbo supply chain included creativity in finding other sources of commodities in the face of stockouts, staff designated to monitor quality of the commodities, high capacity for storage, low incidence of expired products, few instances of poor quality, and strong financial sustainability mechanisms, often including patient fees. weaknesses included unreliable commodity sources and power supplies, long distances to depots, and problems maintaining the cold chain. conclusions: by studying the supply chains of faith-based health facilities, christian connections for international health (ccih) and its members have created new awareness among fbos and international agencies of the importance and challenges of these systems and have suggested actions toward improvement. the alliance of christian faith-based organizations for family planning (acfbofp) formed in cameroon to strengthen commodity security may be a good model for other fbos to consider. cost recovery models with stronger quantification and forecasting systems, including trained staff, can help meet the fp and rh needs of families and can help assure the long-term sustainability of fbo health systems. this study can serve as a frame of reference as we move forward, anticipating an acceleration in interest to strengthen fbo supply chains to reach as many communities as possible with available, quality supplies and services. http://www.cjgh.org 20 | christian journal for global health 4(2) www.cjgh.org introduction christian connections for international health (ccih), a global network of christian health organizations, conducted a survey in 2008 among its members about their family planning and reproductive health (fp/rh) activities.1 one striking finding was their frequent mention of difficulties in ensuring steady supplies of important fp/rh items. to help them address these problems, ccih collaborated with john snow, inc., to produce a simple guide2 and webinar3 about how to get rh supplies for health facilities. in 2014, after years of qualitative reports from faith-based facilities, and in order to document how faith-based hospitals and clinics procure and distribute fp/rh supplies, ccih undertook an investigation focused on a more thorough understanding of supply chain systems and overall commodity security among christian health facilities in africa, funded by the reproductive health supplies coalition (rhsc).4 goals and objectives the goals of the study were to understand the supply chain systems of fbos in africa, including the stockouts and challenges they faced, and to recommend possible solutions. the objectives were to describe the basic characteristics and challenges of the supply chains at the service-delivery level; to deepen understanding of the types of supply chains used to access vital supplies for family planning and reproductive health (fp/rh) activities; to identify potential partners; and to design strategic interventions to improve fp/rh supply availability at the service-delivery level. methods data collection was conducted between october 2014 and february 2015 in three phases: email surveys, phone interviews, and country visits. all phases focused on key drivers of commodity security, including the following: • sources used by fbo facilities to obtain fp/ rh products, i.e., ministry of health (moh) depots, faith-based supply organizations (fbso) (broadly referenced pharmaceutical depots operated by faith-based organizations), other sources (i.e., retail pharmacies, wholesalers, social marketing depots), and international sources (i.e., international funders, donor-funded projects, international non-governmental organizations). • nature of transactions between the fbo facilities and their suppliers. • different types of supply chains and the risk of stockouts associated with each type. • facility practices for inventory and storage of products. • training of staff responsible for logistics and management of supplies. • financing for fp/rh supplies and logistics. • institutional and contextual factors influencing the availability of products. the list of rh products used in this study (see figure 1) was based on the resource “essential medicines for reproductive health”5 from world health organization (who), path, and the united nations population fund (unfpa). essential medicine lists (emls) were determined by committees appointed by who to include medicines that provided safe, effective treatments and were needed to guide a country’s national drug policy to ensure access, quality, and rational use. in most countries, the ministry of health (moh) elected a committee to determine the list for their country, guided by the who emls. survey questions were influenced by the “guide to conducting supply chain assessments”6 from the usaid deliver project. part 1: email survey 7 the survey was written and pretested in english and french. in collaboration with the national health offices of faith groups in 20 african countries, the researchers developed a list of 120 potential fbo health facilities. they then corresponded by email directly with the health facilities, first contacting the medical director, then identifying and corresponding with the staff member responsible for fp/rh metzger and bormet christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 21 supplies. (exceptions were made for some remote facilities without internet access. in these cases, the central fbo health office printed the survey, sent it to the facility, then collected it and sent the replies by email to the researchers). each respondent gave informed written consent for participation. the survey asked about the sources and suppliers from which the facility obtained fp/rh items, the characteristics of supply storage at the service-delivery level, and recent stockouts of selected products. part 2: phone interviews7 investigators conducted follow-up phone interviews with a subset of 16 of the survey respondents in six countries, representing diverse christian groups (baptist, methodist, catholic, pentecostal, presbyterian, etc.), that also had high levels of reported stockouts. the purpose was to clarify and explore further the details of their supply chains, and to understand why stockouts occurred and how they could be prevented. the phone interview guide was written in english and french. some questions for the phone interviews were extracted from existing international logistics assessments; others explored in more detail the responses to the email survey. verbal informed consent was required from each participant at the start of the phone interview. part 3: country visits the purpose of the country visits was to gain more detailed understanding of the situations and challenges of a range of fbo facilities in two different countries, to explore key factors beyond the facilities (at higher levels of the supply chains), and to inform future supply chain interventions. three regions of cameroon (13 meetings) and two regions of the democratic republic of the congo (drc) (17 meetings) were selected for in-person site visits, as they had high levels of study participation and had different types of supply chains. field visits were conducted by a consultant fluent in english and french who had lived for extended periods in both countries. in each country, visits included health institutions (many of which had participated in the email surveys and phone interviews), national-level fbo coordinating offices, warehouses of health commodity suppliers, and officials of the ministry of health and unfpa. results characteristics of fbo health facility respondents of the 120 facilities contacted in 20 countries, 46 facilities from 13 countries responded to the email survey. participating countries included cameroon, central african republic (car), chad, democratic republic of the congo, ethiopia, kenya, malawi, niger, nigeria, tanzania, uganda, zambia, and zimbabwe. table 1 shows the principal characteristics of the facilities surveyed and figure 2 shows survey responses by country. services provided and service fees all 46 faith-based health facilities provided antenatal care services (figure 3), and all but two provided family planning services to their patients. half the facilities charged patients fees for fp services, while nearly all of them charged for delivering babies. figure 1. reproductive health products clotrimazole combined oral contraceptive pills contraceptive implants* cyclebeads®** emergency contraception erythromycin female condoms injectable contraceptives intra-uterine contraceptive devices magnesium sulfate male condoms methyldopa nifedipine oxytocin progestin-only pills *implants added to the list as they are a commonly used fp method **cyclebeads® added to this list as they are a natural form of fp metzger and bormet christian journal for global health | http://www.cjgh.org 22 | christian journal for global health 4(2) www.cjgh.org survey respondents reported an average of 9.7 family planning patients seen per day in their faithbased health facility. the smaller facilities reported a higher number of fp patients per day (13.6) than the medium (5.8) and large (7.2) facilities. rural facilities reported a larger average number of fp patients per day (12) than urban facilities (6). post-abortion care (pac) was provided by some facilities for women experiencing miscarriage or complications from an induced abortion. unintended pregnancy, which was the root cause of induced abortion, could result from lack of supplies, contraceptive failure, non-use, lack of knowledge, and other factors. emergency treatment and post-abortion family planning were part of pac services; the latter helped prevent future unintended pregnancies and abortions.8 management, sources, and availability of fp/rh supplies logistics management of commodities was overseen primarily by clinical staff; only one fbo facility had a professional logistician. the survey asked each facility about 16 selected fp/rh items and about their suppliers (in-country and out-ofcountry). • twelve of the 16 rh products were used by at least 80 percent (37) of the fbo facilities. these were male condoms, injectable contraceptives, combined and progestin-only oral contraceptives, contraceptive implants, erythromycin, clotrimazole, magnesium sulfate, methyldopa, misoprostal, nifedipine, and oxytocin. • among contraceptives, cyclebeads® were the least commonly offered, by only 17 of 46 surveyed facilities. intra-uterine devices (iuds) were next, being offered by 30 facilities. • the mohs (compared to fbsos, international sources, or other sources) were the most common suppliers of oral contraceptive pills and cyclebeads®. in fact, 50 percent or more of the facilities reported that their moh supplied all their contraceptive products, with the exception of iuds. • for non-contraceptive rh products, depots of fbsos were the principal sources. figure 2 metzger and bormet christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 23 • only one product (misoprostol) was received mainly from “other” in-country sources (neither moh nor fbsos). • contraceptive implants and misoprostol were the two products most commonly out of stock on the day of the survey (figure 4). • when facilities were asked whether they would like to be connected with other suppliers of contraceptives, most facilities readily responded, “yes.” one in cameroon responded “yes. supplies have been stable in the past few months, but we have had stockouts in times past. other sources will further stabilize our supply and might even be cheaper, reducing cost, which presently acts as a barrier for a significant proportion of our potential clients.” a large rural hospital in uganda said it had missed opportunities when they did not have supplies. “if a woman comes for contraceptives and we don’t have them, we miss an opportunity to provide for her,” a hospital representative said. a kenyan facility staff said, “oxytocin, received from a commercial supplier, was not working. we injected it, but it was not working. we had to buy another expensive type. we informed the supplier of the problem; they acknowledged it and we took it back. we got a new supply from another supplier.” a closer look — country visits country visits early in 2015 aimed to document in more detail the context of faithbased health supply systems, the current range of suppliers of commodities to fbo health facilities, and fbo relationships with their ministries of health and international donors. case study 1: cameroon the field investigator had contact with health facilities and depots located in three provinces and managed by four fbo groups, the health division of the cameroon council of protestant churches (a countrywide network), the moh, and unfpa. the faith-based groups in cameroon followed moh guidelines and procedures, but each group procured and managed health supplies on its own. the cameroon baptist convention health services (cbchs) had a large central pharmacy depot, with satellite depots supplying 6 hospitals and 80 health centers in many parts of the country. the presbyterian church of cameroon (pcc), the eglise evangélique du cameroun (eec) (evangelical church of cameroon), and the eglise evangélique luthérienne (evangelical lutheran church of cameroon) in northern cameroon were also operating numerous health facilities and depots. the fbsos in cameroon ran depots and purchased medicines (including oxytocin, misoprostol, etc.) from varied sources: some from moh depots, some from overseas shippers, and some from local pharmaceutical companies. the fbso depots then sold figure 3: fp/rh services offered and patient payments (n=46 fbo health facilities) * other health services mentioned by respondents: breast cancer screening, cervical cancer screening, deliveries, postnatal care, post-abortion care metzger and bormet christian journal for global health | http://www.cjgh.org 24 | christian journal for global health 4(2) www.cjgh.org products to their own networks of hospitals and health centers (though they reported not always receiving prompt payment from their health facilities). the fbo hospitals and health centers charged patients for these medicines and services. for contraceptive supplies, on the other hand, cameroonian fbos depended almost entirely on the ministry of health. since the moh obtained contraceptives free of charge from the united nations population fund, fbo facilities were not allowed to charge patients for those fp commodities (though they could charge for related services, such as insertion of an implant or an iud). health facilities mentioned numerous recent stockouts of contraceptives, particularly implants. in a few stockout episodes, the fbos reported that they had purchased contraceptives from the national social marketing association and then had to charge patients to offset the costs. case study 2: democratic republic of the congo (drc) site visits in drc were in two mountainous, landlocked eastern provinces (north kivu and south kivu). they included rural and urban health facilities, drug depots (faith-based and regional), the social marketing agency, the moh, and unfpa. the drc health system is based on the country’s 516 well-defined health zones (hz). within a given hz, the hospitals and health centers are owned and operated by varying groups, such as the moh, one or more fbos, or community groups; they were all expected to collaborate in health zone planning, administrative procedures, and supply procurement. each of the country’s nine administrative provinces had one or more approved depots for medical supplies operated by the moh, by an fbo, or by another registered group. international health agencies and other donor organizations, including faithbased donors, were strongly encouraged to work within the depot system and the hz system, and to figure 4: number of facilities and percent stocked out on the day of the survey metzger and bormet christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 25 collaborate with each zone’s own plans and procedures. they included hz offices, health facilities, depots (faith-based and regional), the social marketing agency, moh, and unfpa. the standard process for obtaining medicines and supplies (including fp/ rh commodities) was as follows: • the central office of each hz compiled monthly service reports and also commodity orders from all its health centers and hospitals. • the hz central depot then placed a combined order from an approved pharmaceutical depot. • when the supplies arrived, the hz depot notified the facilities, and each facility sent their own motorcycle or vehicle, or they rented a vehicle, to pick up their supplies and medicines. all health facilities (government, church-based, or private) charged patients for procedures and for medicines. exceptions included certain products that were entirely funded by the moh and/or international donor programs (immunizations, mosquito nets, tuberculosis tests and medicines, hiv/aids tests and medicines, and contraceptives). these fully funded products were provided to the public without charge, though health facilities were allowed to charge only for related services, such as insertion of contraceptive implants or iuds. the site visits confirmed that most fp/rh products came from europe, india, or the usa, sometimes by air, but usually via ocean, then by truck overland to the regional depots. most fbo health facilities used multiple sources for their rh supplies: primarily the depot of their own health zone, then (when necessary) their regional depot, commercial pharmacies, or a social marketing organization. discussion in the 13 african countries and 46 faith-based health facilities studied, the differences within and among countries, in how they accessed fp/rh supplies and how they managed logistics practices and stockouts, had different strengths and challenges but certain patterns were evident. while fbo health facilities obtained rh medicines from a variety of sources, 50 percent or more of the fbo facilities reported that nearly all their contraceptive products came through the moh supply system. this provided an overwhelming challenge if and when the moh supplies were unavailable or the quantity was insufficient to serve both government and faith-based health facilities. managing fp/rh commodities through an inconsistent source of supplies reduced the ability of the fbo facilities to consistently offer a full range of services and choices to their patients. the strengths, challenges, and possible interventions discussed below attempt to address the variety of logistical issues in fp/rh supply chain systems. the aim was to ensure whether the right product was adequately stocked at the right place and at the right price for everyone in their community. 1. ordering fp/rh supplies generally, hospitals and health centers made their own ordering decisions for fp/rh products using standard logistics tools. exceptions occurred in some facilities completely dependent on the moh (and occasionally on other donors) where the supplier decided on the quantities the facility received. strengths: most fbo facilities considered safety stocks when determining quantities to order, funds permitting. safety stocks are defined by the usaid deliver project as “the additional buffer, cushion, or reserve stock kept on hand to protect against stockouts caused by delayed deliveries, markedly increased demand, or other unexpected events. the safety stock is expressed in number of months of supply, which can also be converted into a quantity.”9 challenges: fifty-five percent of surveyed facilities experienced stockouts of contraceptives in the three months prior to the email survey, though most had found other sources or substituted other products. while the ingenuity of the facilities is commendable, it is not ideal, as it reduces the facilities’ ability to consistently offer a full range of choice to patients. ordering practices were also inconsistent for fbo facilities, in large part due to irregular supply and/ or unpredictable deliveries from sources. facilities metzger and bormet christian journal for global health | http://www.cjgh.org 26 | christian journal for global health 4(2) www.cjgh.org that could not rely on a consistent source of supply for products were more likely to say they did not consider safety stocks in their inventory. some facilities said they received products that were not what they ordered or needed. two facilities that used out-of-country sources reported that supplier stockouts and time-consuming customs procedures were major hurdles; these problems may prevent many fbos from considering low-cost, high-volume purchases of fp/rh commodities from international sources. also, we must wonder if after counseling on all methods, whether the patient’s choice of fp method was influenced by what was available in the facility vs. the method they wanted as their first choice, which was unavailable. also, supply-related bottlenecks such as cost (cost for governments and organizations to procure and distribute methods, and possible costs to the patients) may prevent patients from obtaining and using their methods of choice. fbos and all health facilities should counsel patients on all fp methods so patients may choose the best method for them. at the same time, fbo health facilities must advocate with their governments and drug supply organizations to obtain products at a low overall cost per year so the systems are sustainable (including cost-recovery, noted below) and costs to patients are realistic and accessible. 2. cost recovery and financing overall, the main source of financing in african fbo health facilities was patient fees, followed by external funding or donations, and subsidies from the ministry of health (in the form of salary payments to some staff members, or direct budget subsidies). responses about fees charged to patients varied widely. many facilities charged patients for rh medicines, depending on the source of supply. on the other hand, for contraceptives, if the moh gave them free to a health facility, the facility was typically not permitted to charge patients for the product (though some were allowed to charge for procedures when inserting iuds and contraceptive implants). strengths: the most sustainable supply systems seemed to occur in the facilities with a single faithbased source of all fp/rh products, including contraceptives, and where patients paid something for all products. challenges: a few facilities noted that contraceptives (especially long-term methods) purchased from fbsos were “too expensive,” compared to those provided free by the moh or from international organizations. one facility mentioned having a substantial debt burden with its fbso. even if fp/ rh commodities were funded by international organizations (i.e., usaid, unfpa), many other costs were incurred in getting the items to the people who needed them. in order to provide contraceptives and other rh supplies sustainably, warehouses run by the moh or by an fbo need to be able to recover their costs (for the products, customs charges, transport, their personnel, and related services). fbo health facilities, in turn, must cover costs of their personnel and of commodity transport and storage. at the final service delivery point, the prices charged to the patients (for the product and/or related services) must be low enough for the majority of their patients to afford. if fbos are not allowed to charge any fees, they will sooner or later have serious financing problems. the challenge is to find models of fbos or other non-governmental organizations in africa or other parts of the world that have successfully addressed the issue of long-term sustainability. we noted that rural, small fbo facilities in this survey served more fp patients than urban, large facilities, where people had a wider choice of health facilities and pharmacies to obtain their contraceptives. thus it is essential that staff at smaller facilities be trained to store products properly, to conduct quantification and forecasting, and to provide quality services to their patients. small, rural facilities face particular problems: are travel funds available to send staff for trainings on quantification and forecasting? who will do their job (or multiple jobs) while they are away? consistent pay schemes must be in place to maintain the trust of the patient, and having variations in pay, depending on the ability or inability of the moh to provide reliable products, is an issue to consider and overcome. the ability of an fbo to change its suppliers and/or practices will depend upon relationships with the suppliers, ordering metzger and bormet christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 27 practices, cost of commodities, and the distance and transportation involved. we did not assess why some products were included in some facilities and not in others; presumably such factors as treatment priorities, cost, availability, client preferences, and training all played a role. 3. fbo supply and pipeline management in any faith-based system, planners must analyze: • whether the principal public-sector source has mobilized adequate financing to supply subsidized products in a timely fashion to fbos, • whether the fbso and fbo facilities have access to competitive and high-quality sources, • whether good logistics management practices are in place through the whole supply chain, and whether their staff is trained, • the strength of the relationship between fbos and the supply sources, and • the fbo’s influence in the relationship (either individually or as part of a collective). finally, we can suggest potential areas of intervention for the two countries studied most closely: cameroon and the democratic republic of the congo. seven cameroonian faith-based organizations started meeting in early 2016 with an initial introduction to the smart family planning advocacy framework from advance family planning.10 they developed group goals and objectives to move forward as a group of cameroonian fbos to reduce stockouts in their facilities. they then formally organized themselves as the alliance of christian faith-based organizations for family planning (acfbofp) and registered with the government.11 this group developed a constitution, internal rules, a governing body, and training on family planning methods for its members. it continues to meet on advocacy strategy and is recruiting additional fbos to the alliance. four of the cameroonian fbos have been trained on the country’s unfpa forecasting system to enable them to strengthen and organize their internal systems to monitor and collect data necessary to participate in the national supply chain systems. this allows them to participate in the national process for forecasting and receiving commodities. they are moving forward as a team, ensuring that the concerns and issues of each individual fbo are raised at each meeting. this enables the group to revise their next steps toward the full provision of products for the programs and services that meet the needs of their communities. interventions need to focus on this group’s infrastructure, on collaborative advocacy for the faith-based sector, on equipping all groups to participate in the national quantification and forecasting system, and on ensuring commodities are able to be procured, stored, transported, and distributed in a financially sustainable structure. in the drc, strong multi-sectoral collaboration was evident in the facilities surveyed and visited. addressing stockouts will mean understanding and working within the existing hz system. solutions must complement the drc 2014–2020 fp national multi-sectoral strategic plan.12 most fbo facilities surveyed had staff already trained to provide fp services; the challenge was obtaining regular and reliable supplies. therefore, interventions should target hzs currently offering limited fp services because of stockouts. helping these hzs will mean identifying zones with trained fp providers and helping them link to regular sources of rh supplies at the provincial or national levels. however, the drc is a large country and working with in-country partners is vital to assessing updated needs and interventions. conclusions and recommendations faith entities are a critically important component of the overall health system in many countries, particularly in hard-to-reach rural areas; without them, large numbers of people would be deprived of services. addressing stockouts in a faith-based facility requires understanding its supply chain, its merits and challenges, as well as the broader context in which it exists (i.e., donors of supplies, moh-fbo relationships, etc.). in addition to cost recovery systems, long-term, sustainable foremetzger and bormet christian journal for global health | http://www.cjgh.org 28 | christian journal for global health 4(2) www.cjgh.org casting, quantification, and procurement practices need to be considered because of the multiple types of supply chain systems among and within countries. in order for faith-based organizations to provide their communities with the most robust access to good quality and affordable medicines, these issues must be addressed, and models must be tested with faith-based supply organizations. with the right support and infrastructure, the cameroonian alliance pilot model should be considered for replication by other african countries and fbos to ensure commodity security for the benefit of the overall country systems. as fbos continue to provide a large proportion of health care services in africa, they must be major collaborators in reducing stockouts of reproductive health supplies and ultimately in enhancing the lives of children, women, and families. metzger and bormet christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 29 references 1 christian connections for international health and the fam project at georgetown university. international family planning: christian actions and attitudes: a survey of christian connections for international health member organizations [internet]. mclean, va. 2008. available from: http://www.ccih.org/ccih-publications/166-international-family-planning-christian-actions-and-attitudes-a-survey-of-christian-connections-for-international-health-member-organizations-.html 2 usaid, john snow inc. deliver project and christian connections for international health. getting contraceptives to health facilities: 10 questions for community-based groups to consider [internet]. mclean, va 2012 [updated 2013]. available from: http://www.ccih.org/ ccih-publications/411-getting-contraceptives-to-health-facilities-10-questions-for-community-based-groups-.html 3 christian connections for international health and john snow inc. deliver project. webinar on getting contraceptives to health facilities [internet]. mclean, va. 2013. available from: https://www.youtube.com/watch?v=rzgy-xw_ho8 4 christian connections for international health. building the evidence: unique stockout challenges of fbo health facilities [internet]. washington, dc. 2015. available from: http://www.ccih.org/ccih-rhsc-phase-1-report.pdf 5 path, the world health organization, and the united nations population fund. essential medicines for reproductive health: guiding principles for their inclusion on national medicines lists [internet]. seattle. path. 2006. available from: http://www.path.org/publications/files/ rh_essential_meds.pdf 6 usaid deliver project. guide to conducting supply chain assessments using the lsat and liat [internet]. arlington, va. 2011. available from: http://deliver.jsi.com/ dlvr_content/resources/allpubs/guidelines/condscasselsatliat.pdf 7 survey instruments available upon request: email ccih@ ccih.org 8 huber d, curtis c, irani l, pappa s, arrington l. postabortion care: 20 years of strong evidence on emergency treatment, family planning, and other programming components. glob health sci pract. 2016;4(3):481-94. available from: https://doi.org/10.9745/ghsp-d-16-00052 9 usaid deliver project, task order 1. 2011. the logistics handbook: a practical guide for the supply chain management of health commodities. [internet]. arlington, va. available from: http://apps.who.int/medicinedocs/ documents/s20211en/s20211en.pdf 10 advancing partners and communities. afp smart: a guide to quick wins. [internet]. 2015. available from: http:// advancefamilyplanning.org/resource/afp-smart-guidequick-wins-powerpoint 11 for more information regarding the alliance of christian faith-based organizations for family planning (acfbofp) in cameroon, please contact ccih@ccih.org 12 drc 2014–2020 fp national multi-sectoral strategic plan [internet]. 2014. available from: http://www.familyplanning2020.org/resources/5614 peer reviewed competing interests: none declared. acknowledgements: hany abdallah, mhs (u3 systems work international, llc), judith brown, phd (consultant, ccih), and douglas huber, md, m.sc.(ccih) provided technical assistance in conducting and reviewing this study. the reproductive health supplies coalition (rhsc) funded the study and the initial training sessions in cameroon. correspondence: amy metzger, christian connections for international health. amymtzgr@gmail.com cite this article as: metzger a and bormet m. pharmaceutical stockouts: problems and remedies for faith-based health facilities in africa. christian journal for global health. july 2017; 4(2):19-29; https://doi.org/10.15566/cjgh.v4i2.130. © metzger a. and bormet m. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ metzger and bormet christian journal for global health | http://www.cjgh.org http://www.ccih.org/ccih-publications/166-international-family-planning-christian-actions-and-attitudes-a-survey-of-christian-connections-for-international-health-member-organizations-.html http://www.ccih.org/ccih-publications/166-international-family-planning-christian-actions-and-attitudes-a-survey-of-christian-connections-for-international-health-member-organizations-.html http://www.ccih.org/ccih-publications/166-international-family-planning-christian-actions-and-attitudes-a-survey-of-christian-connections-for-international-health-member-organizations-.html http://www.ccih.org/ccih-publications/166-international-family-planning-christian-actions-and-attitudes-a-survey-of-christian-connections-for-international-health-member-organizations-.html http://www.ccih.org/how-to-get-contraceptives-to-health-facilities.pdf http://www.ccih.org/how-to-get-contraceptives-to-health-facilities.pdf http://www.ccih.org/how-to-get-contraceptives-to-health-facilities.pdf http://www.ccih.org/ccih-publications/411-getting-contraceptives-to-health-facilities-10-questions-for-community-based-groups-.html http://www.ccih.org/ccih-publications/411-getting-contraceptives-to-health-facilities-10-questions-for-community-based-groups-.html http://www.ccih.org/ccih-publications/411-getting-contraceptives-to-health-facilities-10-questions-for-community-based-groups-.html https://www.youtube.com/watch?v=rzgy-xw_ho8 https://www.youtube.com/watch?v=rzgy-xw_ho8 http://www.path.org/publications/files/rh_essential_meds.pdf http://www.path.org/publications/files/rh_essential_meds.pdf http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/condscasselsatliat.pdf http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/condscasselsatliat.pdf http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/condscasselsatliat.pdf mailto:ccih@ccih.org mailto:ccih@ccih.org http://dx.doi.org/10.9745/ghsp-d-16-00052 http://apps.who.int/medicinedocs/documents/s20211en/s20211en.pdf http://apps.who.int/medicinedocs/documents/s20211en/s20211en.pdf http://advancefamilyplanning.org/resource/afp-smart-guide-quick-wins-powerpoint http://advancefamilyplanning.org/resource/afp-smart-guide-quick-wins-powerpoint http://advancefamilyplanning.org/resource/afp-smart-guide-quick-wins-powerpoint mailto:ccih@ccih.org http://www.familyplanning2020.org/resources/5614 http://www.familyplanning2020.org/resources/5614 mailto:amymtzgr@gmail.com http://creativecommons.org/licenses/by/4.0/ book review may 2016. christian journal for global health, 3(1): 95-98. improving aid effectiveness in global health by elvira beracochea, editor, springer new york, 2015 christine kirunga tashobya a a mbbs, ma, msc, phd, director and health systems specialist health systems development group; programme coordinator fellowship programme for health system management at makerere school of public health, kampala, uganda the book is intended to provide guidance to global health professionals for purposes of planning and implementing development projects and various initiatives and programs in global health. it has been written in the context of perceived poor aid effectiveness. from the perspective of the book, effective aid is “that which delivers the required assistance for a country’s health programs and facilities to work as part of an efficient, self-reliable, and sustainable health system that delivers quality health care consistently to every citizen anywhere in the country.” the book has been written by a number of people who have been involved in the planning, management and evaluation of aid programmes in various parts of the world. the book is organised in four main sections as follows: part i describes some perspectives of aid effectiveness and ways to measure and evaluate it. issues covered under this include: what works, challenges encountered in the management of aid, and how health systems work. some specific examples of aid management highlighted in this section include the experiences of oecd using health as a tracer sector for measuring aid effectiveness, and the experiences of the unites states government (usg) with the same. part ii provides highlights of the paris declaration on aid effectiveness and how it has been applied by various global health stakeholders including governments, international partnerships, ngos and the private sector. specifically this section of the book relates experiences of international health partnerships and related initiatives (ihp+), and the global fund to fight aids, tuberculosis and malaria (gfatm) with implementation of the paris declaration on aid effectiveness. part iii documents some challenges regarding aid effectiveness with particular reference to respect for dignity, respecting country ownership and accountability, and building real partnerships. examples are shared from rwanda, peru, the management of food aid, and the involvement of academia in aid management. finally part iv proposes some approaches that global health professionals can use to maximise aid effectiveness in projects, programmes and organisations. some of the approaches proposed include the use of monitoring and transparency by the ihp+, social media, advocacy, and measurement of results. the authors of this book claim that the book marks a point of departure for a new and more effective global health strategy based on international human rights legislation and scientific evidence. the authors argue that a number of provisions have been made at the international level for the right to health for all human beings and that it is the moral responsibility for better endowed governments to provide aid to less privileged countries as a means of facilitating efforts towards improved 96 tashobya may 2016. christian journal for global health 3(1):95-98. health in these countries, and to ensure this aid is effectively provided. some of the documents that provide the basis for this argument include: the declaration of alma ata (1978), the convention on the elimination of discrimination against women (1979), the right to development (1986), the convention on the rights of children (1989), the millennium declaration (2000), the general comment 14 (2005), and the paris declaration on aid effectiveness (2005). the authors state that the fact that every year millions of children, men and women die of conditions for which the global community has the knowledge and technology to treat or prevent is unacceptable, unprofessional and a humanrights violation. the book is a very useful addition to global health literature and especially on aid effectiveness. this is an area that has been changing quite dramatically over the last three decades, and the written word has been scrambling to follow. the book should be particularly useful for young professionals from developed countries starting their careers in global health. i found the book particularly useful as it provided different pieces of information on global health in one place. some of the notable aspects were:  the highlights of usg aid including some information on quantity, purpose and influential factors.  the millennium declaration and the related millennium goals – and how these relate to international aid management efforts like the paris declaration on aid effectiveness.  international health partnerships and related initiatives – what it is and how it has been working to promote aid effectiveness. i found the book easy to read, and i believe it is accessible to many professionals of different backgrounds, as it provides information with the minimum of jargon. i also found the book refreshing given the passion exuded by the authors who have based most of the writing from personal experience and the wish to see a better world. however, there were a number of areas in the book where i was not convinced that appropriate consideration of available information was included. in particular there was a tendency to underplay the complexity of global health, health systems and aid management. this may have been influenced by the desire to project a positive, can-do attitude in this book. however, it is important also to be pragmatic. i mention here some of the examples to which this applies. the notion of complexity very much applies to global health and aid, whereby there are many stakeholders, with different goals, and there is no single point of leverage. this often brings out tensions between political and technical approaches to aid and its management. a number of examples in this book illustrate this:  the usg approach to aid, in this book, has been said to consider defense and diplomacy before development; this has far reaching implications for how usg aid is managed and how it relates to international provisions and guidance for global health and aid management. this is an example of one country, but one which has marked influence on aid, given the amount of resources it contributes, but also its position in global politics. other countries also approach aid with varying objectives.  although many countries assented to the paris declaration on aid effectiveness, and a number are signatories to the ihp+, the experience with tracking implementation of these very commendable approaches to aid management shows that 97 tashobya may 2016. christian journal for global health 3(1):95-98. progress is much less than would be expected. this is related to the different approaches taken by donor and host governments.  rwanda is one of the few developing countries that has in the recent past been noted to have made marked improvements in aid effectiveness. however as is indicated in chapter 14, many challenges still exist, and the experience so far is over a relatively short period of time. other countries have shown such promising innovations in the past, but most have not managed to sustain the improved approach to aid management over the medium to long term. another point that is related to complexity in health systems and global health is in relation to measurement of project and programme interventions. in this book a linear model has been proposed (page 4) whereby it is assumed that a well-designed donor project will contribute to the development of a country’s health sector, which will ensure quality healthcare, and subsequently desired health outcomes. however it is recognised that health systems are very complex, with many stakeholders undertaking different activities, with time lags between actions and their effects and feedback loops. further still, there are many determinants of health outcomes. therefore, however well-designed a project is, it may not lead to measurable improvements in the broader health system and better health outcomes. this contributes to why many donors insist on having projects with clear inputs and outputs without necessarily attempting to relate these to changes in the broader health system. it has been noted that the authors assume substantial power/authority/capacity of some entities in relation to global health. in a number of instances, it is indicated that the world health organisation (who) should ensure coordination of the different players in global health. however in today’s global architecture it is recognised that who has limited authority and capacity to call the national governments (donor and host) and agencies to order. the ebola epidemic in west africa clearly illustrated this. similarly the authors indicate that national (host) governments should prepare plans that provide for inclusion of donor-funded programmes in subsequent years. in many cases this is not possible because sometimes donor portfolios are larger than the entire sector’s budget and quite often the host governments do not even have comprehensive information on what the donor entity is doing. thus, however wellintentioned the host government may be, it is unlikely that they would be able to take on board into national plans the implications of such aid in the medium term. this review has been heavily influenced by my own experience as a health professional practicing in the developing world for the last 25 years. given the comments above, i am of the opinion that the book has provided some very good technical and logistical approaches to improving aid effectiveness, which would be of interest to young global health professionals as i have mentioned before. however, i would have liked to see a better attempt at bringing together some of the different recommendations for improving aid effectiveness into a broader linked framework, taking into consideration the complexity of global health and aid management. in this regard, it may be useful to consider this book alongside other literature that highlights this perspective. 1 . references 1. bossyns p & verle p, eds. development cooperation as learning in progress: dealing with the urge for the fast and easy. studies on health services organisation & policy, 33, 2016. itg press, antwerp, belgium. 98 tashobya may 2016. christian journal for global health 3(1):95-98. competing interests: none declared. dr. tashobya is on the editorial board of cjgh correspondence: dr. christine kirunga tashobya, health systems development group, p.o box 24109 kampala, uganda. tashobyack@yahoo.co.uk cite this article as: tashobya ck. improving aid effectiveness in global health by elvira beracochea, ed, springer new york, 2016. christian journal for global health (may 2016), 3(1): 95-98. © tashobya, ck. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:tashobyack@yahoo.co.uk http://creativecommons.org/licenses/by/3.0/ original article assessing long-term impact of values-based community health education in cambodia amit nirmal cuttilana, ravi amran cuttilanb, si min chuac, annelies wildersmithd a medical student, yong loo lin school of medicine, national university of singapore b alumnus of yong loo lin school of medicine, national university of singapore and anesthesia resident, tan tock seng hospital, singapore c alumnus of yong loo lin school of medicine, national university of singapore d professor of infectious diseases, director, global health and vaccinology programme, lee kong chian school of medicine, nanyang technological university abstract introduction: community health education (che) is a development strategy which aims to address the needs of communities in developing countries through an emphasis on moral values and civic education. the syllabus of the che program guides a trainer to find the needs of a developing community and take a moral values-based approach to health issues such as alcoholism, smoking, injuries to accidents, and sexually-transmitted illnesses. the fundamental philosophy is that of development as opposed to aid. methods: in november 2010 and february 2011, this training was conducted for leaders and volunteers from two cambodian non-governmental organisations (ngos) involved in hiv prevention education and training in cambodia. in order to investigate long-term impact, participants who underwent training sessions in november 2010 and february 2011 also underwent focus group discussions (fgds) and key informant interviews (kiis). results: a total of 28 participants partook in the 3 fgds and 5 participants took part in the kiis. participants were able to recall a number of moral values and concepts from the training. these included forgiveness, love, altruism, unity, respect, empathy, teamwork, optimism, and hopefulness. the organisations were then able to use the che model to change the way their organisation worked together to achieve the goals in their communities. the participants were also able to use the teaching modalities employed by che sessions in their own work with their target communities. conclusion: the che training system has had a number of positive effects. they have influenced the personal lives of the participants, the way their organizations are run and the way they reach out to their target communities. in light of the themes identified in our results, we propose further research to 22 july 2018. christian journal for global health 5(1):21-32 compare the relative magnitude of all of these effects on these organizations in the long run compared to the short run. key words: community health worker, cambodia, value-based education, community health education introduction community health education (che) is a development strategy which aims to address the needs of communities in developing countries through an emphasis on moral values and civic education. the syllabus of the che programme guides a trainer in finding the needs of a developing community and taking a moral values-based approach to health issues such as alcoholism, smoking, injuries due to accidents, and sexually-transmitted illnesses.1 the fundamental philosophy is that of development as opposed to aid. the che strategy includes a large library of training materials to which trainers have access. a training of trainers 1 course (which is part of the che strategy) was conducted for leaders and workers from two cambodian nongovernmental organisations (ngos): reproductive health association of cambodia (rhac) and trans-world radio (twr). both ngos are involved in hiv prevention education and training in cambodia. the course included the fundamental approach of finding the health needs of a developing community as well as the values-based approach of meeting those needs. the initial training of ngo workers was conducted by a team of trainers from singapore. these ngos subsequently applied the che strategy to their work with communities in cambodia. this study aims to determine what effect the moral value-based training had on the personal attitudes and practices of participants from the ngos, and whether this training resulted in any changes in the structural set-up of the ngo and programmatic approaches. this was done through focus group discussions (fgds) and key informant interviews (kiis) in june 2013. all components of this study were approved from the national university of singapore institution review board prior to the commencement of this project. methods organisations rhac is an ngo which works on issues relating to reproductive health. it is a large nonprofit organisation funded mainly by united states agency for international development (usaid), among other donors. their work in the community is done by che volunteers and health centre staff who deal with mother and child health, sexually-transmitted infections, vulnerable groups, and youth health. twr is a faith-based ngo whose main ministry is faith-based radio broadcasts. in addition to the broadcasts, they also make visits to communities of their listeners to organize rallies and engage in community development projects, which they term “holistic ministry.” they are a small organisation with a full time staff of 12. they use che principles as part of their community development strategy. the training conducted in these organisations included the che approach of focusing on helping the community through the facilitation of development rather than provision of relief. this enables sustainable development of the community. the training also included specific values-based strategies to improve the health of the communities. the strategies for improving reproductive health were more 23 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 actively promulgated by rhac as it was their organizational focus. abc and save education we based the health education portion of our trainings on the abc and save approaches to hiv/aids prevention as well as values-based approaches. the abc approach to sexual health and prevention of hiv/aids was first used in 1992. this approach based hiv prevention on three interventions; abstinence, being faithful as well as correct, and consistent condom use. this approach was credited with the reduction of hiv/aids rates in uganda from about 15% in the early 1990s to about 5% by 2001.2 in 2003, the african network of religious leaders living with hiv and aids coined a new prevention approach with the acronym “save” (safer practices, available medication, voluntary counseling and testing, empowerment) intended to encompass a far wider range of prevention needs.2 values-based education much of the research on reproductive health intervention focuses on knowledge-based “sex education,” rather than values-based education.3 on the other hand, while educationbased hiv/aids prevention has been gaining traction over the past years, this should be distinguished from the values-based approach. the education approach is based on raising awareness of hiv/aids, while the values-based approach is focused on moral and civic education that involves many aspects of life, including sexual practices. while there has been some research regarding the criticism, perspectives of, and challenges associated with a values-based education approach, literature regarding the effectiveness of such an approach is relatively lacking.4,5,6,7 interviews in order to investigate long-term impact, participants from rhac and twr who underwent training sessions in november 2010 and february 2011 were invited to attend fgds. in addition, kiis were conducted with the leaders of rhac and twr. these interviews and discussions were carried out in the offices of rhac and twr. all kiis and fgds were conducted in each organization’s national headquarters in phnom penh, cambodia, between the sixth and ninth of june, 2013. in order to maximise representation of views, all participants of the training courses were invited for the focus group interviews. from rhac, there were a total of 22 participants out of 60 that were invited. these participants were involved in fgds 1 and 2. from twr, there were a total of 6 participants out of 12 that were invited. these participants were involved in fgd 3. the main reason for certain invited participants’ inability to participate in the fgds was that they were posted to the provinces for field work and were unable to be at the phnom penh headquarters of the ngos at the time the discussions were carried out. kiis were conducted with the heads of the ngos to investigate the impact the training had on the organisational structure and practices. three of these were done with leaders of twr and two with leaders of rhac. kii interviewees from twr had conducted training sessions, while those from rhac had only participated as trainees. all fgd participants had also only participated as trainees. the interviews and focus group discussions were conducted using a semistructured interview guide. the researcher had a prepared set of questions, which were constructed in line with the aims of the study. during the sessions themselves, however, participants were encouraged to elaborate on points brought up even if they were not immediately relevant to the questions under discussion. all kiis were conducted in english, while for the fgds, participants who spoke both 24 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 english and khmer translated for those who could only speak khmer. results the key takeaways from the participants can be separated into the impact on the participants, the impact on the organizations as well as the impact on the community. personal impact the most important moral value which was brought up during every fgd and kii was that of forgiveness. participants were able to recall a number of other moral values and concepts from the training. these included love, altruism, unity, respect, empathy, teamwork, optimism, and hopefulness. they also mentioned a change in opinion over the course of the training, especially regarding the values of honesty, respect, and forgiveness. the training also highlighted the importance of sharing experiences with one another. however, they found some values, such as altruism, difficult to implement. for example, altruism was difficult to teach as the participants felt that it was not part of their culture to help people without expecting anything in return. impact on organisations and the community the ngos used the che model to improve on their work processes by applying moral values to their daily practices. they were then able to design projects to cater better to the needs of the communities they served. apart from moral values, the communities they served learned to take ownership of the trainings by planning locations for the trainings, and by taking ownership of the problems they faced in the community. this can be closely tied with the teaching of development and relief. the participants gained from learning about the differences between development and relief, and how the latter would help them progress as a community. the role plays helped participants from the communities learn about the importance of relief in the short-term and development in the long-term, where they would continue developing their communities once outside help had left. areas for improvement discussion on areas for improvement revealed four overarching themes: implementation skills, including authorities in training, avoiding christian anecdotes, and facilitation of learning. many participants mentioned they would like the training to further include counseling and facilitation skills in addition to moral values training. one participant also mentioned including one lesson regarding the community, with regard to how to develop their community to be prosperous. one participant felt that village and commune authorities should be invited to the training as training them could help change the way decisions are made in the community. although all felt that the training was appropriate to the cambodian context, the christian references during role plays could pose as a challenge to sharing the concepts with nonchristians of the community. some participants felt that the principles being taught to them were exclusively for christians and hence did not think they were applicable to them. a few participants also felt that facilitation of learning could be improved by providing handouts at the start of the training instead of the end so they could take notes. one also suggested that participants be renumerated for their time and transport expenses. hopes and dreams when asked about their hopes and dreams, the replies were varied, and included having better living standards such as clean water and electricity, and having more roads and modern facilities in their villages; building their own businesses and owning a car and villa; having their family avoid vices such as smoking, 25 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 alcohol, and gambling; and living in peace and harmony. discussion personal impact moral values were a key takeaway for participants from the trainings. the value of forgiveness came up in almost every kii and fgd. not only were participants able to see a personal change in their lives, they were also able to apply forgiveness in their family lives. however, it was noted that this concept was not initially easy to bring across in khmer as there was no direct khmer translation for it. closely tied to the theme of forgiveness were patience and anger management. the participants also learned how to modify their behavior through meditation: one participant shared how moral values were imperative in helping to defuse tense situations that arose in their organisation. in a country where the khmer rouge regime had caused much hardship and hatred among its people, participants found the practice of meditation to be helpful with issues of forgiveness and anger management. while only a few training sessions included a meditation session, those who took part in it gained from it personally, and were able to help their organisations as well. this was a positive step in helping them to build good relationships within their organisations. another value that came up during kii’s was a holistic understanding of health, through one of the lessons titled “good body, good health.” there was a change in the mindsets of the participants about what health was; they were no longer solely focused on physical well-being but also their emotional well-being. this principle of a holistic understanding of health, coupled with the lessons on forgiveness, patience, and anger management, also helped the participants to improve on their relationships with both their family members as well as their colleagues. the lesson about the tree of hope and tree of despair was well remembered by the interviewees, and they used them to train the community leaders as well as their own subordinates. they wanted to apply these lessons in a broader scale in the community. altruism was another key concept taught during the training sessions, focusing on the topic of unconditional giving. most volunteers in the organisations did not get any remuneration other than money for transport, however most of them were willing to do volunteer work because of the potential they saw in their beneficiaries passing on this knowledge to the community. some participants not only shared the lessons learned with others, they also requested for materials to pass them on to family and friends. it was agreed that many of the moral value lessons were appropriate to the cambodian context because they were applicable and not so different from the buddhist beliefs of compassion and doing good. they felt that these would be relevant in development especially at the provincial levels. the certificate given to participants at the end of the training session seemed, by itself, to be a motivator for participants to behave in a certain way, as they felt empowered to apply the concepts learnt. impact on organizations the ngos’ operations were also influenced by the che model. different stakeholders were better able to work together when they had a single, shared goal in mind. the principles in che were seen to complement the ways that the organisations were being run originally. for twr, it provided them with a framework for engaging in holistic ministry, and seeing to the physical needs of the communities they were working with. twr was not only able to apply moral values into their organisation, but they were also able to introduce them to their 26 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 listeners during rallies. once again, role plays were impactful as they were attractive and kept people engaged. the che curriculum provided a model for them to offer concrete help to their listeners; both in terms of improving the communities and spreading basic healthcare knowledge. they also used some of the methods taught by the che curriculum such as role plays and root cause analysis. they felt that this made a greater impact on the communities than previous attempts such as distributing food. for rhac, the che principles complemented the unity and compassion that had been part of the organisation’s shared values. they used a model of supportive supervision to instill moral values among team members, encourage teamwork among members of the organisation and value each member’s contributions. working in teams helped in sharing knowledge among team members, and each of them was able to share responsibilities in solving the problems together. rhac had developed a set of ten shared values as a company and the che training helped reinforce them. within rhac, different leaders had different ways of applying che principles with their teams. for example, leaders in the it team fostered teamwork by bringing up difficult problems for discussion so that a solution could be found while working together. these aspects of organisational performance were not directly and totally attributable to the influence of che training. however the participants did feel that the che principles reinforced these good practices. rhac also found that the moral values training had improved the quality of care (qoc) score that was a performance indicator assessed by an external group. they have linked moral values lessons to sexual and reproductive health as well as community development education in the community. but perhaps the most telling example of how che has had an impact on rhac was the following account of how a new project was being approached. they designed projects to cater both to the needs of the community as well as suit the skills of their stakeholders who run the projects. impact on the community in addition to the moral values recalled, participants remembered some of the teaching modalities used in the che sessions very well. the one that stood out the most was the role playing, which some said they began to apply in their own organizations as it helped keep participants engaged in the sharings. they found that this method was very applicable to the local context, enabling concepts to be shared in a way that was received easily, whether it was the ngo’s staff (who had a higher educational background) or the community leaders (who may not have had any formal education). role plays also proved to be flexible teaching tools, as they could be adapted to the needs of a particular community or group of learners. the role plays were especially effective for participants who were illiterate as ideas could be communicated easier through role plays than through normal lessons. role plays did have their limitations in some contexts though, as villagers were not always willing to participate in them. the adaptability of the che lessons was a strength that was identified. twr, for instance, planned two to three lessons based on che principles whenever they went to the field to train villagers. they would apply the most relevant lesson to the participants, targetting the needs they saw in the community. this flexibility also made it incumbent on the facilitators to be flexible and adapt the topics to relate to the real context of the target groups. the trees of hope and despair were also a useful training tool for the participants from the villages. it helped participants to understand their situations better, contextualise their problems, and understand the importance of applying moral values in their lives. participants 27 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 were able to identify the issues they faced in their communities, think of the pros and cons of the issues, and then were taught lessons on how to respond to these issues. for example, the villages in the puok district came up with a list of problems in their community of which alcohol was the most prevalent, and then they were able to focus more on how to deal with alcoholism. there was also an element of taking ownership of the trainings among the members of the community. participants took an active role in helping to set up locations for training sessions, instead of relying on members of the various organisations to set them up for them. they also started to take ownership of their own problems, first by acknowledging the problems they had in their community; the trees of hope and despair helped the villagers to understand that having good moral values would benefit them in the long run. through this, they learnt how to analyse, find the root cause, and eradicate the problem. for example, some villages had a problem with gangsterism among the youth in the communities, as they used to disrupt moral values training sessions; however, after dealing with the root cause of gangsterism, many of the youth started changing and helping out in the community rather than disrupting day-to-day activities. however, this sense of ownership took a while to get instilled in the community. one twr interviewee noted that they spent a couple of years trying and helping the community understand that the problem (alcoholism) was not an outsider’s problem, but a problem within the community itself. the che curriculum had the effect of empowering communities to solve their own problems and reduce their reliance on relief from outsiders, as well as show the ngos the importance of a partnership with the community. twr saw that che led to change from the “inside out” rather than forcing people to change against their will. anecdotes of changes they had seen in their work with the community included facilitating smoking cessation, making people confident to seek help for hiv infection as well as increased standards of health and hygiene. the focus on enabling the community to allocate its resources to meet its own needs, by giving them tools to analyse their problems and resources, rather than providing money or resources for them, has empowered them and led to a positive ripple effect in the community. challenges faced and areas for improvement interviewees identified a number of challenges posed by the situation in cambodia. one was the priorities of some rural villagers in the way they spent their money – they tended to spend on things such as mobile phones, alcohol, and cigarettes. in other communities, the problem was gambling. some participants suggested that time spent gambling led to rubbish being seen everywhere in the village. there were also instances where villagers did not open up and participate in the training sessions, but the ngo found that this improved over multiple visits as rapport was built between the ngo and villagers. once the trainers were able to get the participants to sit through a training of trainers (tot), it was easier to pass on their knowledge to them. another challenge was how people had a “relief” mindset. this led people to expect some form of payment, such as a per diem fee for attending training. this mindset also made it difficult for ngos to retain employees that they trained. in twr, they recruited employees for competencies in personality and commitment, and trained them; however, they then lost them to other ngos that are able to pay them more. rhac too was unable to maintain their volunteer pool of 22,000 volunteers as they were not able to remunerate them for their work. whenever another organisation was able to offer them even a minimal amount of money, it was a 28 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 very attractive proposition. so it was hard for them to build up a culture of volunteerism when other ngos offered money for similar jobs. another challenge that both rhac and twr faced was that ngos, in general, were reluctant to work with each other. this was particularly apparent when faith-based organisations were involved. they had a resistance to networking, saying, “this is my territory, i won't cross into yours, don’t you cross into mine!” moreover, working with a secular organisation like rhac did not bode well with one of the other organisations. there was one project where rhac was working with two faith-based organisations. one felt very strongly that they did not want to work with a secular organisation while the other was very hesitant until they found out that the project was based on building relationships. at times the che training was only effective after a period of time, requiring repeat trainings from multiple visits to show the communities that the problems they were being taught about were within the community itself. for example, twr noted that communities in the process of development needed time for more training. a challenge that echoed through a number of interviews was the lack of resources, both financial and manpower limitations, that made it difficult for them to expand their work to other target groups. if more resources were available for the organisations, an area for improvement for the che framework would have been to focus different trainings for different groups of people. the trainers felt that the che strategy was easy to implement after going through tot1; however, it was not as easy to get participants to sit through the entire training session. they also felt that supplementary moral values trainings were useful, so that they were able to understand and apply moral values in their lives and also in subsequent training sessions. the trainers also acknowledged that four days for a tot session was ideal, while the five-day-long sessions seemed to drag on. during one of the focus group discussions, the participants also wanted another tot session, as they felt that they wanted to refresh and upgrade their skills further. those who did attend more than one session felt that the second session served to reinforce what they had learnt before. while many of the lessons were suitable to the cambodian context, there were some points that were not apt for the context of each community and conflicted with the local values. for example, the adapted parable of the good samaritan, where a monk passing by chose to not help the victim, was not received well by participants. the language barrier was also an issue as some khmer translations did not make sense to participants. the need for translation also led to the lessons taking longer to cover. in villages, there was also the problem of literacy as group work involved presenting on large pieces of paper. sometimes villagers were partnered in groups where none of them were literate. in these cases, they did not seem as interested in those segments of the training session. hope for the future at the end of the kii or fgd, participants were invited to share their hopes for the future and how the training programme could help achieve them. some participants felt that the training should have been extended to other members of rhac staff beyond just the leadership and middle management. others wanted it to be spread beyond rhac; some even went so far as to suggest that certain components of the che training, particularly the moral values, should be incorporated into the public school curriculum. other staff from rhac spoke about seeing improvements in the work they were doing, such 29 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 as seeing reduced maternal deaths, greater utilisation of public health centres, reduced family violence, and less discrimination against people who are infected with hiv/aids, particularly vulnerable groups. for the organisation, there were hopes for better working relationships between colleagues in order to improve the services, greater empathy for clients, as well as greater accountability and transparency within the organisation. others hoped for a better quality of life, both in terms of reduced stress in the workplace and better relationships with their families. they also hoped that the moral value lessons would help them to reflect more about how they acted and hence help them to change their behavior. one of the twr interviewees felt that integrating media into che could help disseminate the strategies better than merely using training sessions. che has been used in cambodia for over 20 years, and twr has the capacity to reach out to many more people using their radio broadcasts. while normal lessons are limited to a small number of individuals, media broadcasts of che lessons could reach out to much more people whilst still not using too much of the limited resources that the organisation has. a volunteer from rhac also agreed that using media could help them reach out to more people, making more efficient use of their volunteers. however, one problem with using media would be trying to contextualise it for the different target audiences in the different parts of cambodia, as a cd or a radio broadcast would not be able to focus on topics which fit with the context of different villages across the country. some felt that the way to achieve this was through changing peoples’ perceptions, which would change their thinking, which in turn would lead to a change in behavior. this tied in with the hope that future generations would be able to live better lives than the participants did. another rhac member reflected that moral values would be more useful if they were integrated in every program that rhac did. instead of just having stand-alone moral value trainings in the community, integrating it into teachings that focus on agriculture or health would better help to pass on the values. finally, one hoped that there would be a tool to monitor the progress of moral values and the impact of this training. limitations participants reported remembering only a few of the moral values that they had been taught over the course of the training program, admitting that there were likely a number of aspects of the content they had forgotten. this did, however, enable us to see which topics and values they found useful or applicable in their lives or organisations. participants reported that the values they remembered at the time of the interview (which for many was about two to three years after they had attended the training session) were those that they found useful and had been implementing, either in their personal lives or in their organisations. one recounted, “i do not remember all the subjects that i have learned from the training but i thought maybe i lack something that i didn’t apply in my life. if i look at the lesson maybe i will remember.” there is also a possibility of interviewer bias with participants having a tendency to report positive aspects of the che programme and its effects more than negative ones. there is also a probability of responder bias due to the fgds being conducted in english with participants (who were proficient in english) acting as interpreters for fellow participants who answered in khmer. the impact of the training on the community is only assessed indirectly in this study, as it depends on the responses of the ngo workers during the fgds and the ngo leaders during kiis. this impact is inferred by the interviewer based on the responses of the fgd 30 cuttilan, cutillan, chua & wilder-smith july 2018. christian journal for global health 5(1):21-32 and kii participants, and as such, the observations are limited to these perspectives only. it is possible that some relevant themes would not have been captured because of the participants who were invited but unable to participate in the fgds. it is possible that some of the points brought up were “lost in translation.” great efforts were made during the sessions, however, to clarify what was said, through repetition and asking for concrete examples of abstract ideas. the organisations of rhac and twr had trainings other than those with che principles, and there could have been an overlap in material between these. as such, it is likely that some participants attribute to che impact from other training as well, especially where there is an overlap. being a qualitative study, the aim is to find the spectrum of responses in the population being studied and not the prevalence of each individual response. as such, we are unable to draw firm conclusions on the importance of each theme elicited from the fgds and kiis. however, the qualitative study has its strengths as well; it helped us elicit details on behaviour and personality characteristics that a quantitative study would not be able to match. this study helped us to learn more about how applicable che was in the cambodian setting based on the responses of the trainees to the training as well as their application of these lessons in their target communities. conclusion from the findings, it is clear that the che training system had a number of positive effects. they have influenced the personal lives of the participants by helping them recall moral values and concepts from the trainings. these not only helped in their personal lives but some of them were able to pass on this knowledge to others using the handbooks they received from the training sessions. these personal values also aided participants in improving their organisations’ internal operations as well as how the organisations engaged the community. both of the organisations started using che principles in the way they solved their problems, working in more holistic ways to solve problems. they also employed methods used in the che workshops in their work with the communities. this helped with their education efforts in their respective target communities. the two organisations sampled had a number of differences. while both of them were ngos, rhac was a secular organisation whereas twr was faith based. however, both were able to see the benefits of the che training, both in the short and long term. in light of the themes identified, we propose further research to compare the relative magnitude of all of these effects on these organisations 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and second, more local, community-based initiatives. the evidence draws attention to the need to acknowledge the complexities surrounding mental health and inclusion, such as additional stigmatisation due to multidimensional poverty, gender inequality, security issues, natural disasters, and additional stressors associated with access. organisational experiences also highlight the need to work with communities’ strengths to increase capacity around inclusion and to apply community development approaches where space is created for communities to generate holistic solutions. most significantly, approaches at all levels require efforts to ensure that people with psychosocial disability are given a voice and are included in shaping programs, policies, and appropriate responses. 73 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 definitions for the purpose of this paper, the authors use the term “psychosocial disability,” which adopts a social model for understanding mental illness and acknowledges the broader experience of how mental illhealth can affect a person’s ability to participate fully in life. 1 introduction psychosocial disability has generally been researched on the basis of diagnostic categoryisation and medication regimes, which has largely led to a medicalisation of the experience. 2,3,4 in lowand middle-income countries (lmics), the focus of research has been on the treatment gap, the inequalities in mental health systems, and scaling up access to medical expertise and treatment through task shifting. whilst these are key considerations, the issues need to be seen through a broader lens that includes the family, community, and social determinants of health and cultural contexts. 2 there is a growing body of literature that seeks to understand these aspects of lived experience through exploring supportive networks, social change, and promoting meaningmaking of experiences and pathways to participation. 2,3,4,5,6 however, these studies have been predominantly conducted in high-income countries, and there is very little evidence of the experience of people affected by psychosocial disability in lmics. there remains a strong need for contextual experiences from lmics to be recognised and to inform approaches to strengthen inclusion, both locally and globally. context and methodology tear australia is a movement of christians responding to the needs of poor communities around the world. 2 tear has longstanding partnerships with local organisations – the emmanuel hospital association (eha) in india, the centre for mental health and counselling (cmc) in nepal, and an unnamed tear partner in afghanistan (tpa). these organisations have a wealth of experience in implementing contextually-relevant mental health work. this paper brings together learning from the experiences of these organisations, and from the people and communities with whom they work. emerging themes highlight the key challenges faced by people with psychosocial disability and some possible, effective approaches to strengthening inclusion. this practice review is comprised of two phases. the first phase was a field visit to eha, india, and cmc, nepal. during these visits, the authors met together to set the parameters of the review. observation and semi-structured interviews were utilised with project staff and communities. a thematic analysis by the authors was then performed on project reports and evaluations from the three projects conducted from 2012 to 2016. this analysis, in conjunction with themes which emerged during the field visits, has formed the content of this paper. findings there are multiple compounding factors impacting people with psychosocial disability, their families, and communities in lmic contexts, and therefore, a standard model of mental health conceptualisation may not be the most suitable. the work of these local organisations draws attention to the complexities surrounding mental health, such as additional stigmatisation within the caste system, security concerns or natural disasters compounding accessibility, poverty, and additional stressors associated with political uncertainty and social exclusion. their experiences also highlight the need to work within cultural contexts and frameworks to strengthen inclusion and to provide space for communities to generate solutions. utilising combined approaches of community development, which enables problem solving at a local level, in addition to strengthening public health systems and policy development ensures strong synergies and holistic approaches to inclusion. 74 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 stigma, culture, poverty and access . . . people feel shame when they know they have mental health problems because of the social stigma. (tpa) a significant factor, globally, in the experience of psychosocial disability is that of stigma which diminishes opportunities to participate in community life. 2 stigma is complex, and addressing it necessitates a multi-faceted approach beyond simply raising awareness or improving the affordability of treatment. during a wedding, i had a bad time and everyone came to stare at me, because of this, i avoided many weddings. my relatives ask me why i am not looking a good colour. i want to stay at home and lie down. they tease and laugh at me. (woman with psychosocial disability, tpa) it is important to acknowledge the complexities surrounding stigma in light of local belief systems and societal structures. 2,3 some local belief systems can promote effective integration and wellbeing, whilst some impede inclusion. 2 tpa, eha, and cmc have noted that stigma is often compounded by multidimensional poverty, caste, gender, and other factors. 2,3 rich people go to private clinics or hospitals for service and hide the evidence [of their symptoms]. poorer or marginalized people... have no information about mental health problem and its treatment so they are either chained or locked in a room or in the street. (cmc) the type of mental illness experienced can influence the level of stigma experienced and relate to perceived causes such as witchcraft, former life influences, and other beliefs. 2 tpa, for example, has observed that there seems to be less stigma surrounding depression and anxiety in afghanistan when compared with psychosis. this reinforces the need for a cultural understanding of stigma frameworks and tailored approaches to leverage cultural strengths to overcome all types of stigma. as part of creating enabling environments in the community, we developed information brochures. the brochures give information on mental health, types of mental health, social change, stigma, gender, disability, communication and change, relationships, and suicide prevention. they are used to help community volunteers have confidence when talking to families and communities about these issues. (eha) it is important to note that medical information alone may not be effective in reducing stigma. allowing people with psychosocial disabilities a voice in their communities, and media campaigns that seek to increase general understanding about mental illness are considered more effective approaches. 2 access to effective treatment, however, is still a vital issue for many people with psychosocial disabilities, especially where an absence of treatment may lead to an exacerbation of symptoms, and increased stigma and disability. among those who do seek treatment, many may initially turn to non-allopathic service providers such as healers or practitioners of traditional medicines due to beliefs around mental health and its causes. 17 tpa and eha are aiming much of their training and awareness-raising activities towards traditional healers and key religious leaders in order to facilitate an increase in receptivity to mental health services. religious leaders may be willing to see that medication has a role in the cure, and the importance of prevention of mental health disorders, and their roles would be to do referrals for medication and rehabilitation apart from spiritual prayer and healing. (eha) disruptions such as security issues and natural disasters can also contribute to the complexity of psychosocial disability in lmics. the nepal earthquake and violent conflict in afghanistan have brought additional barriers to accessing care where, due to trauma and other psychosocial factors associated with such events, there may have been an increased and more urgent need. utilising community development approaches tpa, cmc, and eha adopt communitycentred approaches to strengthen inclusion through understanding and considering the 75 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 historical, cultural, educational, economic, and social factors at the community level. this community development approach does not see problems as inherent in individuals, but connects locally-based solutions to wider issues of power, participation, and social and economic justice. 2,3,4,5 tpa, cmc, and eha utilise strategies that identify community strengths; uphold inclusive approaches; and value narrative, community connectedness, and a commitment to holistic well-being and development.  context, family and community relationships the three organisations work in contexts which have strong family and community values. the involvement of others is therefore fundamental in understanding causes, appropriate treatments, and pathways for participation. 2 for these participants, the causes of mental distress were not generally located within individuals, but rather in the quality of the relationships they have with those around them. this is congruent with the concept that mental health and well-being is dependent on, and not separate from, people’s social relationships and place in the world, rather than something that people have inside themselves and carry with them wherever they go. 19 a community perspective also highlights the valuable and central role of extended relationships. guerin and guerin assert, “dominant western models for mental illness treatments often focus solely on individuals and their immediate relationships and fail to take account of the importance of extended community relationship.” 27 tpa, eha, and cmc respond to this through utilising social network approaches. eha, for example, employs communitywide approaches to prevention and inclusion, and they have developed culturally appropriate community resources that promote dialogue on mental health prevention and management. eha has also sought to understand community contexts and then incorporated targeted skill-building into their approach to strengthen family relationships, parenting, community cohesion, active listening, tolerance, and inclusion. . . . the peer educator’s interaction helps people to build their identity and understand the cultural norms and values and a wider perspective that enables them to be responsible members of their communities . . . the peers will be available as supportive mechanisms and create enabling environments for sharing and interaction. they use appropriate iec aids within group meetings, trainings, playful events, and community discussions . . . (eha) recognising the valuable role of community and religious leaders is an additional pathway towards change: some community leaders in conservative areas initially were hostile to mental health teaching as they believe it is only god’s area, but after four days of training they came to accept the training. there are also tensions between mullahs and doctors in the local culture; however, by being respectful to mullahs, this can be overcome. (tpa) according to our culture, community leaders can help any program in their area. they are the most respected and influential people at the local community level. it is very important that people know mental health problems are treatable like physical problems, so community leaders easily can communicate with people. (eha)  the use of dialogue for change the use of dialogue as a medium for change and to promote connectedness to family and community has received significant attention. 22,23,28,29 eha and cmc use the principle of dialogism through their support groups, community-based psychosocial workers, and through making counselling available. these approaches create spaces where voices can be heard, thus often breaking down stigma, selfstigma, and other barriers to inclusion. 17 utilising dialogue, people with psychosocial disability are able to strengthen a sense of agency in their own lives by discussing their difficulties, problems, and successes, and often a new understanding is built up between people. 27,30,31 76 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 cmc nepal has also used counselling to support communities following the earthquake in nepal in 2015. cmc found that despite people having no access to their medications, counselling sessions were helpful in aiding recovery from sleep problems and fear.  collective voice: the role of community-based groups community-based groups provide a place for connection, support, and dialogue and for collective voice and action. tpa, eha, and cmc play a conduit role in ensuring that the voices of those with psychosocial disabilities and their families can be heard and supported not only within the group, but also at a broader local, district, and national level. . . . now i can talk to the doctors and village development committee and ask them to respond to our problems too. (participant, cmc) eha and cmc are working with disabled persons’ organisations (dpos) and mental health advocacy groups towards sharing lived experience of psychosocial disability. these approaches “empower the whole community in its relationships and dealings with professionals and governments so people can better manage their own mental health.” 15 . . . community-based organisations utilise their corporate knowledge and skill so that they are active actors in promoting their own group as well as psychosocial wellbeing. these groups are responsible for advocacy, organising meetings, and mobilizing people with psychosocial disability for accessing rights and entitlements. (eha) it is important that broad-scale advocacy is accompanied by community-based approaches. 24 often government policies are developed on the basis of epidemiological evidence, but through the work of tpa, eha, and cmc, these policies are being increasingly shaped by deeper understandings of context and narrative. an evaluation from the cmc project demonstrated the success of self-help groups (shgs) in initiating advocacy activities to compel local service providers to implement government policy in responding to the needs of people with psychosocial disability. cmcand ehasupported shgs are instrumental in these types of advocacy efforts and are facilitating change through widespread awareness-raising and advocacy efforts, and through networking, collaboration, and strategic linkages. working with government to strengthen mental health initiatives tpa, eha, and cmc have been in working with specific government departments across multiple sectors advocating on behalf of people with psychosocial disability and their families and supporting governments’ plans to strengthen mental health strategies. they have faced many challenges, as mental health is one of the lowest health priorities for governments. 32,33 compounding challenges include: funding limitations; the complexity of decentralising services; implementation in primary-care settings; and the low numbers of trained and supervised mental health care workers. 34 much has been written about the treatment gap, with statistics citing that “four out of five people with severe mental illness in low and middle-income countries receive no effective treatment.” 35 despite the challenges, tpa, eha, and cmc have found several effective pathways for working with governments:  raising the profile of mental health tpa, eha, and cmc are taking a role in advocating for appropriate attention and funding allocation to support services and efforts towards inclusion of people with psychosocial disability. [we] participate actively in meetings and conferences regarding mental health . . . we share . . . information with different stakeholders and advocate about mental health with them. this information sharing is very useful to influence the authorities to pay more attention to the mental health problems in the community and take part in the advocacy events. for example, after prolonged advocacy two provinces have decided to re-start the mental health focal point meetings. (tpa) advocacy is . . . one of the core areas for action in any mental health arena because of the 77 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 benefits that it produces for people with mental disorders and their families. the advocacy movement has substantially influenced mental health policy and legislation in some states and is believed to be a major force behind the improvement of services. (eha) the project manager created a link with the mental health department of ministry of public health. now they have good cooperation . . . and they are always involved. this facilitated information sharing and building relationship . . . we found it very important to be in contact with the ministry. (tpa) cmc’s advocacy in nepal has resulted in an increased government budget allocation to train health workers in mental health, and some basic psychotropic drugs have been included on the government’s free list. local government . . . have allocated funds for mental health. similarly, four village development committees have allocated budgets for mental health. this evidence shows that the health service management committee have explored and tapped local resources for promoting mental health and integrating mental health services. (cmc)  strengthening implementation of government mental health strategies the work of the three organisations in strengthening government initiatives and strategies has included: 1. providing training and technical support — investing in a sustainable solution in which mental health services are integrated into existing hospitals and clinics: . . . the strength of partnership between cmc and the district health office is effective and practical . . . all of the stakeholders interviewed during the field visit reflected that the district health office has started to initiate integrating the mental health into the health services as a result of partnership with cmc. (cmc) 2. coordinating with government directly in the implementation of their activities: most lmic government mental health programs are chronically underfunded, especially in rural areas. 31 eha is working to address this through partnering with government health facilities and supplementing these services through linkages with an eha hospital: government medical officers are very happy and keen to have training regularly but they are hardly able to provide medicine and therefore not keen to practice. [in the] meantime the government are interested in working together with the project and the hospital is committed to run the clinics on a fortnightly basis and provide medication at low prices . . . (eha) tpa is coordinating with government and has achieved significant outcomes through the government’s adoption of their awareness raising resources which are now integrated into national mental health education materials. these initiatives strengthen the reach of the government’s programs.  using evidence to support advocacy initiatives tpa, eha, and cmc advocate for effective health and social systems through utilising data and supporting the sharing of lived experience to increase understanding of need and scope for action. [the] project initiated two strategies: first a mental health clinic so that project would have evidence based records and data that could show the scope of mental health issues in the region, as well as . . . showing our credential of work in the field of mental health so far. (eha) regarding the integration of the mental health [services] into the basic health services at the district and phc/hp level, all health service centres (out of 8 service centres visited) have started to keep records of psychiatry morbidity and reporting in health ministry information system regularly. (cmc)  addressing institutional barriers in india and nepal, people with psychosocial disability face barriers in accessing government disability benefits. eha and cmc facilitate access to these benefits and advocate for wider recognition of psychosocial disability. an example from eha: 78 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 . . . key informants reflected that the beneficiaries have developed confidence to demand services from the health service centres and village development committees but [before] they were not aware on what rights they are entitled to and how to access and claim their rights. (eha) eha and cmc work with local and national dpos (both psychosocial disability, specific and more general groups) in order to promote rightsbased dialogue, challenge institutional barriers and strengthen the voices of people living with psychosocial disability within communities. awareness-raising eha, cmc, and tpa implement awareness raising activities through a community development lens and seek to raise awareness of psychosocial disability to strengthen community dialogue, resilience, and problem solving. the organisations utilise different methodologies, including iec, promoting world mental health day, training teachers, and working with key change agents such as village leaders and religious leaders to increase understanding at a community level. a recent evaluation of tpa’s work found that: [the project’s] multi-faceted approach to building awareness has been effective. the training targeted influential people within society . . . to enable systemic change. (tpa) the different awareness-raising mediums have had a number of positive outcomes, including increasing utilisation of services and care, reducing stigma, and promoting rights-based awareness. 36,37 people started coming themselves to seek treatment. bridging treatment gap with education on mental health has brought change in people’s negative attitude towards mental ill people. (eha) she asked patients and their family members how they came to know that there is a clinic about the mental health and how they know generally about the mental health. about half of the patients said that they know from tv program (from tpa’s work) regarding mental health. (tpa) trainees noted that their own increased awareness brought about changes in themselves and those around them. some highlighted their own changes in attitude to people with mental illness . . . (tpa) the challenge is to continue awarenessraising, not only regarding signs and symptoms and where to seek medical assistance, but importantly, around wellbeing, inclusion, and rights, to enable balanced conversations at community level. mainstreaming tpa, cmc, and eha leverage learning from their mental health work and build these learnings into more general development programs: eha is using this and another project as a pilot to see how it can integrate mental health into mainstream health services. the learnings from here appear to be feeding into their wider work. (eha) integration with other programs . . . will [help people] understand the importance of mental health program and take interest how mental health is integrated with nutrition, family planning, immunization and institutional delivery government nationalised program. (eha) tpa has been invited to give mental health training and awareness materials to organisations such as private health clinics, ingos, and the education sector. their work with teachers and students is important in raising awareness and mainstreaming mental health knowledge. it is also important to consider already marginalised groups in mental health awareness and inclusion responses. in afghanistan, it was found that women who stay home, those with low literacy, and people in more rural regions lack access to awareness raising initiatives and knowledge. (tpa) cmc has been involved in conducting training for teachers in deaf schools. the training materials are interpreted into sign language and therefore accessible to this potentially marginalised group. similarly in afghanistan: [tpa] received a request from a blind school to train their teachers and students in 79 fernandes, cantrill, kamal & shrestha nov 2017. christian journal for global health 4(3):72-81 mental health, they promised to print the mental health materials in braille and [tpa] conducted training for the teachers. (tpa) these are valuable examples of how pathways to accessing information on mental health and inclusion may need to be modified to include other marginalised groups. implications for practice this collaborative review of the efforts of local ngos to promote for people with psychosocial disability provides many implications for current and future practice, including:  the importance of creating platforms that strengthen the voices of people with psychosocial disability  seeking to understand the sociocultural context towards inclusion  recognising the role of the family  promoting collective action at a grassroots level  strengthening public health systems and policy development — ngos play a key role in collaborating with governments and networking at district and national levels to bring about change  promoting linkages with people with lived experience and affected communities to inform organisational actions and approaches conclusions the shared experiences of tpa, eha, and cmc provide useful and insightful ways in which to explore some of the barriers and enablers to the inclusion of people with psychosocial disability across three lmic contexts. their approaches provide opportunities for further research into the lived experience of people with psychosocial disability in lmics. strengthening the voices of people with psychosocial disability and seeking to understand the sociocultural context towards inclusion remains crucial. creating change through collective action at a grassroots level, in addition to strengthening public health systems and policy development, ensures a holistic approach to inclusion. non-government organisations play a key role in collaborating with governments and networking at district and national levels to bring about change. their linkages with people with lived experience and affected communities should inform their messages and approaches to these broader collaborations. the key findings from this paper highlight the key 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review. christian journal for global health. nov 2017; 4(3):72-81. https://doi.org/10.15566/cjgh.v4i3.172 © fernandes hl, cantrill s, kamal r, shrestha rl. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1002/anzf.1099 https://www.cgdev.org/publication/ft/making-room-mental-health-recommendations-improving-mental-health-care-low-and-middle https://www.cgdev.org/publication/ft/making-room-mental-health-recommendations-improving-mental-health-care-low-and-middle https://www.cgdev.org/publication/ft/making-room-mental-health-recommendations-improving-mental-health-care-low-and-middle https://doi.org/10.1186/s12992-016-0150-3 http://www.who.int/bulletin/volumes/82/11/en/858.pdf http://www.who.int/bulletin/volumes/82/11/en/858.pdf http://www.who.int/mental_health/action_plan_2013/en/ http://www.who.int/mental_health/action_plan_2013/en/ https://doi.org/10.1016/s0140-6736(07)61263-x https://doi.org/10.1186/s13031-014-0030-5 https://doi.org/10.1192/bjp.bp.114.151944 https://doi.org/10.1080/09540260500073638 mailto:helen.fernandes@tear.org.au https://doi.org/10.15566/cjgh.v4i3.172 http://creativecommons.org/licenses/by/4.0/ original article july 2017. christian journal for global health 4(2):43-52. impacts of community lay-leader health worker training and practice (uttarakhand, india) nicole butchera, nathan grillsb a nossal institute of global health, university of melbourne, australia b mbbs, mph, dphil, associate professor and public health physician, nossal institute of global health, university of melbourne, australia abstract this study investigated the impacts of the community lay-leaders health training certificate course on trainees and their communities in the state of uttarakhand, north india. a suite of semi-structured interviews and focus group discussions were conducted among course stakeholders and graduates, respectively, and textual data was added to the data set. thematic analysis of the results revealed four themes, including: (1) the effectiveness of course design and delivery, together with the key role of the coordinating facilitator; (2) the match between graduates’ practices, the providing institution’s objectives and general expectations of community health workers; (3) the strengthening of the health system through skills multiplication, collaboration with existing authorities, and advocacy for higher quality in professional practice; and (4) the need for ongoing support and training post-graduation. the findings are consistent with literature concerning community health workers’ roles and challenges, although some potentially unique outcomes were noted with respect to the pastoral support provided to trainees and the pro-active transfer of graduates’ knowledge and skills to fellow villagers. key words: community health worker, training, india, primary healthcare, advocacy, health system strengthening introduction community health workers (chws) provide and extend health education and healthcare to remote populations where geography and socio-economic disadvantage typically impede access to health information and services. where chws operate, villagers can experience improved health outcomes.1 acting as a link to formal healthcare services, chws also support or organise community development activities and data collection.2,3 worldwide, the specifics of chw programs and activities vary greatly, however, and the national health mission of india initiated an effective chw program in 2008 to train villagers as accredited social health activists (ashas) to expand healthcare coverage. this program alone remains insufficient to meet the needs 44 butcher & grills july 2017. christian journal for global health 4(2):43-52. of the large indian population in rural areas, and the work of ashas has for the most part been limited to maternal and child health.4 in view of the poor distribution of human resources for health in india’s rural, tribal, and hill areas, the christian medical college (cmc) in vellore, india, sought to enhance efforts to respond to the high burden of largely preventable and often easily treatable diseases by establishing the community lay-leaders health training certificate (clhtc) course in 2011.4-6 the clhtc course trains lay leaders with the knowledge, skills, and attitudes to serve their local villages and schools with health promotion, health education, and basic health care. the course takes an intentionally holistic approach to health and wellbeing by addressing spiritual, emotional, and social, as well as physical aspects of health. “candidates,” as the trainees are known, come from mainly a theological background (i.e., they are trained and/or working as christian workers in their villages and typically have little knowledge of health). in the north indian state of uttarakhand, the community health global network (chgn) has joined with the herbertpur christian hospital (hch) and landour community hospital (lch) to support candidates in its region. chgn has secured funding to employ a coordinating facilitator whose role includes both technical and pastoral support for the candidates, and to provide additional support to up to 40 candidates per year. over 250 candidates have graduated from the course with funding through chgn. the present study sought to determine some of the outcomes of the clhtc course for the candidates and their communities in uttarakhand. it aims to contribute to the literature on the outcomes of training chws, concerning the trainees and the communities they serve.2 methods the study was undertaken during november 2016 in uttarakhand state, north india and consisted of a triangulation of semi-structured interviews and focus group discussions. a research assistant from a global health institute in australia conducted the semi-structured interviews with the chgnemployed coordinating facilitator, the secretary of the clhtc initiative within chgn, the president of chgn, and three managers of course graduates employed by the organisation “ngo1” (a small organisation that conducts community development work among remote districts outside of mussoorie). the interviews were conducted in english. four focus group discussions were conducted with graduates from either hch or lch (14 participants). focus group discussions were held in hindi at the training site at hch (two) or in communities of service (two). three focus group discussions had live translation (hindi to english) through an interpreter, and the fourth focus group’s discussion was audiorecorded for subsequent oral translation by an interpreter with transcription by the researcher. graduates who lived within appropriate reach of the study sites were nominated for participation by the coordinating facilitator of the course or managers of ngo1. the latter recruited the participants by telephone invitation, to a total of five available persons. following translation and transcription of the interviews and discussions, a grounded theoretical approach was used in undertaking a thematic analysis of the interviews and discussions. this involved generating initial codes, searching for themes among codes, reviewing themes, defining and naming themes, and producing the final report. the first author (nb) initiated the initial codes and sub themes, and the second author (ng) reviewed the themes. together, nb and ng determined the final meta-themes and sub-themes produced in the report. the study was considered exempt from a requirement for ethical review. results during implementation of the study, some additional participants manifested, some did not show, and an additional source of data became available. the changes were as follows: a fifth 45 butcher & grills july 2017. christian journal for global health 4(2):43-52. discussion group was scheduled for several graduates, but only one (male) could attend, so this was conducted as an interview. at one focus group discussion, three community health volunteers (not trained through the clhtc course but by a graduate thereof), including one government-trained asha, were present in addition to the female graduate. only the graduate’s remarks were included in this study. in addition, a graduation ceremony for candidates completing the 2016 course was held during the time of the study. therefore, the graduation speeches were audio-recorded and subsequently livetranslated and transcribed, to serve as supplementary textual data. this data included recordings of five of the participants of one focus group discussion. graduates had between approximately nine months to four years of practice experience on which to draw to inform their sharing experiences and observations. the thematic analysis revealed four meta themes, each with a number of sub-themes, as follows: (1) the course delivery is effective in its design and delivery, and particularly in view of the role of the coordinating facilitator; (2) the course has impact at the community level, with graduates’ practices matching the objectives of cmc, vellore, extending basic healthcare to rural and disadvantaged communities, and embedding them in the community as holistic healthcare workers; (3) the course facilitates health system strengthening through the multiplication of skills, collaborating with existing authorities, and advocating for higher quality in professional practice; and, (4) graduates lack ongoing support and training. the findings are presented under these four headings. the course delivery is effective the clhtc course content is comprehensive, delivered in a uniquely practical manner several interview respondents spontaneously commented on the “impressive” (ssi4) range of topics covered in the course manuals. encapsulating these comments, one interviewee said, “the manuals are simple and effective... very easy to follow... the method of training is very good.” (ss2) another interviewee said, “[clhtc] enhances the work of those whose work is faith-based, to understand health in a scientific way.” (ssi1) one female graduate has developed a curriculum for training community health volunteers in a number of surrounding villages based on the content of the clhtc. it was found that the delivery of the content constituted a key strength of the program. one interviewee noted that the combination of theory, curriculum, and “hands-on” opportunities with “assignments to complete in the field” made the clhtc “a good package.”(ssi1) underscoring the effectiveness of the practical mode of knowledge and skills transfer, several candidates alluded to the inferiority of their prior education or training in comparison to the clhtc course. further comments were as follows: • whatever i’ve learnt, i’ve been able to apply it in my work and in my family. (gs1) • whereas community health volunteers have experience, clhtc graduates have training... [the training] has made them qualified. (ssi2) coordinating facilitator, a “pillar” upholding the course the chgn-employed coordinating facilitator was mentioned by many respondents as being of key importance in the successful completion of the course: • i really enjoyed [the coordinating facilitator’s] way of teaching, her approach – she’s a good teacher. the two trainers were so good. not only in the classroom but also outside class, they looked out for us and followed up with prayer. (fgd11) • [her] role has been crucial. she has been very supportive, but had she not been there we wouldn’t have been able to complete the course. she is strict, but she equally cares for and loves us. (fgd32) • we can call [her] if we’re stuck and don’t know what to do. she always makes herself available. she is strict, but loving. (fgd34) 46 butcher & grills july 2017. christian journal for global health 4(2):43-52. three respondents independently told the story of a trainee in the 2016 cohort who managed to deliver a baby on the side of the road, with thanks to the availability and support of the coordinating facilitator by telephone. the course has impact at the community level graduates are active in all intended practices cmc intends for graduates to be active in: health education; illness prevention through health promotion; follow-up and care of mother and child; healthcare for “common ailments”; first aid; followup care of patients on long-term treatments; referral; and health advocacy. across all focus group discussions each of these activities was cited, the most common being health education (through prevention and awareness raising) and healthcare provision (in the form of first aid, diagnosis, treatment or referral). activities associated with health education included calling groups of villagers together for lessons, teaching large school groups, and teaching at village meetings. one male respondent moved strategically through schools in his area. he said, “our target is to reach all the schools in three months. the students are from all backgrounds—low caste, high income. we hope that they’ll take this information home and act as change agents that will have an impact.”(fgd14) two trainees referred to health “camps” they had run over a twoto three-day period in different regions to raise awareness about “[tuberculosis], cancer, and general health” among community members (fgd31, fgd34). two graduates have opened a primary school since completing the course and have the express intention of promoting health among parents as well as the children. healthcare provision was typically one-onone, and involved syndromic diagnoses according to logarithms in the course manual, distribution of basic remedies such as paracetamol, rehydration salts and cough syrups, measuring blood pressure or blood glucose, and referring individuals needing further medical attention (some accompanied their patients to the referred facility). quality, holistic healthcare is extended to remote areas the majority of course participants live and serve in remote locations where access to healthcare is otherwise non-existent outside of a several-hour journey to a hospital. therefore, the presence of clhtc graduates in the community extends the availability of care to remote locations, providing “timely help for those who are sick...” (ssi1), which is holistic in its approach. • people now have someone to go to. it’s a big help. (ssi1) • we are creating a very good grassroots change agent with a good understanding of health and holistic health... [they] address misconceptions and harmful practice in the community. (ssi1) the clhtc course encourages candidates to integrate prayer into their consultations. several candidates reported offering prayer before or after diagnosing a patient and/or treating him/her. one respondent said that some patients appreciate the prayer so much that they return for prayer alone. villagers are mobilised to seek healthcare having clhtc-trained workers in the community has a mobilising effect on community members such that they are beginning to seek healthcare treatment and advice. respondents said that villagers were making careful observation of the effects of consultation/treatment on the graduates’ patients, and acting accordingly. that is, if a patient’s wellbeing was perceived by villagers to have improved after consultation, they would consider consulting the graduate too. some villagers who received the graduate’s services would refer or accompany fellow villagers to see them. in two locations, respondents reported a general growth in attendance for immunisation and antenatal care in their area. this was not verified by means of additional data collection from health services or information management systems. 47 butcher & grills july 2017. christian journal for global health 4(2):43-52. relationships with community members are strengthened completion of the course has had a notable impact on graduates’ relationships with community members, in particular causing them to gain respect, appreciation, and the confidence of villagers. • people in my village respect me now. i’ve become more important to them. when i was away for training, they knew where i was, so they expected me to return with new skills. only a few trusted me at first. they testified that i was reliable and now everyone comes to me. now they come every day. (fgd51) • people appreciate that i take bp but don’t charge... people feel more comfortable with me than the roadside doctor. we’re loving, caring and invite them into our home. we want to look after them... they also call to say ‘thank you’. (fgd22) • i observe that anyone who gives any counselling does it for money. life is short— if we give counsel to someone that influences their worldview, everything is worthwhile. people start to notice that we provide counsel without seeking any reward for ourselves. it’s for the benefit of the community. (fgd13) one manager noted that when encountering opposition, his graduates “press on and let the results of their work speak for themselves.” (ssi2) the course facilitates health system strengthening and advocacy the clhtc course has a multiplicative effect as previously noted, one female graduate has undertaken to train community health volunteers in several villages. she holds regular training sessions for up for forty volunteers (total over 200 female trainees), thus transferring her knowledge through the clhtc curriculum, and providing a point of contact and support to the volunteers. two of her fellow graduates are involved in the training and follow-up of those trainees. other graduates also train health volunteers, underscoring both the multiplicative effect of training candidates effectively and the associated extension of health education and basic healthcare provision to remote villages. one graduate mentioned that he had trained his brother to help villagers when they called during his absence. cooperation with local/government service providers is enhanced respondents spoke of the establishment and improvement of relationships with key community players, including government health workers / volunteers as well as village heads and other local authorities. three respondents mentioned that they have become involved in the government-mandated health and sanitation committee of their village or area. two of these said that due to their joint influence, the local committee had re-formed and monthly meetings had begun with good support from local authorities, police, education and religious sector representatives, and others. for graduates associated with ngo1, their rapport with the government-supported ashas, auxiliary nurse midwives (anms), and local anganwadi (government-sponsored child care and mother care centre) workers has been enhanced. • the anm, asha, the village head, and head of district appreciate our work. that’s why they continue to send people to us. (fgd42) in addition to endorsing graduates’ practices, these government workers willingly collaborate with them. for example, when the anm is scheduled to visit the village for immunisation or maternal and child health clinics, she notifies the asha who in turn informs the graduate, and together they rally villagers to attend the services. the cmo of the district where ngo1 works affirmed the graduates in their work, and one respondent said that the head of her village was “very happy with our work, very supportive, (told) us we’re doing good for the village, and the people (were) keeping well.” (fgd42) clhtc graduates advocate for strengthened professional practice in health 48 butcher & grills july 2017. christian journal for global health 4(2):43-52. by virtue of their work ethic, some graduates are having an impact on the conduct of health practitioners. respondents from ngo1 reported that their collaboration with government reproductive, mother, and child health workers had positively influenced those workers’ practices: • the anms used to work dishonestly, just filling their registers without doing the work. when they came to work alongside us, we urged them to fill in their registers only when the baby had been vaccinated. now they’re working honestly. by our example, we demonstrate the way to truly follow the plan set out for ashas... visit newly-marrieds, and so on. we tell them that the leaders may not be watching but the big god is. (fgd21) another graduate stressed the challenge and simultaneous opportunity of working in the context of unqualified or unauthorised providers: • there are quacks everywhere—they feel threatened by us. the challenge is to develop a relationship with them! sometimes they listen to what we say, agree that, ‘yes, you are right’ but don’t change. (fgd11) a male graduate reported having roused some conflict among local authorities due to his calling health practitioners to account in an assignment: • i conducted a survey on hiv/aids. somehow the media got hold of [my report] and the local officials got angry because it spoke out against them. i learned that what we learn and what we do is a little bit different... local health providers used to be selling iron-folate tablets intended for pregnant women on the market. now, at least, the pregnant women are receiving them. (fgd13) the course could be even more effective improved referral linkages needed many respondents expressed a need for better referral pathways to doctors at the nearest facility. stronger linkages would also legitimise the advice and practice of the graduates. • we need a contact person and to know where/to whom to send the patient—a lot of villagers ask which doctor they should go to and we don’t have an answer. (fgd32) • we need a referral system so we can refer patients to a doctor directly—a lot of patients ask us for medicines and assistance to be taken to the hospital. (fgd31) • linking to doctors in the hospital (contact number) to be able to tell a community member, ‘i don’t know, but i can ask and let you know’ because they have access to a doctor who can advise them. (ssi1) more systematic follow-up support and training needed the relationship between asha workers and graduates associated with ngo1 has given rise to an arrangement whereby the asha workers keep graduates abreast of any government policy updates. in order to keep abreast of these and general developments in health, however, many respondents expressed their need for follow-up support postgraduation. • [we need] occasional checks from clhtc (say, once every six months) to help us know we’re practising well and keeping confident, and to check on my records... the point is to keep us alert... not from the chief medical officer, because clhtc are my people and they’re coming to check on me—the people will see that my people are checking up. (fgd41) • [we need] some practical experience with a doctor to observe what we do. (fgd12) • “a smartphone application,” an “sms reminder” service and/or “a quarterly magazine” from cmc. (ssi1) nearly all respondents referred to the lack of refresher courses. some added that graduates were in need of opportunities for information updates and case discussion amongst peers. 49 butcher & grills july 2017. christian journal for global health 4(2):43-52. • everything is changing—medical guidelines, government regulations on money—so it’s important to [be] refreshed and updated. we need to learn about the changes... every six months. (fgd13) discussion the clhtc training curriculum was found to correspond to many of the standards outlined by lehmann and sanders and oliver et al., and clhtc graduates generally mirrored international understandings and definitions of chws.1,2 respondents were highly appreciative of the course and indicated that the clhtc course, in particular through its provision of a comprehensive training package, equipped candidates to serve their communities effectively and integrate with existing health services. their views echoed those of chws studied by oliver et al., who reported that their training had not only provided “health messages for them to communicate, but also techniques to demonstrate, discuss and collaborate.”2 (p. 12) internationally, the scope of chw practice is broad, however, depending in part on the resources behind the program. whereas many programs offer a basic training course and ongoing participation in a designated chw initiative, this is rather a course that produces graduates whose practice does not form part of such a system. with respect to the training component, the findings suggest that the clhtc course is potentially distinct from other didactic courses, in view of the availability, diligence, moral, and technical support of the coordinating facilitator. playing a key role in the preparation of candidates, the appointment of this person can be considered a strength of the current clhtc program in uttarakhand. clhtc graduates were found to be practicing across the range of activities intended by cmc and most chw programs. in citing both preventive and curative activities as being routine practices, graduates indicated that they struggled less than other chws with the tension of balancing the two forms of care7. moreover, clhtc graduates’ activities comprised pastoral care (counselling, prayer, other) in addition to the common role description of a chw. as indicated by at least one respondent, some villagers valued this spiritual support, returning expressly for prayer, which corresponded to findings in a previous study of the course and the generally accepted notion in india of health comprising the spiritual as well as the physical.8 a possibly unique quality to the clhtc course is that of the proactive transfer of health knowledge and skills, which is evident among graduates in both uttarakhand and other parts of india.8 this multiplication effect indicates that graduates have indeed become change agents, as per the clhtc course motto. apart from encouraging candidates to visit various gathering places (such as village meetings, schools) and comprising communication and presentation skill components, the course does not have a lesson on multiplication per se, and hence it is the graduates who determine what form and extent these activities will take. in terms of the sustainability of that multiplication, it would seem that there is a strong degree of sustainability built into the however-informal model of respondents who were committed to providing regular training to local health volunteers. there was evidence in uttarakhand that cmc had fulfilled its objective to produce graduates who could contribute to meeting the health needs in underserved areas of their residence and outreach. by their own inference, graduates had been making an impact on villagers’ health literacy and healthseeking behaviours. both this social mobilisation and the building of trust were un-quantifiably important impacts of chw programs, which were evident in the findings, including growing access to graduates’ and government primary healthcare services.9 the finding of increased uptake of immunisation was consistent with a cochrane review of chw effectiveness and supportive of efforts to improve routine immunisation coverage in india, though was not verified through external sources such as health service data.10,11 thus, a 50 butcher & grills july 2017. christian journal for global health 4(2):43-52. quantifiable degree of impact on community was not obtained, which may lend to an extension of the study including, for example, a review of graduates’ registers, numbers of referrals made and completed, and health service uptake data. who understands that training chw distinguishes (“separates”) lay persons from their communities.12 indeed, candidates had cause to interact with villagers in new ways and thus had gained a new sense of identity in their community. participation in the course had also had an overall positive impact on candidates’ self-confidence as well as their relationships with family members and villagers, echoing the experience of ashas in manipur and chws abroad.2,3,7 the activities of clhtc graduates had also engendered a strengthening of relationships with local service providers, mainly in health but also in local governance roles. this was achieved in part through their activity within community structures and institutions: participating in (or initiating) village meetings, collaborating with local health practitioners, and establishing links with local schools. in their interface between the health system and the community, the graduates had gained both a good reputation and opportunities for advocacy. the example of graduates encouraging anms and ashas in the quality of their work implies that the attitudes, approaches and practices of the clhtc graduates have had direct and indirect impacts on the performance of those in their sphere of influence— local health practitioners and village authorities, in particular. this is an achievement that the asha program has not realised at scale.3,13 having developed “new beliefs and expectations about health and healthcare,” clhtc graduates have also gained an awareness of the extent and impacts of fraudulent practice.12 respondents noted that practicing alongside “quacks,” as they called them, had created conflict with those providers and that villagers received conflicting messages about health and healthcare. unqualified practice is widespread across india, and practicing in such a context will likely be a persistent challenge to clhtc graduates;14 hence, their work in this context contributes to interventions against that dimension of the health system. regardless of the level of care or standards respondents perceived some health providers applied, there was a clear emphasis on the need for formal links to health professionals. respondents believed that establishing this contact was important for the affirmation of their new role, for the provision of ongoing support, and for making appropriate referrals. in addition to the provision of support and collegiality, it was also a call for supervision. supervision has been tied to good decision-making by chws, motivation/morale, and retention levels and productivity, and indeed, it is widely recommended for chws to be supported by the health system.12,15 however, the interest of health personnel in supervising chws was often minimal and an early study found that the influence of the community was, in fact, greater in assuring chw motivation and performance than supervision by the health system.1,7,16 therefore, an appropriate literature review and contextual analysis of the various influencing factors need to be conducted before establishing any post-graduation support structure. lastly, respondents placed equal emphasis on the need for refresher courses and other forms of follow-up contact with the program. lehmann and sanders note that across all literature, “there is agreement on one matter: that continuing or refresher training is as important as initial training.”1 (p. 4) cmc has extended an invitation to graduates to attend refresher training in vellore every two years, but it seemed that the participants in this study had not known about or used the opportunity. both supervision-based and recognition-based incentives can help chws feel supported and motivated, and post-graduation support can take on innovative forms, such as use of mobile technology, as suggested by one of the respondents.7,15,17 it is important to note, meanwhile, that chw motivation is optimised when multiple incentives are rolled out over time.7 51 butcher & grills july 2017. christian journal for global health 4(2):43-52. limitations the study did not have the capacity to explore responses across a representative proportion of graduates. thus, the involvement of graduates who were available for participation and within access of the researcher may constitute selection bias. however, the reports and themes were largely consistent between discussion groups and interviewees, and data saturation was achieved in that the responses became consistent and somewhat predictable. there is, meanwhile, a possibility of social desirability bias with participants tending to report mostly positive aspects of the clhtc, their role, and its impact. this possibility could have been accentuated in that independent translators and facilitators were not always available. the evaluation was limited in that our methodology did not focus on quantitative data in assessing indicators such as hospitalizations and mortality. this does not invalidate the qualitative approach study but does indicate room for additional quantitative studies. conclusion this study has found that the clhtc course is presently meeting the objectives set by cmc and producing graduates that correspond to the dominant conceptualisation of a community health worker. the course is not only having an impact on the health situation in uttarakhand, but also on course candidates and those who are in their sphere of influence where they live and practice, including health providers. the course content and delivery in uttarakhand are reportedly of excellent quality, particularly in light of the coordinating facilitator’s technically and morally supportive role, and produce well equipped graduates who are highly motivated to meet the “immense health need” of the populations they serve (as per the objective of the course). following graduation, course candidates practice across the range of prescribed activities, balancing preventive and curative measures well. as intended for any chw, clhtc graduates establish or further their relationships with their community, both its members and its authority figures, and effectuate social mobilisation. the clhtc course has led to largely positive outcomes for candidates as well as for their communities and local community structures. weaknesses of the program were the lack of integration with formal health structures and limited opportunities for post-graduation contact including refresher training. references 1. lehmann u, sanders d. community health workers: what do we know about them. the state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. geneva: world health organization; 2007 jan:1-42. 2. oliver m, geniets a, winters n, 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core methodological issues. journal of community health. 2005 jun 1;30(3):221-9. https://doi.org/10.1007/s10900-004-1960-4 10. lewin sa, dick j, pond p, zwarenstein m, aja g, van wyk b, bosch-capblanch x, patrick m, walt g, morrow rh, lewin s. lay health workers in primary and community health care: cochrane systematic review. commentary. international journal of epidemiology. 2005;34(6):1250-3. 11. patel ar, nowalk mp. expanding immunization coverage in rural india: a review of evidence for the role of community health workers. vaccine. 2010 jan 8;28(3):604-13. https://doi.org/10.1016/j.vaccine.2009.10.108 12. kahssay hm, taylor me, berman p; world health organization. community health workers: the way forward. geneva: world health organization;1998. 13. fathima fn, raju m, varadharajan ks, krishnamurthy a, ananthkumar sr, mony pk. assessment of ‘accredited social health activists’—a national community health volunteer scheme in karnataka state, india. journal of health, population, and nutrition. 2015 mar;33(1):137. 14. krishna d rao. human resources for health in india: current challenges and policy options. in: idfc foundation. india infrastructure report 2013-14: the road to universal health coverage. orient blackswan; 2014. p. 251-264. 15. jaskiewicz w, tulenko k. increasing community health worker productivity and effectiveness: a review of the influence of the work environment. human resources for health. 2012 sep 27;10(1):38. https://doi.org/10.1186/1478-4491-10-38 16. bhutta za, lassi zs, pariyo g, huicho l. global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. global health workforce alliance. 2010;1:249-61. 17. funes r, hausman v, rastegar a, bhatia p, dalberg global development advisors. preparing the next generation of community health workers: the power of technology for training. cork, ireland: iheed institute; 2012 may. 59 p. peer reviewed competing interests: none declared. correspondence: nicole butcher, nossal institute of global health, university of melbourne, australia. butcher.nicole@gmail.com cite this article as: butcher n, grills n. impacts of community lay-leader health worker training and practice (uttarakhand, india). christian journal for global health. july 2017; 4(2):43-52. https://doi.org/10.15566/cjgh.v4i2.162 © butcher n, grills n. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.15566/cjgh.v3i2.142 https://doi.org/10.1007/s10900-004-1960-4 https://doi.org/10.1016/j.vaccine.2009.10.108 https://doi.org/10.1186/1478-4491-10-38 mailto:butcher.nicole@gmail.com https://doi.org/10.15566/cjgh.v4i2.162 http://creativecommons.org/licenses/by/4.0/ review article nov 2016. christian journal for global health, 3(2): 6-17. health and wholeness undergraduate course in uganda: potential public health impact and transferability douglas l fountain a , edward mukooza b , edward kanyesigye c a mpa, vice president for operations support, medical teams international, united states b mbchb, dha, mbl, mph, lecturer, faculty of health sciences, uganda christian university, uganda c mbchb, dph, mph, senior lecturer and dean, faculty of health sciences, uganda christian university, uganda abstract over 26,000 students at a major christian university in uganda have completed a single semester course on health and wholeness. while common in other higher education contexts, general education courses and health education courses in particular are uncommon in the africa higher education context. this course therefore is a bold initiative by uganda christian university. the course is designed to help students in a wide range of programs understand how to promote and improve health in their own lives as well as their homes, communities, workplace, and society. students learn about the definitions of health and wholeness. they discuss hygiene; nutrition; sanitation, water, and land use; common occurring health problems, hiv/aids and sexually transmitted infections; sexuality; first aid and early intervention; family health, dependence, fitness and life skills, and leadership for a healthy society. through discussion, students are expected to identify factors that hinder or enhance health. challenges and lessons learned in the course include confronting cultural practices, improving critical analysis skills, addressing information at the right technical level, and improving behavior change. because graduates come from, and move on to, virtually all facets of economic, civil, and social life in uganda and beyond, this course could carry tremendous potential to improve the public’s health. introduction over 26,000 students have completed a semester-long course on health and wholeness at uganda christian university (ucu) from 2005 to 2016. general health education courses like this are not common in low and middle income countries (lmics). yet, such courses prove highly valuable for improving health due to the scale of students they reach and the anticipated trajectory of graduates. a well-designed course should have significant transformational impact not only for the student but for the families and communities in 7 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. which graduates live and work. a course like this has the potential to influence a generation of leaders as “health advocates” in business, government, ministry, and civil society. this paper outlines the development of the course generally and the definition of “wholeness” in particular. the paper also outlines lessons learned based on several challenges that were encountered. background health in uganda the experience of many people living in uganda and throughout east africa highlight the need to continue raising awareness of health and improving health behaviors. uganda, like many low to middle income countries, lags in key health indicators. for example, analysis of world health organization global health statistics indicate that life expectancy is 12 years shorter in uganda than the average for the rest of the world, at 59 compared to 71 years. the under-five mortality rate is 66.1 per 1000 live births in uganda is far higher than the 45.6 per 1000 live births seen globally. 1 save the children’s “mother’s index 2015” ranks uganda at 141 out of 179 countries for maternal health; children’s well-being; and education, economic, and political status. 2 however, recent findings by the uganda bureau of statistics highlight significant improvement in the health status of ugandans as evidenced by:  life expectancy at birth increased from 50.4 years in 2002 to 63.3 years in 2014.  infant mortality improved from 87 per 1000 live births in 2002 to 53 per 1000 live births in 2014.  under five mortality rate improved from 156 per 1000 live births in 2002 to 80 per 1000 live births in 2014.  total fertility rates also improved from 7.1 children per woman in 1991 to 5.8 children per woman in 2014. environmental health conditions are also improving. for example, the proportion of households using improved water sources grew from 24.8% in 1991 to 60.9% in 2002 to 71.2% in 2014. the proportion of households without toilet facilities also dropped from over 25% in 1991 to 8% in 2014. 3 reasons for this are varied. certainly, comprehensive efforts coordinated at the ministry of health involving numerous domestic and international partners are among the ingredients of success. the quality of health stories in the media; the integration of health promotion in the church; the consistent messages across levels of government; and initiatives by business to improve care for their employees and families all suggest what can happen when well informed leaders speak out on health. integrating general health education courses in higher education in lmics could play a further role in improving the public’s health. in such contexts, higher education is a highly coveted opportunity. it is a source of leadership formation. graduates have the opportunity to improve their own lives as well as influence business, church, civil society, and other organizations. how well prepared are university graduates to take up this role? introductory health courses in higher education general or introductory health courses are associated with better health knowledge and behavior according to research compiled over the past several decades. for example, pearman et.al. found that alumni from a college that required a health course were significantly more likely to know their own health, blood pressure and cholesterol, engage in aerobic exercise, not smoke, and take in less dietary fat than alumni from a college that did not require a health course. 4 devoe et al. found that 66% of all health course 8 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. participants made changes in at least one significant health-related behavior. 5 health education can also improve student wellness. higgins et al. found that an introductory wellness course improved students’ sense of wellness. dimensions of wellness they identified are physical, spiritual and psychological "being," physical, social and community "belonging," and practical, growth and leisure "becoming." 6 creative alternatives to traditional lecture formats may increase health course effectiveness. for example, health courses could be more effective when they support students’ self-assessment, contract with students for change in health behavior, and encourage students to engage in campus-wide health programs. 7 courses that mix online learning and traditional lectures yielded higher student satisfaction and achievement. 8 as a result of the mounting evidence, general health education courses are considered an important part of general education in united states higher education. in 2003, the institute of medicine of the national academies of science recommended that “all undergraduates should have access to education in public health” in part to assure an educated citizenry. 9 a consensus conference on undergraduate public health education affirmed this objective and further recommended that public health courses be integrated in general education requirements, especially by focusing on particular topics such as hiv/aids. 10 personal experiences of the authors demonstrate, however, that general education requirements are uncommon in the african higher education context. no other universities in subsaharan africa were known to offer a required health course at the time this course was developed. this is because, in uganda, traditional higher education was historically utilized to train people for specific careers such as finance or teaching. integrative general education courses that reach outside the specific technical discipline seem to not to be popular in this education context. this observation, if true, could be changing. the seventh day adventist universities may now offer general health courses, for example. there is unfortunately not much guidance or research on health seeking behaviors or effective ways to reach general university students in africa with messages of health. most ucu students selfreport that they are in good health — 14% report their health as excellent, 32% report very good, 40% report good, 13% report fair, and 1% report their health to be poor. 11 men were more likely than women to report their health to be excellent or very good. moreover, 26% of students reported an unmet health need in the current or prior semester. the most commonly cited reason for this was hoping that the problem would go away on its own; this was followed by institutional challenges with receiving health care. these results are comparable to another recent study of health-seeking behavior among students at a different university in uganda. there, two out of five students reported unmet medical care needs, and one out of five reported unmet sexual health counselling needs. acceptability of services was the main barrier faced by students. students from rural or peri-urban areas were less likely to seek health care than their counterparts from urban areas. 12 it is within this context that ucu leaders determined to launch a bold experiment, to establish a semester long course on health. uganda christian university ucu is an accredited private nonprofit university system with over 12,000 students. it was established by the church of uganda in 1997, promoting the historic bishop tucker theological college into a full university. at the time the course was developed, the university included only 2500 students at the main campus. it was the first private university to be chartered by the government of uganda and is africa’s first affiliate of the council for christian colleges and universities. 9 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. the vision for ucu is a “center of excellence in the heart of africa.” their ambition is nothing less than to use university education as a means to change the hearts and minds of a broad swath in society. the ucu system now includes the main campus near kampala, constituent colleges in the east at mbale and southwestern uganda at kabale, a rural campus in the north and an urban campus in kampala. the university is composed of faculties of education and arts, business, social science, law, science and technology, health science, and the bishop tucker school of divinity and theology. students at ucu reflect diverse economic and social backgrounds. currently, 52% of students are female; 95% come from uganda, while the other 5% come from up to 14 other african countries. students represent every tribal/ethnic line in uganda as well. a recent study of ucu students found that 80% of the students came from households headed by someone with postsecondary education, and 3% of heads of households had no formal education at all. 6 many ucu graduates have moved into significant leadership positions in government, business church, and civil society. some work in the capital, others work in cities and towns or villages throughout the country and beyond. development of the course in 2003, the ucu university council created a requirement that all students should be trained in principles of healthy living. ultimately this requirement fit within a general education framework adopted by the university senate, which included 8 required courses:  old testament  new testament  understanding your world view  christian ethics  mathematics  writing and study skills  basic computing  health and wholeness the health and wholeness course was assigned to the department of health sciences at ucu that was established in 2004, within the faculty of science and technology. department leaders assembled 12 experts in public health and/or medicine to provide input into the course; eight were from uganda and four from the united states and canada. course content was drawn from a variety of community and public health resources and books, along with original writing from the experts. ucu published health and wholeness: student workbook in 2005, with significant updates in 2007, 2010, and 2013. 13 the health and wholeness course was created mostly with east african students in mind. topics reflect a mixture of general health and specific issues facing uganda and the rest of east africa. the language used emphasizes the issues that local health experts desired to have promoted, informed by understanding of relevant cultural and religious norms. for example, discussions about sexual behaviors reflect the values of both uganda’s government and church leadership. more casually, discussions about nutrition reflect the preponderance of carbohydrates and the lack of micronutrients in local diets. students began taking the 12-week course at the main campus in september 2005, and the course has continued to be taught to this day throughout the ucu system. each year, approximately 3,000 students complete the course — totaling over 26,000 to date. the course was recognized in 2006 with an award for innovations in uganda higher education. course objectives the objective for the course is to educate students to make healthy life choices and become effective “health advocates” within whatever situation they live and work. almost immediately after the course was launched, students reported sharing their course content with their families. 10 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. ministers spoke of using the course content in their sermons. a new vision and renewed objectives formed around creating effective “health advocates” in any context in which they live and work. as a result of this course, students are expected to:  be encouraged toward better “health seeking” behavior.  acquire knowledge, skills and abilities that promote a longer, healthier, and more complete and holy life.  recognize that health and wholeness is a product of individual, family, and community factors, including knowledge, beliefs, attitudes, and behaviors.  understand how the christian concept of the whole person is integral to complete health.  recognize their role as health leaders even if they are not professional health workers. specifically during the course, students are expected to:  define and apply concepts in health and wholeness, including relationships of physical, mental/emotional, social, and spiritual health factors.  identify and describe subjectively how personal behaviors and choices affect short and long term health of self and family.  develop personal goals and make recommendations to family, friends, or a local community for improving health.  identify and apply concepts in prevention: hygiene, nutrition, healthy sexuality, maternal/child health, and fitness.  identify and apply concepts in intervention: first aid and early intervention, infectious disease, sexually transmitted infections, and alcohol or drug dependence.  identify and apply concepts in community/environmental health such as sanitation, water and land use, as well as social topics that influence the health of society. course synopsis the course content is then divided into 12 sections. each week there is a lecture followed by course reading and a discussion in tutorial (table 1). table 1. ucu health and wholeness course overview subject key message introduction health is more than the absence of disease: it is a state of physical, social, emotional/mental, and spiritual wellbeing. components of health understanding physical, social, emotional, and spiritual components helps make wholeness more clear. nutrition we need macronutrients and micronutrients each day to remain healthy, but we often eat the wrong balance of food. hygiene we transmit germs and disease by when our bodies and hands are not clean, and also by improper handling and food storage. sanitation, water, land use families and communities must protect sanitation and water sources and not destroy the land they need to live on. common occurring problems bacterial, viral, and parasitic infections cause diseases like diarrhea, pneumonia, tuberculosis, and malaria: knowing their signs and treatments can save lives. hiv/aids and sexually transmitted infections hiv is not the only disease transmitted through sexual contact; early identification of the symptoms can save men and women from serious complications. sexuality sex is god’s gift to a married couple. breaking that gift has consequences in life and relationships. first aid/early intervention correctly identifying a problem and providing assistance or seeking help can keep a bad situation from becoming worse. family health mothers and children die around child birth or when children are young; family planning, safe delivery, and other preventive measures save lives. 11 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. dependence sometimes we lose control over some activity we enjoy or some substance we take in, and it controls us. breaking such habits is very hard. fitness and life skills we need endurance, strength, and flexibility in all aspects of lives: physical, social, emotional, and spiritual; we should know and apply healthy life skills. leadership for a healthy society social health is influenced by our attitudes and beliefs; some social problems compromise everybody’s health. tutorials during the course, students meet in a 2-hour lecture and then again in 2-hour tutorials led by a tutorial assistant. the course is always taught by a person knowledgeable in health. the tutorials, however, are designed to foster discussion among students about those practices that promote or challenge adoption of healthy behaviors. it is when students interact with the information and seek how to apply it in their lives that change should take place. therefore, students were divided into small groups for the tutorials to discuss healthy practices, with the intent to share these concepts and information with other students. defining health and wholeness – making it “real” most students start the course with a belief that health is simply not being sick. medical care helps restore health through medicine; the message of the church is that health is restored through healing and compassionate care. this perspective on health is lacking in two ways. first, students may not appreciate how their own choices and decisions affect not only their personal health, but that of others in their family, community, and society. second, this view is often limited to physical health rather than holistic wellbeing. as a result, students in health and wholeness first learn the world health organization’s definition of health: “health is the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” 14 this broadens understanding of dimension in health. it causes the student to ask: even if i am not sick, am i healthy? the result is a radical departure in understanding for many students. in a christian world view, this definition of health lacks a specifically spiritual focus and the transformational element of our faith. in this view, health surpasses individual and even social determinants. health is also more dynamic and active than implied with “complete wellbeing” — like our faith; it is a journey or process of learning and acting followed by more learning and acting. course developers turned to scripture to identify the foundation for a vision of wholeness and found jesus’ affirmation of the two greatest commandments: “you shall love the lord your god with all your heart and with all your soul and with all your strength and with all your mind, and your neighbor as yourself.” (luke 10:27, english standard version) the course developers thought that heart, soul, strength, and mind create a framework for wholeness. wholeness incudes social, spiritual physical and emotional health. heart is often thought of as love or compassion, which is social health. soul is clearly spiritual. strength is physical. mind is our mental and emotional health. in this way, jesus says we must be whole by loving god with all we have and all we are. the fact that we are to love others as ourselves directly relates to both self-esteem and our capacity to love others. with this foundation in mind, course developers created a definition of wholeness that complements the previous definition of health: “wholeness is a state of personal physical, social, mental, and spiritual health, in which a person knows their value in the eyes of god, their families and their communities, and where 12 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. they are empowered to make good health decisions.” this definition still affirms that health is a personal state. it is influenced by others but fundamentally “belongs” to the individual. this definition overtly integrates four facets of health: physical, social, mental, and spiritual. this definition further identifies health and wholeness as dynamic. it reflects self-worth and self-efficacy as central to making change in oneself or in one’s community. for example, the quality and depth of our self-esteem as well as our capacity to make good health choices will vary. ultimately then, this course encourages students to apply both knowledge of health and understanding of wholeness in order to improve their own health behaviors. application of wholeness the challenge that the course developers faced was to apply an esoteric definition of wholeness to an immensely practical circumstance. there were three particular and unique applications of wholeness developed for the course. inter-connections physical, social, mental, and spiritual components of health all affect each other. students should identify how strength or weakness in one area affects others. for example, positive self-esteem affects whether people seek help or take care of their bodies. poor social habits such as arrogance and pride, or conversely, isolation, can increase the chances of high risk behavior. physical activity helps counter depression. spiritual health helps students understand love — and lift their selfesteem. in fact, dwelling on psalm 139:14, “i am fearfully and wonderfully made,” was a great launching point for a discussion of health. hygiene students learn that physical germs are not the only problems that are too small to see that can grow into huge problems. students identify and discuss social, mental, and spiritual germs as well. negative thoughts, poor self-esteem, and doubt are good examples of problems that start small but grow large if not checked. fitness the object of physical fitness is defined as strength, endurance, and flexibility. students discuss how those same principles apply to social, mental, and spiritual situations. for example, social flexibility implies being able to adapt to the situation. mental endurance is needed especially for students in demanding courses. spiritual strength is necessary during life’s dark periods — and develops over time along with “exercise” in the form of good study, healthy prayer, and accountability. lessons learned this course was new to the ugandan higher education context, and there were several challenges encountered. culture seems impenetrable, for good reason. as noted, this course was formed by public health and medical experts from uganda and north america and relied heavily on published works in health. many students in uganda possess strong cultural identity. this is a source of considerable positive social esteem. social structures are especially strong in many african contexts. the culture of circumcising young men in mbale, eastern uganda is a good example. among the bamasaba or gisu tribe, for a young man to be declared an adult man, he must be circumcised. traditionally, his fore skin would be removed by elderly men who specialize in this practice. the cutters, as the circumcisers are known, do not receive modern training in surgical techniques, and the circumcision culture is prone to complications such as excessive bleeding and post cutting infections. there is also a possibility of disease 13 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. transmission, but this is now minimized since separate knives per candidate are now used. men who are circumcised medically in hospitals under pain control may be considered cowards. to convince bagisu men to go for modern medical circumcision, which is safer, is an uphill task as they believe that men have to be circumcised traditionally. 15 as noted earlier, teaching assistants and students break into groups to discuss the topics for the week during their tutorial sessions. they focus on how to apply health messages in their lives, discussing the factors and forces that would promote or that would challenge adoption of healthy lifestyles, including facets of culture. the benefit of this is that tutorial assistants and fellow classmates are more likely to elicit authentic conversations about what students view as real issues. further development of the course should consider ways that students could commit to improve in self-identified areas. this would be ideal for subsequent evaluation of course impacts. the church is a logical focal point for action, and training its members can be a means. the integration of personal and public health is widely regarded as vital for community health improvement. how do individuals prioritize their own health and that of those around them? the church, despite not being filled with health professionals, are a logical organizing point to have lasting change at the community level. 16 this is an expanding frontier in health mission. perhaps the greatest impact for these future health advocates is not the specific content of any particular health innovation, but the realization that they can make better individual and collective choices to create better health. developing critical analysis skills and applying information to people’s lives is essential. myth may be deeply held as truth in any context, including uganda. will drinking or eating cold food cause blood to congeal, leading to a heart attack? will use of certain types of toilets render a woman infertile? those are comparatively easy myths to discuss with students, provided that they apply critical reasoning skills. this is the challenge though, as many students enter the university from schools that rewarded memorization. critical reasoning and analytic skill is certainly needed for more complex challenges, such as whether and how condoms reduce the spread of hiv in the general population, or how harmful impacts of poor solid waste management can be mitigated. one exercise that health and wholeness includes is monitoring current media for stories about health and analyzing them for their truth and their implications for the student’s life. converting head knowledge into practical action is important. it may be unrealistic to believe that just because an authority recommends that students change their behavior that they will simply do it. university students like any adult learner take in the information and compare it with other things they know and weigh the benefits of the change against the complexity or cost of change in their life. to address this, the health and wholeness course incorporates practical application during tutorial discussions. each week, the tutorials discuss factors that promote or hinder people taking up the recommendations in the class. in addition, the course relies on an assessment tool created for the course. this tool is driven by course content as a way to help trigger student interest in the subjects and ease them in to the content. striking the right balance of technical content is crucial for non-medical audiences. most public health reference material widely available in africa focuses on village health or the urban poor; or it is directed to health professionals who possess a strong scientific background. this course had to adopt non-medical language and yet impart enough factual scientific language to truly enhance people’s understanding. for example, it is less important to 14 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. understand the exact types of bacteria that can make people sick and more important to understand the conditions by which bacteria grow or spread. course content should appeal to diverse student profiles and include professionallyoriented audiences. the course content had to be clearly compelling for students who could end up in a wide variety of living situations. for example, the course had to appeal to future leaders and address them as such. the course also acknowledged the pitfalls of professional, middleclass lives, including the income that affords richer diets that are high in carbohydrates and fat and the pressures on time that restrict physical exercise. the course, therefore, included content on body mass index, hypertension, diabetes, and the need to establish a regular fitness regimen. integrating the course with other health awareness activities could bolster course impact. for example, ucu offers a health awareness week each semester that could reinforce key messages in health and wholeness. additionally, ucu offered a special week-long short course on health for working professionals. the content was based on professional public health topics rather than the more popular health and wholeness course design and messages. this could be re-evaluated. the course has to be kept up to date. first, content needs to reflect current information about health problems and ways to mitigate them. second, the course format, learning methodologies, and behavior change methodologies need to be reviewed periodically. these both require input from specialists in health promotion, adult learning, and behavior change. investment by the university in keeping the course current and well-grounded is necessary. at this time, the course is fully managed in a department under the faculty responsible for theology. neither the course instructors nor tutorial assistants are affiliated with the faculty of health sciences. there may be too few interactions with the faculty of health sciences to assure that the course is reaching optimal health impacts. discussion almost immediately, this course struck a nerve with students. one group of students became impassioned to share messages with people in their home villages and created the mission for community awareness and health that sought to increase standards of health in villages. similarly, theology students incorporated messages in their sermons; one even said that he incorporated the subjects in his sermons each week. some course information is lifesaving but heart breaking when we see it come too late. during one class in which we taught the heimlich maneuver to help someone who is choking on food, a student began to sob. she disclosed that her fouryear-old brother had died during the recent christmas celebrations because he tried to swallow too much meat at once. cultures change and not always for the better. the spread of media and internet accessibility brings people into contact with dramatically different global cultures and can challenge long held assumptions or beliefs. in this case, the course is intended to support those changes that promote health and wholeness, while not undermining the positive elements of cultural identity. three questions should be addressed in future development of courses like this. 1. what other conditions will make it possible for a course like this to truly help improve the health of a society? a bold and holistic approach to changing health of a society requires not only awareness but a commitment by everybody to bring about change. an educated and motivated citizenry results in educated and motivated leaders. in such a case, any person properly equipped can encourage their 15 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. families, offices, communities, and churches to a higher standard for health and wholeness. so far, this health and wholeness course has trained 26,000 people with knowledge to be a health leader in any situation. a university degree in lowand middleincome countries, like uganda, has great potential to transform leaders with modern skills and knowledge. in this case, matching critical analysis skills, timely and relevant information about health, and a compelling, shared vision for health and wholeness is a potent trifecta. further research on the effectiveness of this course is needed. if it is as effective as believed, it could be more broadly introduced as a general education requirement. further research into which elements of the course bring about the most change would help refine the course and increase impact. 2. how can learning from this course, developed in a christian university context, apply to other university settings? obviously, it is easier to discuss the unique role of spiritual factors in health in any faith-based context. a christian higher education context adds the benefit of core values and beliefs that positively shape both the learning environment and the message of wholeness. perhaps a christian education context presumes that behavior changes not only because of good technical information but because of agreement on core values and principles of compassion and value of the dignity of life. in this case, the application of wholeness to personal and communal behavior was easier in a christian learning environment. while the idea of wholeness was developed with a christian world view, it adds to positive core beliefs in ways that should be helpful and transformational beyond a strictly christian context. 3. how can this model be replicated in other universities or countries? the use of a compulsory course on health in a higher education context is nothing new in many countries, though predominantly this is not the case in africa. the application of this course, to bring about improved understanding and behavior change in the african context, seems appealing. obviously, much of the course content is intended to address ugandan or east african health priorities. definitions of health and wholeness and other basic course principles were designed with ugandan audiences in mind but should be fully transferable to many other settings. more research will help shed light on those elements of the course that work well and that are replicable. more research, specifically at ucu, would certainly help, given the scale of the course and the diversity of the student populations present. what is needed is for one or two other universities to explore offering the same course concept and generate further ideas and strategies to improve the course. in sum, the health and wholeness course that was developed at ucu has thus far reached 26,000 students. it will likely reach another 25 to 30 thousand students in the decade to come, but this could be at least doubled if additional universities adopt and adapt this learning framework. students seem highly receptive and motivated. continued improvement in the course and experimentation of alternative learning approaches would add tremendous value to future effort. references 1. world health organization. world health statistics 2015. available from: http://www.who.int/gho/publications/world_health_statis tics/en_whs2015_part2.pdf?ua=1 2. save the children federation. the 2015 mother’s index and country rankings. isbn 1-888393-30-0. available from: https://www.savethechildren.net/stateworlds-mothers-2015 http://www.who.int/gho/publications/world_health_statistics/en_whs2015_part2.pdf?ua=1 http://www.who.int/gho/publications/world_health_statistics/en_whs2015_part2.pdf?ua=1 https://www.savethechildren.net/state-worlds-mothers-2015 https://www.savethechildren.net/state-worlds-mothers-2015 16 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. 3. uganda bureau of statistics. the national population and housing census 2014 – main report. kampala, uganda. 2014. available from: http://www.ubos.org/2014-census/census-2014-finalresults/ and http://www.ubos.org/onlinefiles/uploads/ubos/nphc/20 14%20national%20census%20main%20report.pdf 4. pearman sn, valois rf, sargent rg, saunders rp, drane jw, macera ca. the impact of a required college health and physical education course on the health status of alumni. j am coll health. 1997;46(2):7785. http://dx.doi.org/10.1080/07448489709595591 5. devoe d, kennedy c, ransdell l, pirson b, deyoung w, casey k. impact of health, fitness, and physical activity courses on the attitudes and behaviors of college students. j gender cult health.1998;3:243. http:dx.doi.org/10.1023/a:1023226530739 6. wharf higgins sj, lauzon ll, yew ac, bratseth cd, mcleaod n. wellness 101: health education for the university student. health educ. 2010;110(4):309–27. http://dx.doi.org/10.1108/09654281011052655 7. clemmens d, engler a, chinn pl. learning and living health: college students' experiences with an introductory health course. j nurs educ. 2004 jul;43(7):313-8. pmid: 15303584. 8. melton bf, bland hw, chopak-foss j. achievement and satisfaction in blended learning versus traditional general health course designs. int j scholarship teach learn. 2009;3(1), article 26. available from: http://digitalcommons.georgiasouthern.edu/ijsotl/vol3/iss1/26 9. gebbie km, rosenstock l, hernandez lm. who will keep the public healthy?: educating public health professionals for the 21st century. washington, d.c.: national academy press; 2003;144. available from: https://www.nap.edu/catalog/10542/who-will-keep-thepublic-healthy-educating-public-health-professionals 10. riegelman r, albertine s. recommendations for undergraduate public health education. washington dc: association of american colleges and universities; 2008. available from: https://www.aacu.org/sites/default/files/files/publichealt h/recommendations_for_undergraduate_public_health _education.pdf 11. mukooza ek. students’ health seeking behaviour and its rationale at uganda christian university: a postgraduate dissertation presented to the virtual university of uganda in partial fulfilment of the requirements for the award of the degree of master of public health. kampala, uganda: virtual university of uganda; 2015. reference vuu-pgdph-2014-003. 12. boltena at, khan fa, asamoah bo, agardh a. barriers faced by ugandan university students in seeking medical care and sexual health counselling: a crosssectional study. bmc public health series; 2012:986. http://dx.doi.org/10.1186/1471-2458-12-986 13. uganda christian university department of foundation studies. health and wholeness: student workbook. mukono, uganda: uganda christian university, department of foundation studies and department of health sciences; 2013. 14. preamble to the constitution of the world health organization as adopted by the international health conference [internet]. new york, 1946 june 19-22. [signed on 1946 july 22 by the representatives of 61 states (official records of the world health organization, no. 2, p. 100) and entered into force on 1948 april 7]. available from: http://www.who.int/about/definition/en/print.html 15. sarvestani as, bufumbo l, geiger jd, sienko kh. traditional male circumcision in uganda: a qualitative focus group discussion analysis. plos online. 2012. http://dx.doi.org/10.1371/journal.pone.0045316 16. gorske a, myers bl. the slow-motion disaster in healthcare missions: will the churches respond? in myers bl, dufault-hunter e, voss ib, editors. health, healing, and shalom: frontiers and challenges for christian health missions. william carey library. 2015. kindle edition. digital ebook release bp2015. isbn 978-0-87808-675-7. http://www.ubos.org/2014-census/census-2014-final-results/ http://www.ubos.org/2014-census/census-2014-final-results/ http://www.ubos.org/onlinefiles/uploads/ubos/nphc/2014%20national%20census%20main%20report.pdf http://www.ubos.org/onlinefiles/uploads/ubos/nphc/2014%20national%20census%20main%20report.pdf http://dx.doi.org/10.1080/07448489709595591 http://dx.doi.org/10.1023/a:1023226530739 http://dx.doi.org/10.1108/09654281011052655 http://digitalcommons.georgiasouthern.edu/ij-sotl/vol3/iss1/26 http://digitalcommons.georgiasouthern.edu/ij-sotl/vol3/iss1/26 https://www.nap.edu/catalog/10542/who-will-keep-the-public-healthy-educating-public-health-professionals https://www.nap.edu/catalog/10542/who-will-keep-the-public-healthy-educating-public-health-professionals https://www.aacu.org/sites/default/files/files/publichealth/recommendations_for_undergraduate_public_health_education.pdf https://www.aacu.org/sites/default/files/files/publichealth/recommendations_for_undergraduate_public_health_education.pdf https://www.aacu.org/sites/default/files/files/publichealth/recommendations_for_undergraduate_public_health_education.pdf http://dx.doi.org/10.1186/1471-2458-12-986 http://www.who.int/about/definition/en/print.html http://dx.doi.org/10.1371/journal.pone.0045316 17 fountain, mukooza & kanyesigye nov 2016. christian journal for global health, 3(2): 6-17. peer reviewed competing interests: none declared. correspondence: douglas l fountain, medical teams international, united states. dfountain@medicalteams.org edward mukooza, uganda christian university, uganda. mukooza_edward@yahoo.com edward kanyesigye, uganda christian university, uganda. ekanyesigye@ucu.ac.ug cite this article as: fountain dl, mukooza e, kanyesigye e. health and wholeness undergraduate course in uganda: potential public health impact and transferability. christian journal for global health (nov 2016), 3(2):6-17. © fountain dl, mukooza e, kanyesigye e this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:dfountain@medicalteams.org mailto:mukooza_edward@yahoo.com mailto:ekanyesigye@ucu.ac.ug http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ original article july 2018. christian journal for global health 5(1):32-43 how u.s. conservatives perceive and respond to international nutrition issues, and how to shape messaging for successful advocacy jennifer eaton dyera and brian lloyd heuserb a phd, lecturer, vanderbilt university for global health; ceo/executive director, hope through healing hands, usa b ed.d., m.t.s, associate professor of the practice of international education policy, department of leadership, policy and organizations; affiliated faculty, institute for global heath, vanderbilt university for global health, usa abstract since 1990, tremendous strides have been made in global health and development toward achieving the millennium development goals. with a united front of forces, including governments, coalitions, private sector, foundations, philanthropic organizations, and the faith community, millions of lives have been saved from extreme poverty and disease. yet, some issues enjoy more robust funding and notoriety than others. for instance, aids, tuberculosis, and malaria enjoy the majority of the u.s. foreign assistance funding in global health. nutrition, notably, has remained stagnant for decades. through this research, we sought to test the appetite for increased funding for international nutrition and food security issues among political, religious, social conservatives (prscs), and the general population (gp) to gauge perception and response to the issue and its correlates. our objective with these national surveys was to understand the best choice of language to promote awareness, education, and prompt advocacy for global nutrition and food security issues. with this research, we found that conservatives were motivated by national security issues first and at a macro-level, not their faith, finances or moral foundation. we recommend that education be enhanced among conservatives regarding u.s. foreign assistance, nutrition funding and implementation, and nutrition-related terminology, including stunting, wasting, and anemia. moreover, we recommend communicating strong narratives about mothers, children, and infants, particularly a child’s first 1,000 days, from conception to two years, which has proved to elicit the most positive response among all messaging. key words: global nutrition, national security, conservatives, advocacy, policy, first 1000 days, nutrition, international aid 32 dyer & heuser july 2018. christian journal for global health 5(1):32-43 introduction since 1990, the u.s. has led the world in reducing by half the number of people living under $1.25 per day and also reducing by half the number of deaths from epidemic diseases such as malaria and tuberculosis.1-3 maternal mortality and child mortality numbers have also been cut in half.4,5 access to health care, clean water, nutrition, family planning, and medicines played a role in these historic advances worldwide. yet this epic story is not being heard. in two national surveys conducted, when asked if people’s quality of life around the world has gotten better, worse or remained the same over the last ten years, more than twice as many prsc respondents (59%) believed life had gotten worse over those (25%) who believed it had gotten better. even so, the gp respondents were slightly more optimistic, whereby almost half (49.5%) believed life had gotten worse, and almost one-third (29.3%) believed it had gotten better. continuing the momentum of success in health and development depends upon continued funding by the u.s. for the global assistance programs that have made these achievements possible. in 2003, less than 50,000 people in sub-saharan africa had access to anti-retroviral medications. today, president bush’s president’s emergency plan for aids relief (pepfar) program supports over 14 million men, women, and children globally with these life-saving drugs.6 alongside pepfar, the global fund to fight aids, tuberculosis, and malaria (gfatm) also contributed greatly with u.s.-led investments for the increased decline of deaths from these three infectious diseases. because this is a multi-lateral mechanism, the u.s. is just one of many contributors, yet perhaps the most critical. the legislation for gfatm stipulates that for every $1 we invest in it, other donors must match it at $2, leveraging funding from other nations, foundations, and donors. the gfatm has saved more than 22 million lives since its inception in 2002.7 these programs have been the catalyst for the dramatic drop in deaths in hiv/aids, tuberculosis, and malaria since the beginning of the bush administration. in the wake of this historic effort, president obama wanted to expand upon this work and announced his global health initiative (ghi) which would increase and streamline funding as well as broaden efforts to include a focus on the issues of women and girls in poverty. ultimately, ghi was a grand vision but it faced obstacles of controversy amongst leadership and an austere budget environment after the 2008 crash allowing the funding to simply plateau with little increase. yet in recent years, the u.s. has led the world in global health investments not only to combat infectious diseases but also other areas, such as vaccines (gavi) and international family planning. however, this funding depends upon the advocacy of informed citizens to their elected representatives. therefore, if we want to continue to lead the world in investments and successes in global health and development, it is important to understand how such citizens understand the life-and-death issues underlying global health efforts. encouragingly, more than 70% of the respondents in both studies — with women significantly more than men — reported that they believed it was important for the u.s. to have a positive image in countries around the world. despite such a strong basic affirmation, only 42% of prscs believed that the u.s. should take a leading role in helping poor people in other countries. there is an obvious ignorance to be rectified that foreign assistance funding is a critical component to boost u.s. branding worldwide. more specifically, we sought to clarify how best to construct and communicate explanations of international nutrition as a crucial global health issue. while some global health issues have enjoyed robust increase in funding, nutrition has consistently remained at less than 2% of the global health account. this survey explores the appetite or interest among prscs and the gp as well as the method by which to promote an increase for bilateral and multilateral funding through awareness and 33 dyer & heuser july 2018. christian journal for global health 5(1):32-43 advocacy. that being said, the findings below will predominantly focus on the prsc group results. this survey research is timely given the current crisis of famine in four sub-saharan countries, president trump’s recommended budget cut of bilateral funding for nutrition by 38%, and the rising questions of how climate change will influence access to water and food sources in the near future. it is now more critical than ever to gain a better understanding of how prscs think and feel about global nutrition. with this knowledge, individuals and organizations on the frontlines of awareness, education, and advocacy for global nutrition can better shape their language, rhetoric, and arguments to compel conservatives, faith leaders and the gp, and to engage members of congress to maintain or increase funding for global nutrition. materials and methods this research was conducted by developing and administering a perception survey to a sample of 1,000 self-identified prscs as well as to a sample of 1,000 respondents of the gp. our sampling protocol, which was administered by qualtrics, provided three seven-point scales respondents were asked to use to rate the degree of their political, religious, and social views from “extremely liberal” (1) to “extremely conservative” (7). in order to be selected to take the survey, respondents had to score 5 or above on each of the three scales. first, to contextualize our findings in a macromotivations framework, we measured the degree to which prscs/gps reported that they were compelled by various rationales to address health and development efforts. we then explored how prscs/gps prioritized global nutrition against other critical global health issues. to gain a better handle on prscs/gps’ knowledge and grasp of the subject of global nutrition, we tested related nutrition concepts and perceptions about those affected by hunger and starvation. we also tested nutritionrelated messaging to see what resonated most highly, cognitively, and emotively with them. and finally, we probed with questions of personal versus general responsibility at various levels to ascertain how compelling the issue had to be to motivate the groups to advocacy or engagement. the demographic profile for our prsc respondent pool was: gender 49.7% of our respondents were male; 50.3% female. race 88.9 percent were white/caucasian; 5.8% black/african american; 3.9% asian; 1.3% native american; hispanic and other were only 1.70%. self-identified religion protestants comprised 41.9% of the reference group; roman catholics, 24.7%; “something else” (likely those who could be classified as “non-denominational”), 17.7%; and “nothing in particular,” 6.2%; mormon, 2%; jewish, 1.8%; buddhist, 1.5%; orthodox, 1% and muslim, 0.8%. consonant with our prior research on prscs, 84.7% of respondents considered themselves to be a “committed christian.” the demographic profile for our gp respondent pool was: 49.3% of our respondents were male; 50.7% female. race 77% white/caucasian; 14.8% black/african american; 4.2% asian; 2.5% native american; hispanic and other were 5.10%. self-identified religion protestants comprised 25.1% of the reference group; roman catholics, 20.1%; “something else” (likely those who could be classified as “non-denominational”), 18.4%; and “nothing in particular,” 20.2%; mormon, 1.7%; jewish, 3%; buddhist, 1%; orthodox, 0.9% and muslim, 0.9%. results macro-motives framework: rationales for global health and development prsc respondents are most compelled by domestically-focused rationales for international health and development efforts as seen in figure 1. 34 dyer & heuser july 2018. christian journal for global health 5(1):32-43 figure 1. importance of rationales for international health and development among prscs • an overwhelming majority of respondents (90% prsc, 84% gp) answered that safeguarding national security was of key interest. notably, education played a key role differently for each study. in the gp study, 100% of those with a doctoral or professional degree ranked safeguarding national security as an important reason, and at the 90% confidence level those with doctoral or professional degrees were significantly more likely to find the “safeguarding national security” rationale important as those with less education. conversely, among prscs, those with a doctoral degree were the least likely of any educational group (86.3%) to rank it as important. • respondents also viewed protecting the public health of citizens (81% prsc, 86% gp) as a compelling rationale for international health and development. within the gp, those with a master’s degree were significantly more likely to find the “public health” rationale more important than any other educational group, at the 95% confidence level. • honoring moral or ethical responsibilities (76% prsc) was the third most compelling rationale among respondents, especially among those with a master’s degree (82%) or doctorate/professional degree (88%). (the confidence interval test for comparison of means was statistically significant at the 95% level for this prsc question (q4).) interestingly, those with master’s degrees were most likely to view it as important across both studies. yet, different age cohorts responded differently in the two studies: among the gp, the 66+ age group found it most important; and among prscs, the 25 and under age group viewed the moral rationale as most important. in the gp, women were more likely than men to find this “moral and ethical responsibilities” rationale important at the 95% confidence level. those with a master’s degree were more likely to see it as important, at the 90% level. • respondents were significantly less convinced by the phrase “advancing economic possibilities in the developing world” (49% prsc), “advancing us economic interests abroad” (52% prsc) or 0 10 20 30 40 50 60 70 80 90 100 moral/ethical responsibility u.s. financial interests abroad economic possibilities for people in developing nations safeguarding our national security advancing democracy and freedom protecting the public health of citizens a more connected and cooperative world when you think generally about international health and development, how important do you think each of these six rationales for action are? 35 dyer & heuser july 2018. christian journal for global health 5(1):32-43 “advancing democracy and freedom in other places of the world” (53% prsc). yet, it was encouraging to see that prscs still assigned value to these rationales. moreover, these lower rationales among prscs were significantly more important to men than women, by an approximate average of seven percentage points. in the gp study, however, there was no consistent significant difference between male and female responses. global health issues: priorities similar to the rationales, global health priorities of both prsc and gp respondents align with those that are most likely to affect people in their own country. while we report on the prsc findings below, it should be noted that a higher percentage of the gp found every issue more urgent than did the prscs, at an average difference of 6.15 percentage points and by at least 55% of respondents. both groups found the same top five issues most urgent — in order: water pollution, infectious/communicable diseases, malnutrition, chronic diseases, and mental health as shown in figure 2. females were more likely than males to find each issue more urgent. figure 2. urgency of global health priorities among prscs • water pollution (73%) ranked the highest among all as the most critically urgent global health priority. • infectious/communicable diseases (66%) ranked second as either very or critically urgent to respondents. • malnutrition/nutrition (63%) and chronic diseases (63%) co-ranked as third highest for urgent global health priorities. • across all priority areas, women attributed more urgency to the global health priority areas. perhaps most notably, women (71%) 63.4 55.4 65.9 72.6 54.4 53 55.3 63.5 58.8 39.5 59.1 46.1 58.7 0 10 20 30 40 50 60 70 80 which of the following global health priorities do you believe to be most urgent? 36 dyer & heuser july 2018. christian journal for global health 5(1):32-43 were more likely than men (62%) to identify nutrition as a global health priority. (the confidence interval test for comparison of means was statistically significant at the 99% level for prsc q10 and the 95% level for prsc q20; both questions related to the perceived urgency of nutrition/malnutrition). • the only areas where fewer than 50% of prsc respondents attributed urgency were climate change (39%) and refugee health (46%). in both areas, individuals with a doctorate or professional degree were much more likely to be concerned. global nutrition: preferred definition(s), knowledge of related terminology, and perceptions of vulnerability when responding to this definition of nutrition by the world health organization (who), 66% of prsc respondents said that nutrition was a very or extremely urgent global health priority: nutrition is the intake of food, considered in relation to the body’s dietary needs. good nutrition — an adequate, well balanced diet combined with regular physical activity — is a cornerstone of good health. poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.4 when asked how to define the need/problem of a nourishing diet for stronger population health, 36% of prscs chose to label it as “global nutrition,” instead of selecting other words such as “malnutrition,” “food security” or “hunger.” at the very start of our survey, prior to introducing prsc respondents to information related to particular aspects of nutrition and hunger, we asked them in an open-ended format to briefly describe the first thing(s) they thought of when they read the word “nutrition” in the context of developing nations. their responses reflected little more than rudimentary understanding of the most basic dimensions of nutrition (figure 3). very few respondents were able to construct a response that revealed either correlates to or deeper knowledge of nutrition-related characteristics. moreover, almost none of the respondents demonstrated a familiarity with technical aspects of nutrition or nutritional interventions. figure 3. responses to open-ended question about “nutrition” in developing nations paste your text below! word th in k one many food he alt hy co un tri es good p o o r nutrition p e o p le health lack e at enough d o n t need world pr op er b e tt e r foods ea tin g qu ali ty diet th ird water getting b a d fee d b a sic hungry first much help n o n e le ss w e ll g et lot right sure na body li fe care thing g re at wa ntways stay like kids sa d fruit liv e id k typ e a id h e ar go fresh cant fru its sleep no n o k yes fa t d a y us a q u e du e 3rd far try 5 q 5 re ad n e e d s know best feel am p le parts co u n try m a y co un try s ki n d sta rvi nga cc es s oth er s diets united daily really so u rces pr od uc e protein e ve n area re al no thi ng ad eq ua te im p o rt an t v ita mi ns supply clean going healthier american gr ow n h ig h w ith h o ld in g masses just mind lots la ck in g ma lnu tri tio n starvatio n h u n g e r children p o ve rty av ail ab le availability fe e d in g famine p ro vid in g balanced n u tr it io u s n u tritio n a l needed grow m al n o u ri sh e d everyone means ci ti ze n s fa rm in g population vegetables go ve rn me nt de ve lop ed meals properly s tate s african e ve ry r ic e different am o u n t developing ed uc ati on nutrientsnations p ro vid e su rvive u su al ly ab ilit y afford shortage un de rd ev elo pe d he alt hin es s options re ce ive st ru g g le m o n e y improve h e at h y g ro w th b alan ce calories i n ad e q u at e su rv iv al standards organic context sustainable w h ol e so m e v it am in political ve g e ta rian re ce iv in g processed veggies d rou g h t maintain general eu ro p e ce rta in whether decent ele m en ts probably challenges me an comes often taken delicious suffer someone p os it iv e co rru pt ion livin g facts label b e n eficial no ur ish ed thereof undernourished su pp os ed unhealthy co un tie s africa r am p an t g ive tim e im p ov e ri sh e d peoples co ol able co m e natural value allow begin for tu na te s u ff ic ie n t you n g ke ep so me thi ng nourish h u m an a lw ay s ordered fried th in g s co m m o n su pp or t wondering energy especially con ce rn average teach in g nation w it h o u t am er ica sim ply word cloud generator https://www.jasondavies.com/wordcloud/ 1 of 1 6/23/17, 3:01 pm 37 dyer & heuser july 2018. christian journal for global health 5(1):32-43 unfortunately, fewer than half of the prsc respondents were familiar with the provided nutrition concepts and related health terminology, with the exceptions of vaccinations and breastfeeding as noted in figure 4. figure 4. prscs familiar with nutrition-related terminology • vaccinations (55%), breastfeeding (51%), and family planning (46%) were the terms with which respondents were most familiar. no other term scored over 50%. • fewer than a quarter of respondents were familiar with the terms demographic dividend (24%), child wasting (23%), and child stunting (22%). • 63% of respondents claimed that more education about nutrition and nutritionrelated issues was needed in the u.s. “very much so” or “absolutely.” among the gp, those with no college education were significantly less likely to be familiar with most of these concepts than those with higher levels of education. • when thinking about nutrition in international aid, the vast majority of prsc respondents (83%) perceived that infants and children combined were the ones primarily affected vs. other potential populations as shown in figure 5. among the gp, infants and children were also seen as most affected; however, those with a doctoral or professional degree were significantly more likely than any other group to also see the elderly as affected (22.7%). 0 10 20 30 40 50 60 38 dyer & heuser july 2018. christian journal for global health 5(1):32-43 figure 5. perception of groups primarily affected by global nutrition nutrition messaging: focus on mothers and children in testing key words across 30 nutrition messaging statements, prscs were most compelled by language that focused on mothers and children as vulnerable populations, as seen in figure 6. key words that triggered positive responses by larger majorities of respondents included: pregnant mothers, unborn children, children, babies, and kids. figure 6: most compelling key words contained within nutrition messaging statements 0 5 10 15 20 25 30 35 40 45 50 infants children adolescents mothers adults elderly when you think about nutrition in international health, please rank order which groups you think are primarily affected. men women 55 57 59 61 63 65 67 69 71 73 75 mothers/pregnant mothers children/kids babies families people how compelling do you find the following statements about nutrition and its related issues? men women 39 dyer & heuser july 2018. christian journal for global health 5(1):32-43 across all questions, women found the language of mothers (+5%), children (+6%), and babies (+5%) significantly more compelling within nutrition statements than men when key words were examined, as demonstrated in figure 7. across the questions that contained concepts most familiar regarding mothers and children, the average difference between women’s and men’s responses increased to 7.5%. • among both prscs and the gp, women were more likely than men to respond to the language of mothers and children: 5.5% average difference among prscs and 4.1% among the gp. figure 7: five most compelling statements about nutrition • women in particular were most compelled by “malnutrition causes children to die of preventable deaths” (80%), a full 13.8 points higher than men on this question. (the confidence interval test for comparison of means was statistically significant at the 99% level for prsc q15.) see figure 6 for more information. 50 55 60 65 70 75 better nutrition for pregnant mothers protects their unborn children malnutrition causes children to die of preventable causes better nutrition for pregnant mothers combats infant mortality proper nutrition for babies can prevent mental and physical handicaps nutrition is most critical for mothers and children early in a child's life 40 dyer & heuser july 2018. christian journal for global health 5(1):32-43 figure 8: five least compelling statements about nutrition taking responsibility for acting on the issues with regard to how the prsc and gp groups ranked those responsible for handling issues of international nutrition/malnutrition, the two groups were surprisingly similar in their first-rank positions. for both, the majority of respondents signaled that it was, “the government of those people struggling with nutrition” that should bear primary responsibility. however, prscs ranked “individuals struggling with lack of nutrition” in the second most responsible place, while gp respondents assigned that rank to “international organizations such as the un.” both groups ranked “agricultural companies,” “nonprofit organizations,” and “the u.s. government,” among the least responsible for taking action. when we aggregated the top three rankings (out of 8) for each group, we were encouraged to find a nearly identical relationship between prscs and the gp assigning responsibility to “people from developed countries, such as myself,” at surprisingly high rates: 45.92% (prsc) and 45.15% (gp). interestingly, both groups’ scores gravitated significantly toward the bottom two positions of the rankings (58.35% for prscs and 50.57% for gp) for designating “the u.s. government” as responsible. given the overwhelming need for the u.s. to lead in bi-lateral and multilateral development assistance, this finding was particularly disturbing. at the same time, though not surprisingly, prscs were more than twice as likely as the general population to rank churches and faith-based organizations as responsible (10.44% versus 3.90%). below are the findings solely based upon the prsc study: • 85% of prsc respondents answered “yes” when asked if they were committed christians and three-fourths (76%) indicated that honoring moral or ethical responsibilities was a compelling rationale for international health and development efforts. • yet, only 49% said that feeding the hungry in other countries was an important commitment with respect to their personal faith. 25 30 35 40 45 50 55 60 65 70 75 families who thrive in sustainable communities are less likely to emigrate ensuring all people have enough food creates a more prosperous world nutrition and food security programs are extremely cost effective to increase national security and decrease poverty nutrition and food security programs are critical to national security, ultimately reducing the chances of conflict and need for u.s. military involvement family planning counseling is more successful when it includes nutrition 41 dyer & heuser july 2018. christian journal for global health 5(1):32-43 • while 88% of (prsc) women identified themselves as committed christians (seven percentage points higher than male respondents; the confidence interval test for comparison of means was statistically significant at the 95% level for prsc q33), they were just as likely as men (50%) to say that feeding the hungry in other countries was a “strong or very strong” commitment with respect to their personal faith. • moreover, only 32% were (very or extremely) willing to donate their personal resources to fight malnutrition internationally. • while 70% believed that it was important for the u.s. to have a positive image in countries worldwide, only 42% said that it was important for the u.s. to take a leading role in helping poor people in other countries. • prscs agreed with the statements that we should provide those in other countries with resources (66%) and that it was important to prevent people from other countries from starving (68%). limitations limitations of our survey methodologies were similar to those for most survey research and included: (1) potential bias toward younger and more technologically-savvy respondents, as the survey was administered via internet through qualtrics; (2) potential bias in excluding some conservatives who scored lower on our prsc ideological filter scales but may still have constituted part of the reference group; (3) potential bias associated with the low representation of minorities (especially latina/ latino) in the samples; (4) potential error as a result of the use of technical language associated with nutrition and international development efforts; (5) potential error associated with overstating the degree of concern or familiarity respondents had with certain related constructs. qualtrics estimated the sampling error to be +/4%. discussion this survey was conducted in the first and second quarters of the trump administration. the prsc respondents, many of whom were likely to have voted for this administration, may have had in mind a more nationalist agenda compared to the global-minded philosophy of the previous obama and bush administrations, perhaps particularly represented by foreign assistance. this potential bias might explain the emphasis in their responses on national security and public health as strong rationales for foreign assistance, as well as their apparent uncoupling of personal faith with a responsibility to “feed the hungry” in other countries. given the findings, we offer the following observations and recommendations in which to shape messaging for successful advocacy to maintain or increase funding for global nutrition among prscs and the gp in the u.s.: better u.s. foreign assistance branding the american public consistently overestimates the share of the federal budget spent on foreign aid: the average answer is 31% (kaiser family foundation health tracking poll (conducted december 1-7, 2015)).8 debunking the twin myths of quality (the u.s. government is inefficient with foreign assistance) and quantity (the myth that foreign assistance comprises 25%+ of the u.s. budget) remains a challenge, including among prscs. we must tell a better story to uplift the branding. as a correlate, the public, including prscs, need further education on the role of foreign assistance as “soft power,” “smart power,” or the “third leg of the stool” as development, alongside diplomacy and defense. though we find that 90.2 percent of prscs overwhelmingly note that safeguarding our national security is important for international health and development efforts, when nutrition is paired with national security, we find only 53.6 percent find the correlation compelling. on a more micro-level, we believe the respondents 42 dyer & heuser july 2018. christian journal for global health 5(1):32-43 shifted into analytical, deliberative thinking which can override both emotion and action. in a macro view of global health and development overall, among the metaphors of impetus, national security is the clear motivation. much collaboration with the media and spokespersons is needed to aid in telling of the good news of progress in fighting disease and poverty, including with nutrition, with less than 1% of the u.s. budget, including the efficiency and efficacy with which the u.s. implements this funding through governmental infrastructures and partnerships worldwide. moreover, linking national security with global health and development issues is also imperative in order to elucidate the relationship between the two. the good news is that most prscs do believe we should provide international assistance to combat starvation (68%). this belief can be a powerful leverage in a time of historic famines in order to mobilize prscs and the gp for advocacy. better education on global nutrition due to the open-ended response(s) of the most basic language around “nutrition,” juxtaposed to the findings that fewer than a quarter of respondents were familiar with the terms such as child wasting (23%), child stunting (22%), or micro-nutritional deficiencies (24.7%), we recommend using the most basic of nutrition language when speaking with prscs of the importance of global nutrition. educating prscs on the international affairs account (150 account), the role of nutrition in u.s. international food aid programs and agriculture programs, the importance of nutrition for mothers in the crucial 1000-day window between a child’s conception and the age of two, and related nutrition terminology (e.g., wasting, stunting, anemia) will be necessary for this constituency to better understand the critical importance of funding for nutrition worldwide. with such learning, committed christians and others may experience an increase in empathy for those humans behind the issues and a stronger commitment to foreign assistance. better stories about mothers and children we recommend narratives that feature stories of the daily struggles of mothers, children, and infants for the most effective method of education and awareness building. from the research, we know that the most compelling messaging for nutrition stays close to saving the lives of both mothers and children or their flourishing. eighty-three percent believe that infants and children are primarily affected by malnutrition, and more than 70 percent of prsc respondents find this language about the mother-child connection with nutrition most compelling. our hope is that this research will better inform the messaging and education of both the american public at large, and more specifically, prscs in an effort to galvanize the interest of the members of congress to enhance and shape better policies on global nutrition. references 1. united nations (un). the millennium development goals report [internet]. 2015 available from: http://www.un.org/millenniumgoals/2015_mdg_rep ort. 2. world health organization (who). world malaria report summary [internet]. 2015. available from: http://apps.who.int/iris/bitstream/10665/205224/1. 3. dirlikov e, raviglione m, scano f. global tuberculosis control: toward the 2015 targets and beyond. ann internal med. 2015;163(1):52-8. https://doi.org/10.7326/m14-2210 4. world health organization (who). trends in maternal mortality 1990-2015 [internet]. available from: http://apps.who.int/iris/bitstream. 5. you d, hug l, ejdemyr s, idele p, hogan d, mathers c, et al. global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the un inter-agency group for child mortality estimation. lancet. 2015 dec 5; 386(10010): 2275-86. https://doi.org/10.1016/s01406736(15)00120-8 6. pepfar: 2018 annual report to congress [internet]. 2018 [cited 2018 june 14]. available from: http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20(july%201).pdf http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20(july%201).pdf http://apps.who.int/iris/bitstream/10665/205224/1/who_htm_gmp_2016.2_eng.pdf?ua=1 https://doi.org/10.7326/m14-2210 http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1 https://doi.org/10.1016/s0140-6736(15)00120-8 https://doi.org/10.1016/s0140-6736(15)00120-8 43 dyer & heuser july 2018. christian journal for global health 5(1):32-43 https://www.pepfar.gov/documents/organization/2798 89.pdf 7. friends of the global fight. global fund results [internet]. 2018 available from: https://www.theglobalfight.org/impact/global-fundresults/ 8. dijulio b, norton m, brodie m. americans' views on the u.s. role in global health. kaiser family foundation. health tracking poll [conducted december 1-7, 2015] [internet]. 20 jan 2016. available from: https://www.kff.org/global-healthpolicy/poll-finding/americans-views-on-the-u-s-rolein-global-health/ peer reviewed: submitted 31 jan 2018, accepted 17 june 2018, published 12 july 2018 competing interests: none declared. acknowledgements: special thanks to douglas c. heimburger, md, ms and lindy fenlason, md, pns, mph for their expertise and contributions to this work; and to the eleanor crook foundation for their funding to make this research possible. correspondence: jennifer eaton dyer, vanderbilt university and hope through healing hands, united states of america. jenny@hopethroughhealinghands.org cite this article as: dyer j e, heuser b l. how u.s. conservatives perceive and respond to international nutrition issues, and how to shape messaging for successful advocacy. christian journal for global health. july 2018; 5(1):32-43. https://doi.org/10.15566/cjgh.v5i1.207 © dyer j e, heuser b l. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.pepfar.gov/documents/organization/279889.pdf https://www.pepfar.gov/documents/organization/279889.pdf https://www.theglobalfight.org/impact/global-fund-results/ https://www.theglobalfight.org/impact/global-fund-results/ https://www.kff.org/global-health-policy/poll-finding/americans-views-on-the-u-s-role-in-global-health/ https://www.kff.org/global-health-policy/poll-finding/americans-views-on-the-u-s-role-in-global-health/ https://www.kff.org/global-health-policy/poll-finding/americans-views-on-the-u-s-role-in-global-health/ mailto:jenny@hopethroughhealinghands.org https://doi.org/10.15566/cjgh.v5i1.207 http://creativecommons.org/licenses/by/4.0/ editorial may 2016. christian journal for global health, 3(1):1-2 educating globally for health the theme for this issue is health-related education, and the editors are pleased at the numbers of submissions and the enthusiasm for this topic. clearly there are efforts on a broad front to relate christian understanding to education with a global health perspective. here is a survey of what you will find in this issue. additionally, several more articles to supplement this theme are being considered for publication in the near future. huw morgan and sharon falkenheimer describe the efforts of prime, a uk-based christian medical education charity, to restore a christian moral and spiritual character to healthcare globally. helen wordsworth describes the development of parish nursing in the uk, again an effort to restore a spiritual character to healthcare. fountain, mukooza, and kanyesigye describe the establishment of an undergraduate university course in health and wholeness, now taken by more than 26,000 students in uganda. the effectiveness of these efforts has not been directly measured, but in other areas assessments are ongoing. michael brooks and maggie ehrenfried report the development, implementation, and measurement of healthcare capacity and quality over nine quarters from 2012 to 2014 in burundi using a horizontal franchise business model. this work is the brainchild of lifenet international whose leadership is particularly strong in entrepreneurship, business management, and economics. thomas and maliekal from the catholic health association of india present a comprehensive approach to maternal child health based on human rights, and the impact of nun-nurses trained as locally active community health enablers for better maternal-child health. butcher, et al.evaluate the effectiveness of a community health worker training course in india to build capacity for health promotion access in rural areas. shumba, miyonga, et al. present a well-done qualitative study on the cultural, economic, and social barriers to family planning in uganda. these studies assess the effectiveness of very grass roots efforts in developing world contexts to build health capacity. young, et al. use realist evaluation to study the formation and function of disabled peoples’ groups in north india. slashcheva, et al. give a description and growth analysis of the yearly conferences sponsored by the us-based christian medical and dental associations for missionary doctors and staff. deborah kroeker and anne walling describe an analysis of the effectiveness of a medical education international conference in mongolia. kathryn butler gives a moving personal account of how in the midst of the frustrations of inadequate resources, practicing loving presence, and learning from the afflicted is what god desires beyond technical health care provision. this issue has four reports from a preconference held in november 2015, immediately prior to that year’s global missions health conference in louisville, kentucky, usa. these are mentioned separately along with commentary by the editors with guest vinod shah on the sometimes understated challenges of learning/ teaching methods, paternalism, and corruption in health-related education. the commentary by jose miguel deangulo and luz stella losada deserves special mention. this article follows an earlier review “health paradigm shifts in the 20 th century” in vol 2 issue 1 of the journal by the same authors that lays out the evolution of the paradigms by which we have come to our current framework for understanding health care provision and prevention. in this issue, they explain how new findings in the neuroscience of the developing infant may provide the grounds for an entirely http://journal.cjgh.org/index.php/cjgh/article/view/127 http://journal.cjgh.org/index.php/cjgh/article/view/140 http://journal.cjgh.org/index.php/cjgh/article/view/141 http://journal.cjgh.org/index.php/cjgh/article/view/123 http://journal.cjgh.org/index.php/cjgh/article/view/113 http://journal.cjgh.org/index.php/cjgh/article/view/113 http://journal.cjgh.org/index.php/cjgh/article/view/125 http://journal.cjgh.org/index.php/cjgh/article/view/142 http://journal.cjgh.org/index.php/cjgh/article/view/114 http://journal.cjgh.org/index.php/cjgh/article/view/145 http://journal.cjgh.org/index.php/cjgh/article/view/131 http://journal.cjgh.org/index.php/cjgh/article/view/146 http://journal.cjgh.org/index.php/cjgh/article/view/126 http://journal.cjgh.org/index.php/cjgh/article/view/150 http://journal.cjgh.org/index.php/cjgh/article/view/38 http://journal.cjgh.org/index.php/cjgh/article/view/38 http://journal.cjgh.org/index.php/cjgh/article/view/37 http://journal.cjgh.org/index.php/cjgh/article/view/37 2 editors may 2016. christian journal for global health, 3(1):1-2 new framework for understanding global health priorities. there have indeed been astounding advances in knowing how the brain works and, especially, the amazing amount of plasticity and interplay with the environment. because of similarities between these new findings and the earlier paradigm involving the social determinants of health, neither editors nor reviewers were convinced that an entirely new paradigm was indicated. however, given the evidence of the high impact and cost-effectiveness of interventions during the formative first 1000 days of life, this perspective requires emphasis for our future in transformative global health and sustainable development. www.cjgh.org original article recruiting long-term healthcare missionaries: insights from surveys of those who have gone and those who aspire to go john mcvay a , christopher l. place b , david l. stevens c a mdiv, coo, in his image international medical missions, usa b md, associate residency director, in his image family medicine residency, usa c md, ma (ethics), ceo, christian medical & dental associations, usa abstract background: the cmda/medsend healthcare missions leadership summit is an annual gathering of leaders from 75 mission sending agencies who work around the world in healthcare missions. the summit is jointly sponsored by medsend and the christian medical & dental associations (cmda). the purpose of the meeting is to share best practices, network, and examine cutting edge research issues in the field of healthcare missions. objective: the purpose of the 2015 launch survey was to learn from medical missionaries how to more effectively recruit and launch new healthcare professionals and their families into longterm missions. the objective of the 2016 relocating for the gospel survey was to learn from students and other aspiring healthcare missionaries the obstacles they perceive in their journey into long-term missions. results were presented at the 2015 and 2016 healthcare missions leadership summits. methods: two multiple-choice surveys were developed to ascertain the positive and negative factors involved in the decision making process to launch into the healthcare mission field. participants were invited to participate in the surveys via email. results: the 2015 launch survey analyzed 177 responses from healthcare missionaries with 63% of respondents still currently serving as long-term missionaries. 37% of the respondents were missionaries previously. participants included millennials (n=39), gen xers (n=54), and baby boomers (n=84). responses indicated that key positive factors include personal interaction with a long-term worker as well as a supportive agency, leader, or team to join. the 2016 relocating for the gospel survey analyzed responses from students and other aspiring missionaries who are millennials (n=79). the strongest overall factor that discouraged missions involvement was student loan debt. other key obstacles include concerns over being lonely or isolated overseas, as well as difficulty in finding a good fit with a team or organization. conclusion: the overall findings from the two surveys include four main points. first, effective launch into missions service is more relationally dependent than informationally dependent. second, launching into missions service is more like a marathon than a sprint. third, those who are exploring missions want to join a team so they will not feel lonely or isolated. finally, aspiring missionaries want a placement that fits them well even if that does not match the top priorities of the agency. 82 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 introduction long-term healthcare missionaries are in high demand as the need is great. according to the 2011 prism survey, “the biggest perceived challenge to medical missions is not enough qualified workers.” 1 one part of the lack of qualified workers on the mission field is attrition. as one survey respondent noted, “launching is one thing. sticking it out is another.” according to the global health workers needs assessment survey (ghwna), the average length of service for those who left the field was 4.77 years. the ghwna survey examined this attrition and noted that this can exact a considerable toll on those who leave prematurely as well as those who are left on the field shorthanded. 2 the initial challenge of finding qualified workers is the other part of the insufficient number of workers on the mission field. while many young health professionals are interested in missions, only a handful of them continue into long-term commitment. missiologist ralph winter, who launched the perspectives course and the frontier ventures think tank, estimates that only about one out of a hundred ‘missionary decisions’ results in actual career mission service. 3 in matthew 9:37-38 jesus said to his disciples, “the harvest is plentiful but the workers are few. ask the lord of the harvest, therefore, to send out workers into his harvest field.” (niv) discussion of the recruitment and launch process for healthcare professionals and their families was part of the cmda/medsend 2015 healthcare missions leadership summit. well in advance of the summit, a workgroup at in his image family medicine residency in tulsa, ok developed a survey to determine how agencies can become more effective in recruitment and launching of long-term healthcare missionaries. the survey was designed to determine what draws (positive factors) individuals to this commitment to service as well as what concerns (negative factors) they weigh when making their decision. the draws and the concerns match closely with those identified by the qualitative survey published in the 2016 world evangelical alliance book mission in motion. 4 participants’ responses in the 2015 survey of healthcare missionaries came from a mix of millennials, gen xers, and baby boomers. most participants were baby boomers, age 51 – 69 years of age as of 2015. over half of respondents were still serving in long-term healthcare missions while the rest had been previous long-term missionaries. while the 2015 survey offered worthwhile information on the positive factors, it was difficult to identify the main hindrances to long-term service from the results of that survey. this is probably explained by the respondents’ success in having already overcome the obstacles, and not fully remembering the challenges they had faced initially. the subject of recruitment was again a topic for the following year’s 2016 cmda/medsend healthcare missions leadership summit. months before the summit, workgroup members at in his image conducted a second survey to learn how students and other aspiring healthcare missionaries explore their options when considering relocating for the gospel, whether across town or across the world. the survey further explored concerns that held significant impact for the survey participants, as well as factors that could affect aspiring longterm healthcare missionaries’ decisions. in addition, this survey included questions regarding the ways in which millennials prefer to learn about opportunities to relocate, as well as which life experiences most significantly affect their decision to serve in this capacity. methods for the 2015 survey, a workgroup at in his image developed an initial qualitative survey of open-ended questions. the workgroup consisted of a former missionary, three resident physicians, two psychologists, and an administrator. they received twenty responses from current medical mission83 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 aries. the workgroup took those responses and created a likert-scale draft survey. respondents ranked each positive factor as “did not help,” “helped a little,” “helped some,” “helpful,” or “very helpful.” the survey was tested and revised using responses from an additional 12 current or recent long-term medical missionaries. (see appendix a.) the survey was deployed through survey monkey. questions were presented in random order. dr. david stevens sent an email in april of 2015 inviting responses from the 1,609 on the cmda “e-pistle” list, most of whom are long-term medical missionaries. percentage of responses selected as “helpful” or “very helpful” were calculated and used to rank the factors. answers were analyzed using simple statistics. a workgroup at in his image developed the second survey in 2016 to learn how students and others might explore relocating for missions. the workgroup consisted of five residents, a psychologist, and an administrator. this group developed an open-ended survey and received 13 responses from attendees to a missionnext forum and 29 responses from those who had previously participated in medicalmissionsmentoring.com, a ministry in his image offers through the global missions health conference (gmhc). the workgroup then took those open-ended responses and created a multiple-choice survey, which was tested and revised using responses from 14 additional resident physicians. respondents ranked each concern as “not a concern,” “a little concern,” “some concern,” “concern,” or “strong concerns.” (see appendix b.) the survey was deployed via survey monkey. questions were presented in random order. dr. david stevens sent an email in march of 2016 inviting responses from the 1,579 on the cmda “your call” e-newsletter list, most of whom are students, resident physicians, or recent graduates. that cmda e-newsletter also mentioned the survey twice to solicit additional responses. at the end of the survey, participants were given a free e-book. percentage of responses selected as “strong concerns” were calculated and used to rank the obstacles. results the 2015 survey examined positive factors that draw healthcare professionals to the mission field. there were 253 responses for a 16% response rate, which is strong for an email survey. 63% of participants were male and 37% were female. the majority of respondents, 89%, listed their passport country as the united states. all others were less than 5% per country indicated. a majority of the respondents in the 2015 survey were currently serving as long-term healthcare missionaries (63%). of the 177 analyzed responses, 39 were millennials, 54 were gen xers, and 84 were baby boomers. random sampling error for this 2015 survey was 7.1% and calculated from 177 responses out of 1,609 who were sent the email invitation. responses not analyzed included participants who only anticipated going one or two years when they launched, those who only did short-term missions, those who launched first to north america, duplicates (identified by email or ip address), and those responses from individuals over age 70 (23 respondents). the most important positive factors for participants were the following: guidance or call from god, desire to share the good news, and the desire to provide healthcare to the underserved. one participant aptly stated, “the only thing to overcome all the obstacles is a deep conviction of god’s leading plus the opportunity to see real needs and practical ways to meet them. a half-hearted conviction is not enough.” having supportive friends, spouse and family members rounded out the top six positive factors. (see table 1) the survey further explored factors which might draw potential healthcare missionaries to serve in the mission field. survey participants highly valued personal interaction with long-term workers and having a supportive agency, leader, or team to join in the field. participants indicated these 84 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 two draws to be even more influential in their decisions than short-term missionary trips they had taken. table 1. positive factors that missionaries experienced % draw to mission service 98% guidance or call from god 89% desire to share the good news 86% desire to provide healthcare to the underserved 77% supportive friend(s) 72% supportive spouse (or potential spouse) 70% supportive family 70% personal interaction with long-term worker(s) 69% supportive agency, leader, or team to join 54% reading biographies of long-termers 53% short-term trips of two months or less 47% sermon(s) or worship or other with my church 47% mentor(s) 43% conference(s) about international opportunities 39% short-term trips of two months or more 36% perspectives course or other mision course 31% sermon(s) or worship or campus ministry note: the top six are predictable. factors 7 and 8 above (in bold) being so high on the list are key findings. also note that the above numbers total more than 100% because respondents could and did select multiple factors. n=177. other factors, while ranked somewhat lower in terms of influence for aspiring long-term healthcare missionaries, are still worth noting. these included reading biographies of long-termers, shortterm trips, sermons or worship with their church or campus ministry, their experience with mentors, and conferences about international opportunities. mentoring or coaching was ranked helpful or very helpful by 47% of survey respondents and only 16% of participants reported not having a mentor. one survey participant advocated that mentoring is an area of huge opportunity and proposed mentoring could bring in ten times the number of long-term healthcare missionaries to service. when asked which stages of life were most significant in making the decision to go into longterm healthcare mission work (see table 2), the top three rated responses indicated participants made their decision during their undergraduate years, their teenage years, or during graduate school/ medical school. other responses included during childhood, in their career, or during postgraduate training or residency. a small percentage reported they made their decision zero to two years before launching. a key finding is that the average number of stages checked was 2.3. table 2. decision stages % stage 45% undergraduate 43% teenage years 42% grad school/med school 29% childhood 25% career 22% postgraduate training e.g. residency 18% zero to two years before launching note: the above numbers total more than 100% because respondents could and did select multiple stages as significant. n=177. survey participants were asked if they found using an agency helpful in the decision-making process. responses included both positive and negative feedback. one participant shared that he/she appreciated the approachability and humility of doctors and nurses in the field as well as the interest those same healthcare professionals expressed in the candidate’s life and walk with god. another participant reported, “the recruiter was very patient and walked with us over the course of several years of discernment.” in contrast, there were also comments from survey participants mentioning that some agencies were not helpful to them as they weighed their options. one participant cited an example of contact with multiple mobilizers and found these to be more obstructive than helpful. another offered the following: “i contacted workers from two agencies; one didn’t have time to answer my questions and the other did.” the 2016 survey examined obstacles students and other aspiring missionaries face in their journey to long-term missions. of the 178 responses received, 99 were not analyzed. responses not analyzed included the following: duplicates (identified by email or ip address), responses from participants that had previously relocated for the gospel, responses from participants who were not citizens of either usa or canada, and responses that were not from a millennial. the 79 analyzed survey responses came from millennials aged 21-35 85 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 years old as of 2016. over 78% had attended the global missions health conference. the margin of error for the 2016 survey was 11%. the 2016 survey participants’ demographic data differed significantly from the 2015 survey participants. the 79 responses analyzed were from millennials, ages 21-35 as of 2016. more than half of the 2016 survey participants were female (65%) and slightly more than half were married (58%). the largest percentage of participants were specializing in family medicine or heading that way. the highest rated negative factor that aspiring missionaries face is student loan debt (table 3). the average loan balance for those who indicated student loans as a strong concern was $200,000. one participant commented that there should be more options for loan repayment while serving overseas. they further noted that they were aware many colleagues had chosen to delay going overseas until their loans were paid off. for millennials who took the 2016 survey, the next two top rated concerns were the possibility of relocating and then being lonely or isolated, and raising financial support. other concerns included being far away from family and friends, lack of experience and/or training, fear of burnout, and consideration regarding their children or future children. another notable concern for aspiring millennial healthcare professionals was finding a good fit with a team or organization. table 3. concerns of millennials who are aspiring missionaries % strong concerns 35% student loan(s) 32% if i would relocate and be lonely or isolated 32% raising financial support 27% being far away from family and friends 26% my lack of experience and/or training 23% fear of burnout 22% my children or future children 21% difficult to find a good fit with team or organization 19% if i would need to learn a new language after i relocate 15% god's guidance in a major decision is difficult to find 14% objections from my parent(s) 9% difficult to keep up to date if i lived in another country note: many of the above are predictable. concerns 2 and 8 above (in bold) being so high on the list are key findings. also note that the above numbers total more than 100% because respondents could and did select multiple concerns. n=79. the 2016 survey explored the best way to connect with millennials regarding opportunities to relocate for the gospel. participants shared the two main ways they as millennials would like to learn of these opportunities. results indicated that 80% would prefer personal interaction with someone already serving there (table 4). the second highest ranked answer, selected by 77% of respondents, was through a short-term visit to that location. table 4. how millennials would like to learn about opportunities % connection point 80% personal interaction with someone already serving there 77% short-term visit to that location 67% conference 56% pastor, mentor, leader or teacher 53% email 39% friend or family member 32% meeting at church 18% web browsing 6% social media note: connection points 1 and 2 above (in bold) being so high on the list are key findings. also note that the above numbers total more than 100% because respondents could and did select multiple connection points. n=79. 86 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 millennials also shared which experiences impacted them most in considering relocating for the gospel. short-term mission trips ranked first with the global missions health conference a strong second (table 5). table 5. experiences that impact millennials to consider missions % experience 80% short-term mission trip(s) 59% global missions health conference (gmhc) 42% reading biographies 35% mentoring relationships 35% sermon(s) or worship or other with my church 25% perspectives or other missions course 19% other conference(s) besides gmhc note: gmhc above (in bold) being so high on the list is a key finding. also note that the above numbers total more than 100% because respondents could and did select multiple experiences. discussion a viewpoint expressed by a missionary was, “it’s not about more people, but rather suitable people.” the question is, then, how can the recruitment process be improved to help more qualified and suitable healthcare professionals choose to launch and then remain in the mission field long-term? examining the survey results, we know what concerns many aspiring long-term healthcare missionaries have. we should begin by providing resources to minimize the causes of these concerns. for example, student loans is the number one concern of healthcare professionals. all agree that $200,000 is a huge amount to have hanging over one’s head. one participant’s response addressed this concern, “i do not know if we would have made it to the field if it were not for medsend! i could see us getting established at home as we paid off loans and then got comfortable, even though we had a strong call to go into missions.” however, another wrote, “we need more options for loan repayment while serving overseas. many colleagues are delaying going overseas until loans are paid off as they are not comfortable with the duration of loan repayment with medsend.” it would be worthwhile to examine all the resources available to remove or at least lessen this obstacle to help aspiring newly launched healthcare missionaries. building relationships between someone in the field and a newly launched healthcare professional is another factor that can counter the concern of being isolated, far away from family and friends. david frazier, author of mission smart: 15 critical questions to ask before launching overseas, suggests that the millennial generation seeks mentors, who partially fill the role they had previously valued in their parents. 5 mentorship, then, is highly important. perhaps there is a way to encourage more long-term missionaries to become mentors. healthcare missionaries mentoring while on home assignment visits may be more effective at mobilizing aspiring missionaries than full-time mobilizers. it is worth noting that while mentorship is important, not every experienced missionary can mentor, just as not every english-speaking person can teach english effectively. an e-newsletter by medicalmissions.com (sep. 2015) reported that over one hundred aspiring healthcare missionaries asked for a mentor, but only 15 practicing healthcare missionaries offered to become a mentor. mentoring is sometimes formal and sometimes informal. christian community health foundation (cchf) in usa did multiple surveys and identified students who 1) did a rotation early in their training with a christian physician who is practicing quality medicine and integrating faith in his/her medical practice and 2) attended a healthcare missions conference. over 80% of these students chose a path to serve the poor through missional medicine for a significant portion of their careers (personal communication with steve noblett, executive director, christian community health fellowship, nov. 2015). in the article developing cross-cultural healthcare workers: content, process and mentoring strand, chen, and pinkston point out the “younger generations of cross-cultural healthcare mission87 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 aries are shifting toward shorter terms of service.” 7 the two-year samaritan’s purse post residency program connects recent graduates to a location, provides financial assistance and reliable support, etc. and has helped many go. but one missionary commented that too many of these do not continue long-term. “somehow convince those who go that that they should go indefinitely, not ‘we'll go for two years and see how it goes.’ it seems that the two years just ‘inoculates’ them: ‘been there, done that.’” regarding the desire to share about christ, one millennial stated, “at first sharing the gospel sounded like proselytizing on the street, which i don’t like. but i am drawn to using my skills to build relationships and sharing the good news through authentic conversations.” the two surveys reported in this paper were done on healthcare missions. other insights may be found by comparing and contrasting healthcare missionaries and students with similar surveys taken of non-healthcare missionaries and nonhealthcare students. those surveys were recently published in evangelical missions quarterly by brown and mcvay 8 and also posted online at www.launchsurvey.wordpress.com. 9 this website has full powerpoint reports on the surveys with additional data not included in this paper. those can also be a resource for future surveys which could be done every five to ten years to give recruiters up to date recommendations. as we examine the future of global long-term missions, it is crucial that we pass on the wisdom of the current and former dedicated generation of missionaries so those following have the value of that hard-earned knowledge to build upon. recommendations one recommendation for building relationships with aspiring international healthcare missionaries involves mentoring by those who host short-termers. while hosting, build in small group or one-on-one time with those short-termers exploring long-term. maintaining this relationship might help new missionaries not feel so isolated. therefore, it is recommended that healthcare missionaries who meet an aspiring long-termer should continue that relationship via long-distance mentoring. improving the approach to mentoring and coaching could increase its effectiveness, making these stronger tools for recruitment and launching long-term healthcare missionaries. suggestions for increasing mentorship include providing more than one coach for different areas of healthcare ministry, following the mentee’s agenda, and finding a good match of mentor and mentee so expectations are in harmony. it is also important to utilize diverse types and approaches to mentoring which coincide with the mentee’s progression along the healthcare missionary track. for example, when mentoring or coaching from long distance, start with practical topics and later address deeper issues. when mentoring or coaching in person, increase the frequency of meetings, listen well, find a book to discuss together, discuss heart issues, and be available by phone, text, and social media. a key resource is www.askamissionary.com with over six hundred answers to two hundred questions including many answers specifically about how to become a long-term healthcare missionary. 6 limitations one significant limitation of the 2015 survey is the confounding variable of recall bias. not only may it be difficult to remember information, thoughts, and feelings from years ago, but participants may not remember the hindrances or helpful aspects of launching accurately. another limitation was the potential that participants from different generations understand terms like mentoring or coaching differently. also, some participants in restricted access countries may not have taken the survey to avoid being identified as missionaries. to reduce that risk the survey did not http://www.launchsurvey.wordpress.com/ http://www.askamissionary.com/ 88 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 use the words “missions” or “missionary.” also, no consent form was used and participants could omit their email address. the benefit of participating in the survey, i.e. more missionaries would be sent, was implied and not explicitly stated in the introduction: cmda and others want to learn how to more effectively launch healthcare professionals and their families into long-term international service. a limitation of the 2016 survey was that all respondents had previous missions interest and were already subscribers to that cmda enewsletter list. conclusions information gleaned from the 2015 and 2016 surveys has revealed important points to consider as we adjust current recruiting and launching practices. it is important to help aspiring healthcare missionaries find a team so they do not feel isolated. if an individual or family has gifts and talents that are not a good fit for the mobilizer’s agency, help them find another organization that would be a better fit. a second conclusion drawn from the surveys is that launching into long-term missions is like a marathon with multiple stages. the decision to launch is a process that requires patience and the process takes years and, on average, at least two life stages. one participant commented, “the recruiter was very patient and walked with us over the course of several years of discernment.” another missionary suggested, “get the children talking early about missions before their minds get cluttered. be honest with teenagers about the struggles of being a missionary. instead of teams, recruit short-term apprentices to work alongside long-termers.” the main survey conclusion is that effective launching is more about relationships than just more information. after the top six predictable positive factors, personal interaction with long-term workers ranks most helpful by 70% of survey participants. to launch, aspiring long-term healthcare missionaries need meaningful time with those who have experience in the field. references 1. strand ma. medical missions in transition: taking to heart the results of the prism survey [internet]. christian medical & dental associations: 2011. available from: https://cmda.org/library/doclib/prism-survey2011.pdf. 2. strand ma, wood a. that healthcare missionaries might flourish: global healthcare workers needs assessment report. fargo, nd: medsend; 2015. 3. winter rd. the editorial of ralph d. winter, founder of the u.s. center for world mission. mission frontiers. 1995: january – february. 4. matenga j, gold m. mission in motion: speaking frankly of mobilization/ new york, ny: world evangelical alliance (wea); 2016. 5. frazier dl. mission smart: 15 critical questions to ask before launching overseas. memphis, tn: equipping servants international (esi); 2014. 6. askamissionary.com [internet]. st. louis, mo: mission data international; c1998-2017 [updated 2017 may 1: cited 2017 may 24]. available from http://www.askamissionary.com/ 7. strand ma, chen ai, pinkston lm. developing cross-cultural healthcare workers: content, process and mentoring. christian journal for global health. may 2016; 3(1): 57-72. https://doi.org/10.15566/cjgh.v3i1.102 8. brown mr, mcvay jw. the launch survey: helpful and hindering factors for launching into longterm missions. evangelical missions quarterly (oct 2016), 52(4): 46-51. 9. mcvay jw. the launch survey [internet]. in his image international medical missions: 2017. available from: https://launchsurvey.wordpress.com/ https://cmda.org/library/doclib/prism-survey-2011.pdf https://cmda.org/library/doclib/prism-survey-2011.pdf http://www.askamissionary.com/ https://doi.org/10.15566/cjgh.v3i1.102 https://launchsurvey.wordpress.com/ 89 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 peer reviewed competing interests: none declared. correspondence: john mcvay, in his image international medical missions, usa. jmcvay@inhisimage.org cite this article as: mcvay j, place cl, stevens dl. recruiting long-term healthcare missionaries insights from surveys of those who have gone and those who aspire to go. christian journal for global health. nov 2017; 4(3):82-95. https://doi.org/10.15566/cjgh.v4i3.178 © mcvay j, place cl, stevens dl. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:jmcvay@inhisimage.org https://doi.org/10.15566/cjgh.v4i3.178 http://creativecommons.org/licenses/by/4.0/ 90 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 appendix a: survey of healthcare missionaries cmda and others want to learn how to more effectively launch healthcare professionals and their families into long-term international service. (yes, we know we need your help!) can you give about 10 minutes of your expertise? you will first be asked basic demographic information and then about your journey into long-term service. we know your time is short; we only need brief responses. at the end, you may remain anonymous or you may enter your email address to receive the final survey report. demographic information 1. what year were you born? 2. what is your gender? 3. what year did you first enter long term service internationally? 4. marital status when you entered long term service internationally. 5. how many children, if any, did you have and take when you first entered long term service internationally? 6. if you had any children when you first entered long term service internationally, how many years old was your oldest child? 7. before you first went long term internationally, how many years did you anticipate being a longtermer? 8. when you first went long term internationally, what was your passport country? 9. when you first went long term internationally, to what region of the world did you go? 10. when you first went long term internationally, to what country did you go? 11. when you first went long term internationally, what agency, if any, did you join? 12. are you currently serving long term internationally? 13. years served as a long termer 14. which of the below fits best: i am a healthcare professional and single. i am a healthcare professional and my spouse is a healthcare professional. i am a healthcare professional and my spouse is not in healthcare. i am not a healthcare professional but i am the spouse of a healthcare professional. i am not a healthcare professional and i am single. i am not a healthcare professional and my spouse is not a healthcare professional. healthcare professional information 15. main specialty during training 16. what year did you finish your main specialty training? 17. when you first went long term internationally, what were the main things you went to do? factors that helped your journey when you were first deciding about going into long-term service internationally, there were likely factors that helped or hindered your journey. please rate the following factors as not significantly helpful or definitely significantly helpful for you launching long-term. 18. conference(s) or retreat(s) about international opportunities none did not help helped a little helped some helpful very helpful 19. perspectives course or other m. course none did not help helped a little helped some helpful very helpful 20. reading biographies of long termers none did not help helped a little helped some helpful very helpful 21. mentor(s) 91 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 none did not help helped a little helped some helpful very helpful 22. supportive spouse (or potential spouse) none did not help helped a little helped some helpful very helpful 23. personal interaction with long term worker(s) none did not help helped a little helped some helpful very helpful 24. sermon(s) or worship or other experience(s) with my church none did not help helped a little helped some helpful very helpful 25. sermon(s) or worship or other experience(s) with a campus ministry none did not help helped a little helped some helpful very helpful 26. supportive agency, leader or team to join none did not help helped a little helped some helpful very helpful 27. supportive friend(s) none did not help helped a little helped some helpful very helpful 28. supportive family none did not help helped a little helped some helpful very helpful 29. desire to provide healthcare to underserved not a factor helped a little helped some helpful very helpful 30. desire to share the good news not a factor helped a little helped some helpful very helpful 31. guidance or call from god none did not help helped a little helped some helpful very helpful 32. samaritan's purse post residency program na did not help helped a little helped some helpful very helpful 33. medsend grant na did not help helped a little helped some helpful very helpful 34. short-term trip(s) less than two months na did not help helped a little helped some helpful very helpful 35. short-term trip(s) two or more months na did not help helped a little helped some helpful very helpful 36. optional: other factor that was significantly helpful for me launching long-term. obstacles to your journey when you were first deciding about going into long-term service internationally, there were likely obstacles that were a concern or which hindered or delayed or interfered with your journey. please rate the following obstacles as not a significant concern or definitely a significant concern as you were deciding whether or not to go long-term. 37. concerns about being far away from family and friends not a concern a little concern some concern concern strong concerns 38. established where i was and i did not want to leave na not a concern a little concern some concern concern strong concerns 39. attracted by future opportunities (position, salary, etc.) if i stayed na not attracted a little attracted some attracted attracted strongly attracted 40. feelings of inadequacy did not hinder hindered a little hindered some hindered strongly hindered 41. concerns for safety na not a concern a little concern some concern concern strong concerns 42. unsure of god's guidance or confirmation to go long term not a concern a little concern some concern concern strong concerns 43. difficult to find a match with an agency/organization to send us not difficult a little difficult some difficult difficult very difficult 92 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 44. difficult to find a good fit with a location or team not difficult a little difficult some difficult difficult very difficult 45. fear of isolation or loneliness not a concern a little concern some concern concern strong concerns 46. fear of burnout not a concern a little concern some concern concern strong concerns 47. health issues personal or in my family no issues issues but no concern a little concern some concern concern strong concerns 48. concerns about needing to learn another language not needed needed but no concern a little concern some concern concern strong concerns 49. long process/time before launching not long for me no concern a little concern some concern concern strong concerns 50. objections from friend(s) no objections objections but no concern a little concern some concern concern strong concerns 51. objections from spouse (or potential spouse) no objections objections but no concern a little concern some concern concern strong concerns 52. concerns for child(ren) or future children na no concern a little concern some concern concern strong concerns 53. objections from parent(s) no objections objections but no concern a little concern some concern concern strong concerns 54. concerns about being a single and going long term not a single when i went single but no concern a little concern some concern concern strong concerns 55. raising financial support did not have to had to but not a concern a little concern some concern concern strong concerns 56. student loans no loans loans but not a concern a little concern some concern concern strong concerns 57. optional: other obstacle that was a significant hindrance to me launching long-term. wrapping up 58. which stage(s) of your life were most significant in making the decision to go long -term? 59. how many short term trip(s) less than two months long did you do before launching long-term? 60. how many short term trip(s) of two or more months did you do before launching long term? 93 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 appendix b: survey of students and others aspiring to healthcare missions cmda and others want to learn how people may explore moving for ministry or missions. (if you have previously relocated for the gospel, this survey is not intended for you – but for those who have never done so.) we need your help. can you give 5-10 minutes of input? you will first be asked some questions and then basic demographic information. we know time is precious; we only need brief responses. near the end, you may remain anonymous or you may enter your name and email address in case a clarifying or follow-up question is needed. at the end of the survey we will give you a free e-book as our appreciation for your help. 1. have you previously relocated for the sake of the gospel? that is, did you move somewhere for 1+ years for the sake of the gospel (i.e. not for education and not a round trip). if yes, thank you for serving, but this survey is not for you. 2. what is the farthest geographic distance you would most likely explore moving for the sake of the gospel? this would be relocating for several years and not a round trip. and if you are currently in training, this would be some period of time after you complete your education. cannot consider any move across town medium distance away, e.g. 2-10 hour drive across the country across the world 3. how many years would you be ok with living that far away?(living away would still include periodic visits home.) factors that may draw you to relocate if you would relocate (across town, across the country, or across the world) for the sake of the gospel, there may be factors that draw you towards exploring such a move. please rate the following factors as not a draw, some draw, or a strong draw. 4. desire to provide practical service to those in need not a draw some draw strong draw 5. passion for justice not a draw some draw strong draw 6. encouragement from my spouse, fiancée, etc. (skip this question if single) not a draw some draw strong draw 7. encouragement from a friend or sibling not a draw some draw strong draw 8. encouragement from parent(s) not a draw some draw strong draw 9. encouragement from a pastor, mentor, leader or teacher not a draw some draw strong draw 10. desire for adventure not a draw some draw strong draw 11. ready for a change after finishing education (or military service, etc.) not a draw some draw strong draw 12. if friend(s) would relocate to the same place about the same time ... not a draw some draw strong draw 13. if someone i know (or may come to know in the future) located somewhere else and i would join them not a draw some draw strong draw 94 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 14. desire to share christ with a specific unreached group or city or country not a draw some draw strong draw 15. desire to share christ with others (but no specific group or city or country) not a draw some draw strong draw 16. god's guidance through scripture not a draw some draw strong draw 17. god's guidance through prayer not a draw some draw strong draw 18. optional: god's guidance through other ways or other factor(s) that would be a strong draw for me to explore relocating for the gospel factors that may hinder you relocating if you would relocate (across town, across the country, or across the world) for the sake of the gospel, there may be concerns that would hinder you from considering such a move. please rate the following factors as no concern, some concern, or strong concern. 19. concerns for my children or future children not a concern some concern strong concern 20. i find it difficult discovering god's guidance in a major decision like relocation not a concern some concern strong concern 21. if i would need to learn a new language after i relocate, that would be... not a concern some concern strong concern 22. if i would have to raise financial support to live in a new place for the sake of the gospel, that would be not a concern some concern strong concern 23. if i would relocate somewhere that is less safe, that would be... not a concern some concern strong concern 24. if i would relocate to a place where i may be lonely or isolated, that would be... not a concern some concern strong concern 25. concerns about being far away from family and friends not a concern some concern strong concern 26. concerns about my lack of experience and/or training in ministry na or not a concern some concern strong concern 27. difficult to find a place that really needs me/where my skills and talents would make a difference not a concern some concern strong concern 28. difficult to find a good fit with a team or organization not a concern some concern strong concern 29. difficult to keep up to date in my profession if i lived in another country for years not a concern some concern strong concern 30. i am well established where i am and i would not want to relocate. not a concern some concern strong concern 31. i have good opportunities (position, salary, etc.) where i am and i would not want to relocate. not a concern some concern strong concern 32. current or potential health issues mine and/or spouse/kids not a concern some concern strong concern 33. objections from friends not a concern some concern strong concern 34. fear of burnout not a concern some concern strong concern 35. objections from my parent(s) not a concern some concern strong concern 95 mcvay, place & stevens nov 2017. christian journal for global health 4(3):82-95 36. my concerns for my parent(s) health or aging not a concern some concern strong concern 37. optional: objections from my spouse or fiancée or potential spouse not a concern some concern strong concern 38. optional: concerns about being single and finding a spouse if i relocate not a concern some concern strong concern 39. optional: concerns about student loan(s) no loans not a concern some concern strong concern 40. optional: approximate student loan balance at conclusion of my education 41. optional: other hindrance that would be a strong concern before i would relocate for the gospel more about you 42. do you have a personal connection to anyone who has relocated for the sake of the gospel? other information 47. which stage(s) of your life or experiences have most significantly impacted your willingness to explore relocating for the sake of the gospel? 48. optional: what are the main areas in which you may want to serve if you would relocate for the sake of the gospel? 49. what are the main ways you may like to learn about opportunities to relocate for the gospel? demographic information 50. of what country are you a citizen? 51. what year were you born? 52. what is your gender? 53. current marital status 54. which race/ethnicity best describes you? 55. optional: how many children, if any, do you have? 56. optional: if you have any children now, how many years old is your oldest child? 57. optional: currently in training or currently not in training 58. optional: if you are not currently in training, about how many years ago did you finish your most recent formal education or degree? 59. optional: during your current or most recent phase of formal education what was (or is) your major/specialty/focus/goal etc.? 60. optional: if you happen to know and remember your myers-briggs type indicator, please enter that below. wrap up 61. optional: other comments 62. optional: how many times have you already attended the global missions health conference in louisville? original article nov 2014. christian journal for global health, 1(2):29-41. a study of volunteer community health workers promoting maternal health services in rural kenya: a christian viewpoint bradly alexander kimbrough a and lisa baker b a university scholars major / undergraduate student, baylor university b md, phd, clinical professor in the honors program at baylor university abstract introduction: despite the call for community-based health care interventions in the developing world, there is little research examining the effectiveness of paid versus volunteer community health worker (chw) programs to increase women’s use of maternal health services. from a christian perspective, the chw model is, at its root, discipleship: a credible person leads a neighbor to a source of help and health. this effective model can be expanded to address the health of the whole person, both spiritual and physical. this study of a government health center program in rural kenya addresses these issues. methods: the current study analyzed the change in maternal health services after a government program, starting with 30 volunteer chws, had been in place for nine months. the intervention was designed and carried out by the authors in collaboration with sigoti district health center in the western kenyan province of nyanza. results: the proportion of facility-based deliveries (fbds) showed a statistically significant increase (p=0.003), from an average of 38 deliveries before the intervention to 60 afterwards. the proportion of health center deliveries of hiv-positive women also significantly increased (p=0.04) from an average of 6.5 to 14 fbds. compared to another program in rural lesotho with paid chws, the sigoti intervention led to a similar increase in fbds. despite their successes, the community-based strategies were time-intensive for both programs, with one chw adding between 1.12 and 1.7 fbds per year. discussion: this study demonstrates that a chw program can be successful, even when using volunteers. using solely a metric of time and/or money, the chw model produces value at a high cost. however, the concerns of cost-effectiveness and chw attrition, as well as the success of the chw model, can be meaningfully addressed from a christian perspective. using the outcome measure of changed lives, volunteer chws could be motivated by a christian call to discipleship. chws may be trained and supported to contribute to the health of the whole person. future research will test these assumptions with a chw program operating from a christian health center to be built soon in the study area. 30 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. introduction the challenge of disease and death in the developing world has provoked a variety of responses from the international community, including grants of billions of dollars from development agencies, the investment of thousands of overseas micro-loans, and government interventions to build health care infrastructure. all of these approaches have brought some success, and widespread systemic change is essential to address the complex issues of health today that are inextricably linked with poverty and social injustice. on the other hand, a response that is deeply personal and local is the popular strategy of using community health workers (chws) in their own neighborhoods to encourage individuals to access health care and to teach the means of health promotion. since the alma-ata declaration in 1978, chw programs have become a key element in maternal and child health. the chw model later became an essential strategy in working toward the fifth millennium development goal (mdg) of having 80% of births take place with skilled personnel. 1 in another aspect of maternal and child health, chws have been utilized to reduce mother-to-child transmission of hiv, 2,3 which can potentially be decreased to less than 2% with the appropriate use of anti-retroviral therapy (art). 4 this approach of affecting one person at a time in the context of a personal relationship is precisely what jesus modeled throughout his ministry. it is not surprising that chws have been well received and are believed to be successful. however, there remains a dearth of evidence to support the claims of success and costeffectiveness of chw programs. 5,6,7,8 outcome studies that do exist generally focus on chw programs aimed at health promotion, 9 tuberculosis care, 10, 11,12,13,14,15 and immunization services. 16 consequently, in 2013 the world health organization (who) called for a comprehensive research effort on the efficacy of chw programs. 17 the effectiveness of chws in reaching pregnant women is still largely unknown. two major studies have addressed this gap by evaluating chw programs in sub-saharan africa. 18,19 in an attempt to achieve the mdgs, the country of ethiopia initiated the health extension program in 2003. with approximately one salaried worker for 2500 residents, there was a documented increase in antenatal care (anc) and family planning after the program was instituted, but the proportion of women delivering at a health facility did not change. 18 in a more comprehensive effort that employed a much higher concentration of chws than in the ethiopian study, a program was instituted in a highland region of lesotho where 46 deliveries per year (out of a population of 25,000 in the catchment area) were occurring at a local facility. traditional birth attendants (tbas) were retrained as chws by the nonprofit organization partners in health. 19 the catchment area was served by one hundred chws (a ratio of 1 to 250, i.e., ten times more workers per population compared to the ethiopian intervention) who were paid an incentivebased salary equivalent to approximately $36 usd per month (extrapolated from original article using the exchange rate at the time of the study). 19 notably, the chws were part of a multi-faceted approach to increase utilization that also included the establishment of a maternal ―waiting house‖ where pregnant women could go and receive three meals a day for up to two weeks prior to their due date. the combination of these changes showed an increase from 46 to 178 facility-based deliveries in the first year and 216 in the second year of the program. during the twoyear intervention, 55% of the women who delivered at the facility took advantage of the opportunity to stay in the maternal waiting house. it is unknown how much of the improvement was due to the chws versus the benefits of the maternal waiting house. broader approaches of examining the costeffectiveness of chws that include relational 31 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. changes and changes in behavior have generally not been well recognized, 5 though in recent years there has been an increase in this literature. 20,21,22 one such study was of a community-based midwifery program that evaluated whether perinatal outcomes and anc attendance improved in addition to other factors, such as empowerment and family-centered care. 20 though the quantitative improvements were negligible in the midwifery study, the qualitative results were quite positive. the current study took place among a community of luo people living on the nyakach plateau in the nyanza province of western kenya, a destitute area of rocky dirt roads, inadequate subsistence farming, no dependable clean water source, no sanitation services, and little health care. kenya ranks fourth in the world in the number of people living with hiv/aids, 23 and women of the luo tribe of western kenya have the highest hiv rate (22.8%) and the highest infant mortality (9.5%) in the country. 24 kenya‘s maternal mortality has been volatile over the last twenty-five years. in 1990, the maternal mortality rate was 380 per 100,000 births, but in 2005, it increased to 580/100,000. 25 as of 2013, the rate decreased again to 360/100,000, 26 a figure that is still alarming and does not meet the fifth millennium development goal (mdg) of reducing maternal mortality by 75%. one issue driving the high maternal mortality is that only one-third of women living in rural kenya give birth with skilled personnel. 24 some locations in kenya have a rate as low as 5.4%, 27 in spite of the fact that skilled birth attendance has been deemed as the most important factor in preventing maternal deaths. 28 on the nyakach plateau, the local government district health center (sigoti health center) is staffed by a clinical health officer and two nurses who have had great interest in increasing maternal services. one village in the catchment area is east koguta (referred to as a ―sublocation‖ in kenya) with a population of 7360 and an estimated 260 births a year, 59 of them to mothers with hiv. 24 approximately 19% of those births and 15% of the hiv deliveries were occurring at the sigoti health center up to mid2011. this health center has no resources to pay chws. however, the clinic personnel appreciate the value of the chw model and decided to experiment by training volunteers who wanted to contribute in a meaningful way and invest deeply in their own community. data suggest that sustainable success depends on salaries and other monetary incentives, 29 yet these leaders believed that their consistent, supportive relationships with the workers, combined with simple incentives of food and help with travel, would be enough to make a difference. they hoped that financial resources might emerge at some point, but they decided to see if the workers would participate based on the value of the expertise they gained and the satisfaction of doing an important task. thirty people from east koguta volunteered to work with their own neighbors to identify needs and serve pregnant women. more than two-thirds of these workers stayed with the program for its first nine months. methods east koguta community health worker (ekchw) program over a two-week period in august of 2011, a public health officer and the head nurse from the sigoti health center trained thirty volunteer chws (twenty-nine women and one man) according to the international center for aids care and treatment programs (icap) at columbia university‘s mailman school of public health. the requirements for becoming part of the ekchw program were to have at least a fourthgrade education and to be a respected community member. the chws were predominantly christian and served in a part of kenya that has been traditionally christian for many years. however, this government program did not deliberately attempt to recruit christians or to frame their activities in a christian context. the east koguta chws were trained to provide health education for pregnant women, 32 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. encourage them to go to anc visits, and urge them to deliver their babies at the health center instead of at home or with a tba. hiv-positive mothers and other high-risk pregnant women were especially targeted and encouraged to deliver at the health center. the sigoti health center goal was to increase the number of facility-based deliveries from 19% (the rate prior to the program) to 30% of all births occurring within the area. maternal health services were a primary focus of the chw program, but the workers were also trained to conduct a variety of other tasks: tracking former patients for check-ups, bringing hiv-positive patients to the health center who had neglected to receive treatment, health education, and identifying and referring community members with suspected illnesses such as malaria, tuberculosis, and hiv-associated illnesses. during nine months of implementation, eight women discontinued volunteering. according to the head of the ekchw program, the main reason for volunteers dropping out was unrealized hopes of future wages, while the main reason for deciding to continue was the chws‘ ―heart‖ for the community. the chws met weekly with the public health officer and head nurse. the chws were expected to work an average of two to three hours a day beginning in september of 2011. the only compensation for the workers was an occasional free meal or refreshment, use of a communal bicycle, and informal community recognition. analysis of health records the current study analyzed health center records from the sigoti district health center located in the nyanza province of kenya. the data included information about all women from east koguta who delivered at the health center from september 2009 through may 2012. the original information was collected and entered by hand into the record by the nurses or the clinical officer at each anc visit and at the time of delivery. relevant data were later copied from the medical record by a trained research assistant and were then coded and transferred into an excel spreadsheet for analysis. data from a nine-month period (the first of september to the first of june) for the two years prior to the intervention were compared to the same nine-month period during the intervention year (see figure 1). 33 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. these three time periods are referred to as period 1, period 2, and period 3 (chw), respectively. the most recent available regional data were used (dhs 2008-2009 for crude birth rate and 2009 kenya census data for population statistics) 24 to compare the sigoti health center numbers with the number of women who gave birth in the entire area (sub-location of east koguta) during the timeframe of the study. given the crude birth rate and the number of people living in east koguta, the number for a nine-month period was extrapolated to yield 195 deliveries. the number of deliveries was estimated using the following equation: number of deliveries = [cbr*(pop/1000)]*0.75. the cbr is the crude birth rate for the area (kenya dhs 2008-2009), pop is the population of east koguta, and the total was multiplied by 0.75 to yield the estimated number of deliveries in nine months. the number of births from hiv-positive women during a nine-month period was estimated by multiplying 195, the estimated number of deliveries, by the hiv-prevalence among luo women, 0.228, giving an estimate of 44 hivpositive women delivering in east koguta over a nine-month period. 24 data from periods 1 and 2 were combined and compared with period 3 (chw) to determine if the intervention significantly increased the number of facility-based deliveries, the number of hiv-positive women who delivered at the facility, and the number of women who received the 4 + anc visits recommended by the world health organization. the mean, standard deviation, and range for continuous variables are reported, and the frequencies, proportions and percentages are reported for categorical variables. the chi-square and t statistics were used to test differences from before and after the intervention for discrete and continuous variables, respectively. alpha was set at .05. statistical analyses were done using the statistical software sas 9.2 by sas institute inc. (cary, north carolina). results from the current study were then compared to data from the more comprehensive, salaried chw program in lesotho 19 to determine if this volunteer program was as effective in achieving positive results. ethical considerations this study was approved by the baylor university institutional review board and was exempt from the requirement for informed consent, as it was a study of anonymous subjects with information drawn from previously collected clinical data. during the research process, no patient names were associated with any of the data. the names of individual patients were not recorded in the research database. results sample characteristics the mean age and parity of women delivering at the health center during period 3 (chw) were not significantly different than women in periods 1 and 2 (see table 1). during each time period, about a quarter of all deliveries were by first-time mothers. every woman attended at least one anc visit. table 1. sample characteristics before and after east koguta chw program variable meann mean (sd) t p age 0.17 0.87 periods one and two 22.66 ± 5.07 period three (chw) 22.81 ± 5.78 parity 0.94 0.35 periods one and two 1.70 ± 1.72 period three (chw) 1.98 ± 1.74 results of the intervention the data for the three outcomes of interest are presented in table 2. 34 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. table 2. comparison of three outcomes before and after the east koguta chw program variable proportion percentage chi-square p deliveries 8.65 0.003 periods one and two (combined) 76 / 389.7 19.5 periods one and two (average) 38 / 194.9 19.5 period three (chw) 60 / 194.9 30.8 hiv-positive 4.23 0.04 periods one and two (combined) 13 / 88.9 14.6 periods one and two (average) 6.5 / 44.4 14.6 period three (chw) 14 / 44.4 31.5 4+ anc visits 3.47 0.06 periods one and two (combined) 19 / 389.7 4.9 periods one and two (average) 9.5 / 194.9 4.9 period three (chw) 18 / 194.9 9.2 there was at least a 50% increase in all three outcomes: number of facility-based deliveries (58% increase), number of hiv-positive deliveries (115% increase), and number of women with 4+ anc visits (89%). the sigoti health center did, in fact, reach its goal of having 30% of the actual number of catchment area deliveries occurring at the clinic after the intervention began. when comparing the combined number of facility-based deliveries in periods 1 and 2 (76 out of 390 expected deliveries) to the number in period 3 (chw) (60 out of 195 expected deliveries), the change after the intervention was statistically significant (p=0.003). the increase in the proportion of hiv-positive women delivering was also statistically significant (p=0.04). more hiv-positive women delivered during the intervention than in periods 1 and 2 combined. the number of women receiving 4+ anc visits during the intervention also increased from an average of 9.5 women (periods 1 and 2) to 18 during the intervention. however, even with this substantial increase, the small sample size did not provide enough power to achieve statistical significance, though it was close (p=0.06). despite these encouraging results, it is sobering to note that over two-thirds of hivpositive women in the area did not deliver in the health center, and less than 10% of women were receiving the recommended number of anc visits, even during the intervention. part of the explanation lies in the difficult geographical environment in which these women live. health care services are delivered sporadically due to periods of flooding and drought that make travel difficult for patients and for those delivering supplies to the clinic. a pattern of monthly variation exists each year in the number of deliveries, as shown by figure 2. 35 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. peaks in the number of deliveries occurred in the months september, november, and february while troughs occurred in the months october, january, and may. dirt roads are rough or nonexistent, almost no one has transportation other than walking, and most women have many children to care for. a trip to the health center for an hiv-positive, pregnant woman with toddlers can be challenging in the best weather. in periods of flooding, during active labor, and perhaps at night in an area with no lights, this journey may be impossible. comparison of east koguta and lesotho chw programs a comparison of this study‘s data with the success of the lesotho chw program 19 is shown in table 3 below. the lesotho program had a baseline of far fewer facility-based deliveries (6.8% vs. 19% in east koguta). with their interventions, however, both programs achieved the same results, i.e., approximately 30% of deliveries occurring at the health facility. east koguta went from 19.5% to 30.8%. lesotho increased from 6.8% to 26.3% in year 1 and to 31.9% in year 2, an average of 29.1% facility-based deliveries). the two programs had a comparable ratio of chws to the population (one for every 250283 residents). it is unknown how much of the improvement in lesotho was due to the addition of chws and how much was a result of the establishment of the maternal waiting house. in the east koguta region, where people rarely eat more than one meal a day and women must walk an average of 3.8 kilometers to the health center, such an opportunity would be not only an incentive, but sometimes would be life-saving. 36 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. table 3. comparison of east koguta and lesotho chw programs population chw salary number of chws chws per population additional fbd per chw per year east koguta 7360 none 26 * 1 / 283 1.12 lesotho (yr 1) 25000 about us $36 per month 100 1 / 250 1.32 lesotho (yr 2) 25000 about us $36 per month 100 1 / 250 1.70 non-intervention number of fbd percentage of fbd per total deliveries east koguta 51 19.5% lesotho 46 6.8% *** intervention east koguta 80 ** 30.8% lesotho (yr 1) 178 26.3% lesotho (yr 2) 216 31.9% notes. *the number of ekchws (26) is an average based on the 30 original chws and the 22 who were still active after nine months. ** the table shows the number of facility-based deliveries (fbd) during the ekchw program extrapolated to one year and the actual numbers for each year from the lesotho chw program. *** to calculate the percentage of deliveries occurring at the lesotho health facility, the total number of deliveries was estimated to be 677.5 by using the catchment area of the health center and the crude birth rate for rural lesotho. 30 in east koguta, one chw produced an average of 1.12 additional facility-based deliveries per year (extrapolated from nine months). in the lesotho study, the yield was slightly higher — one chw (plus the maternal waiting house) produced an average of 1.32 additional deliveries during the first year and 1.70 additional deliveries the second year. this better result was achieved with a slightly more favorable ratio of chws to population residents (1:250 in lesotho vs. 1:283 in east koguta). with an approximate cost of $432 (us) per year for a lesotho chw, the cost of bringing in one additional woman to deliver in the health center is between $327 (year 1) and $254 (year 2). in terms of cost-effectiveness, this strategy is relatively expensive and extremely time-intensive. in contrast, if the chws are volunteers and if the health center can absorb the lost workdays of the trainers, then the intervention easily becomes financially cost-effective, though still quite costly in terms of the time invested by the workers. the lesotho program, with paid chws, did not show vastly different results from the east koguta volunteer program. however, the lesotho program also included the excellent resource of the maternal waiting house used by over half of the women in addition to the chw intervention. the cost of the waiting house is not reported, but it is likely to have substantially increased the cost of the program per woman delivering at the health center. discussion success, sustainability, and costeffectiveness: a christian viewpoint this study provides evidence that volunteer chws can be effective in increasing the number of facility-based deliveries, especially for hivpositive women, and the results are encouraging for increasing the number of women with the recommended 4 + anc visits. it is striking that this impact was achieved by volunteers in a highly challenging physical environment within only nine months. in fact, the onset of the program‘s impact was rapid. within the first few months, there was already a noticeable difference in the number of facility-based deliveries compared to 37 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. the same months from previous years. it is also promising that this program was just as effective, at least in the short run, as a chw intervention in a comparable rural african setting that had financial incentives for chws and a ―waiting house‖ for pregnant women. viewed another way, what is notable about the results from the current study is that so many east koguta chws did continue to volunteer with no financial incentive. the sigoti health center staff believes that success has been due to: close contact between the chws and the health center personnel, non-monetary rewards that are meaningful, and early feedback to the chws about the apparent success of the program (personal communication, march 2013). also, the east koguta intervention was generated and implemented by residents of east koguta, instead of being imposed by the government or by an outside organization. another contributing factor was believed to be the important support from the local tbas, and an increased role for them is possible in the future. a christian is not surprised at the success of a chw model, because the method is the same as that used by jesus in his work of discipleship. neither is a christian discouraged by threats to sustainable motivation for volunteers or by work that is extremely time-intensive in producing results. the approach of jesus was not to create institutions, but to empower his followers to share the good news with one person at a time. he sent them out with instructions to travel light, meet the needs of the whole person, and spend time with those who have ears to hear and eyes to see. ―when you enter a town and are welcomed, eat what is set before you. heal the sick who are there and tell them, ‗the kingdom of god is near you‘‖ (luke 10:8-9, niv). an effective chw is one who shares her experience with someone she knows and brings that person along with her to the next level of understanding. an effective follower of christ does the same. the positive results from the current study and the lesotho study are tempered by the questions they raise about sustainability and costeffectiveness. having volunteer chws may answer the troubling challenge of paying salaries, but it is unknown how much worker attrition over a longer time period would affect success. the positive outcomes achieved in the first nine months of the east koguta chw program were accompanied by an average attrition rate of about one chw per month. it is possible that relying on volunteers is only productive for a short time, regardless of how meaningful the work is. further research can evaluate this issue. no attrition among the paid chws in the lesotho program is reported, so it is impossible to compare this aspect of the two programs. the omission in the description of the lesotho program may indicate no attrition, but it is more likely that the number of chws was maintained by replacing any chws who left with new paid workers. to the degree that a volunteer chw program is framed as meaningful christian service, it can be maximally sustainable. as this government program did not attempt to frame the work in a christian context, the attrition of chws suggests that altruism alone is not enough to sustain some volunteers. however, it is our belief that volunteers can be uniquely and successfully motivated by a christian call to the healing of the whole person accompanied by formation and support for that task. the other concern raised by this analysis is that a program that takes one worker eight to twelve months to yield one facility-based delivery is not likely to be judged as cost-effective by most organizations. still, when unemployment is high and chw activities can be meaningful, the volunteer chw strategy remains viable. this is the case when a cost-benefit analysis is restricted to an outcome of increased facility-based deliveries. a more convincing case may be made if broader outcomes are considered. it has been said that ―examples of wider benefits may result from chws that are unlikely to be captured in cost-effectiveness analysis are employment and training opportunities, the value attached by cli38 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. ents to the process of receiving such services, and institutional change,‖ where institutions are described as: ―the patterns of behavior that determine how individuals, groups and organizations interact with one another.‖ 5 if the desired outcomes are expanded even further and the health that is sought is spiritual as well as physical, the volunteer chw model may be the most effective investment of time that can be made to achieve those goals. for a christian, the ―cost‖ of discipleship is life itself, and the ―benefit‖ is the kingdom of god. this perspective brings a new meaning to concepts of success, volunteerism, and cost-effectiveness. the chw strategy can be supported — not in spite of, but because of its time-intensive nature — when the task is expanded to address the health of the whole person. there is a spiritual and material component to every structure, even when it is not created with a spiritual focus in mind. from a christian perspective, the physical health of the community cannot be the centerpiece of an intervention to the exclusion of the spiritual, nor can the spiritual be the center to the exclusion of the physical. jesus said about his own purpose, ―the spirit of the lord is on me, because he has anointed me to preach good news to the poor. he has sent me to proclaim freedom for the prisoners and recovery of sight for the blind, to release the oppressed, to proclaim the year of the lord‘s favor.‖ (luke 4:18-19, niv) community health evangelism (che), a model for community development and discipleship, is commonly used by christian development organizations and churches. 31 che trainers, generally under the supervision of a local church or mission agency, introduce che to their communities and train volunteers to teach lessons on preventive health and christian discipleship. the east koguta chw program differs from the che model primarily in two ways: it was established and supervised by a non-church entity, the local health center, and was created in response to very specific health problems, namely a high hiv prevalence and maternal/infant mortality. the models are similar in that both are formed and operated by community members in order to provide the community with ownership of the program. future efforts in the luo community that is the setting of this study include building a new health center by a christian non-profit organization (straw to bread) that has been working in collaboration with local residents in the area since 2001. this initiative, informed by data from the current study seen through a christian lens, can move toward building a chw program that is intentionally christian in orientation. the volunteer chw model is a great fit for those who are working to lead people toward spiritual as well as physical wholeness. a chw who is also a follower of christ could bring all of who she is to the role. following the example of christ in teaching his followers, a chw program built on christian principles would enhance sustainability and the potential for success by placing heavy emphasis on training and encouraging the chws. the commitment of the trainers to the chws becomes the model for the commitment of the chws to the people with whom they work. trainers for such a program would: 1) take seriously the formation process — invest deeply and develop relationships with and among the chws. 2) develop a common vision of the health of the whole person. 3) equip chws to bring hope, knowledge, and transformation to the whole person. 4) serve, encourage, and learn from the chws by listening, adapting, and continually revising plans based on input from those doing the work. 5) trust the chw to deliver good news out of the strength of her uniqueness. 39 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. summary based on the current study in rural western kenya, a volunteer 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http://dx.doi.org/10.1016/s0277-9536(98)00228-7 http://dx.doi.org/10.1016/j.socscimed.2007.11.010 https://www.cia.gov/library/publications/the-world-factbook/rankorder/2156rank.htmlkenya https://www.cia.gov/library/publications/the-world-factbook/rankorder/2156rank.htmlkenya http://dhsprogram.com/publications/publication-fr229-dhs-final-reports.cfm http://dhsprogram.com/publications/publication-fr229-dhs-final-reports.cfm http://www.unfpa.org/webdav/site/global/shared/documents/publications/2010/trends_matmortality90-08.pdf http://www.unfpa.org/webdav/site/global/shared/documents/publications/2010/trends_matmortality90-08.pdf http://www.unfpa.org/webdav/site/global/shared/documents/publications/2010/trends_matmortality90-08.pdf http://data.worldbank.org/indicator/sh.sta.mmrt https://extranet.who.int/iris/restricted/bitstream/10665/42191/1/9241561955_eng.pdf https://extranet.who.int/iris/restricted/bitstream/10665/42191/1/9241561955_eng.pdf http://www.who.int/hrh/documents/community_health_workers.pdf http://www.who.int/hrh/documents/community_health_workers.pdf http://dhsprogram.com/publications/publication-fr241-dhs-final-reports.cfm http://dhsprogram.com/publications/publication-fr241-dhs-final-reports.cfm 41 kimbrough and baker nov 2014. christian journal for global health, 1(2):29-41. 31. what is che? [internet]. community health evangelism; [cited 2014 oct 3]. available from http://chenetwork.org/whatische.php peer reviewed competing interests: none declared. correspondence: bradley alexander kimbrough, baylor university. alex_kimbrough@baylor.edu cite this article as: kimbrough, ba and l. baker. a study of volunteer community health workers promoting maternal health services in rural kenya: a christian viewpoint. christian journal for global health (nov 2014), 1(2):29-41. http://dx.doi.org/10.15566/cjgh.v1i2.18 © kimbrough, ba and l. baker. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://chenetwork.org/whatische.php mailto:alex_kimbrough@baylor.edu http://dx.doi.org/10.15566/cjgh.v1i2.18 http://creativecommons.org/licenses/by/3.0/ conference report mar 2017. christian journal for global health, 4(1):55-59. what works? evidence on the role of faith in poverty reduction daniel w. o’neill a a md, ma(th), managing editor, cjgh and assistant clinical professor of family medicine, university of connecticut school of medicine introduction this unique conference was held at yale university in new haven, ct, usa on 20 and 21 september 2016. matthew frost, chair, joint learning initiative on faith & local communities (jliflc), and former chief executive of tearfund, began the conference describing faith’s role in defining narratives and providing service grounded in key social networks. faith can no longer be thought of as a “side show” in the populations served in developing world contexts. there are gaps between the development community and the faith community – no common language, a topdown delivery system, limited accountability, and poor communication from fbos (using “spooky” language). this calls for 1. building evidence (including the role of religious beliefs and practices in development), 2. seeking to understand practitioners’ perspectives, and 3. communicating clearly for effective change. striving for impact dean karlan, professor of economics, yale university is founder and president of innovations for poverty action (ipa). this organization brings together leading researchers and decision-makers to ensure that the evidence created leads to tangible impact on the world. he shared that fbos are often either good at marketing but not results, or good at results without marketing. donors respond to stories, but limited outcomes data lead to ineffective programs and policies, which leads to wasted money and enduring poverty. data gathered might end up stuffed in inaccessible academic journals– there needs to be a bridge to action, and a move toward scalability. this requires collaboration between academics, service providers, government agencies, researchers, funders, etc. funders are seeking better evidence for philanthropy initiatives. this requires proactively sharing solutions to 1. design and evaluate; and 2. mobilize and support – to enable better programs and policies. david sutherland and lincoln lau from international care ministries (icm) described their work as a learning and business organization to fight extreme poverty. motivated by faith and promoting hope, they shared some of their unpublished data on measuring values, health and livelihood outcomes using protestant christian values and theology education interventions (entitled transform) for their service population in philippines. 1 the distinction between inputs, outputs and outcomes was discussed, with caution that correlations did not equal causation. data gathering was to follow the cart principle: credible, actionable, responsible, and transportable. organizations were to also follow the goldilocks principle: not too much data and not too little. with professor karlan, they presented and received participant feedback on the preliminary data from an unpublished paper entitled “the impact of protestant evangelism on religious, psychosocial and economic outcomes: a randomized experiment in the philippines”. the study design seeks to distinguish correlation from causation for a faithbased intervention. 56 mar 2017. christian journal for global health, 4(1):55-59. faith and public funding a panel moderated by jean duff, president of partnership for faith & development, and coordinator of joint learning initiative on faith & local communities (jli) discussed the increase in the faith-based organization portion of the hundreds of billions of dollars of development assistance invested into developing nations. mark brinkmoeller, director of the center for faithbased and community initiatives for usaid described their rules: 1. no use of funds for inherently religious activities (separate in time and location) and 2. no discrimination against beneficiaries of services. the work needs to conform to the country’s goals. he noted increased cooperation between ngos, fbos and governments. 2 adam taylor, lead for faith-based initiatives at world bank group, reminded us of their prior perceptions of fbos as “defunct, divisive and dangerous” but that since katherine marshall, berkley center for religion, peace and world affairs, georgetown university, opened the conversation, there has been increasing receptivity to the importance of behavioral and social change at the level of world views and beliefs. several reasons were proposed: the rise of violent extremism, the recognition of the religiosity of 80% of the world, the interest of secular peers due to the key presence of faith actors as resources, the recognition of the population influence of faith leaders, and the increase in inter-denominational cooperation. 3 the barriers to garnering support are lack of time, resources and evidence. azza karam, senior advisor on culture at the un population fund, traced the change at the united nations through the past 5 years, moving from “we don’t do religion,” to “what on earth are you doing?” there was a reappraisal of their highly secular approach after sept 11, 2001, and there has been a recent movement from “how can we use religious leaders to do what we want?” to “what can we do to equip them?” since they provide often over 30% of the healthcare in many countries. ulrich nitschke, head of sector program values, religion and development, deutsche gesellschaft für internationale zusammenarbeit (giz), described the international partnership on religion and sustainable development (pard) 4 . this new collaborative highlights religion’s positive role in change (not as the problem) and the importance of the 17 th sdg on diverse partnerships which show shared responsibility for development outcomes. the challenge is in using language for mutual understanding between faith actors and governments and other agencies. proposed was a religious literacy course, and studying the religious landscape of the country. achieving scale and impact chris udry, henry j heinz ll professor of economics, yale university with dr. karlan proposed a challenge to increase fbo credibility by presenting studies on the evidence of outcomes, not just outputs of services or “good intentions,” and including control groups measuring indicators to determine effectiveness and causality. analyzing if and why interventions work, how long they are sustainable, and making them scalable for greater impact and replicable in other settings is important. icms experience with pastor networks was used as an example of creating synergy toward the common good in impoverished areas. david clingingsmith, professor of economics, weatherhead school of management, presented a randomized controlled trial which demonstrated the socially favorable effects of the hajj on muslim participants through exposure to cultural diversity. bruce wydick, professor of economics, program director of international and development economics, university of san francisco presented their evidence from mexico that non-material interventions like hope, resilience, and faith can have an impact on material well-being. 5 julian jamison, senior behavioral economist of the global insights initiative (gini) at the world bank presented research on the effectiveness and 57 mar 2017. christian journal for global health, 4(1):55-59. sustainability of cognitive behavioral therapy on post-war youth in liberia. 6 he noted the importance of constant intervention feedback loops; designing studies with fewer indices, pre-analysis plans, stronger theory; and using the terms of the recipients – including them as stakeholders. the line in the sand on the second day the conferees met at dwight chapel on yale’s main campus where they heard a message from commissioner christine mcmillan, director of public engagement, world evangelical alliance (wea). this was followed by ed stetzer, executive director of the billy graham center for evangelism at wheaton college, who traced the history and described the distinctive features of the trans-denominational movement of evangelicals (biblicism, crucicentrism, conversionism and activism) and their global contributions to societal transformation. he mentioned that there was an emerging body of scholarship that supported global faith-based interventions on education, religious liberty and social democracy. 7 he referenced lewis rambo’s work on metrics of spiritual transformation. 8 as the lausanne covenant states, “presence is indispensible–serving the hurting, saving the lost.” while some recent studies have documented changes in multiple parameters of societal well-being through spiritual conversion and active presence, more quantitative evidence is needed. spiritual metrics david sutherland and lincoln lau of icm presented and critiqued their 50-question “spiritual temperature” instrument as an attempt to measure intrinsic change using multiple indicators. mark forshaw, director of global scripture impact, emphasized the value of showing results “moving the needle” and sharing lessons learned regarding witnessing, understanding and acting using the engle scale. paul penley, director of research for excellence in giving, emphasized the importance of entering a service population in order to design study instruments, and discussed the santa clara sorf spiritual metric. 9 chloé quanrund from tearfund, uk, shared the levels of transformation using the light wheel as indices and its pilot projects in uganda. 10 dan williams from hope international shared the hope quotient tool which measures material, personal, social and spiritual impact on interventions. 11 significant group discussions ensued on metrics for the conclusion of the conference. science of delivery the world development report 2004: making services work for poor people called for greater accountability to improve the quality of service delivery to the poor. the world bank recognized that there had been some progress recently with converging agendas in taking local contexts seriously; building capacity of agencies (teams) to implement increasingly complex and contentious tasks at scale; and solving concrete problems and adapting solutions in real time to emergent successes and failures (as opposed to crafting elaborate plans up front and measuring success by faithful adherence to it). closing the gap between policy aspiration and performance is a challenge that requires systematically collecting and understanding insights from practitioners in the field, “what works and what doesn’t, applying it to deliver needed services to the poor.” this requires 1. relentless focus on citizen outcomes, 2. multidimensional response (including fbos), 3. evidence to achieve results (contributing to the global body of knowledge), 4. leadership for change (transformation), and 5. adaptive implementation (iterative experimentation feedback loops). 12 religion, evidence and sustainable development there is new acknowledgement by the united nations, funders, governments, multilaterals, the private sector, civil society and faith communities that faith plays a critical role in human develop58 mar 2017. christian journal for global health, 4(1):55-59. ment. 13 the sdgs bring incredible new opportunity for christian and other faith-based organizations to be included in cooperative field operations, information sharing, and resource procurement. to be of influence this will require diligent effort to design programs, initiate interventions, and share results which are based on the best evidence available, using tools that are tested and validated. the evidence working group of the joint learning initiative for faith and local communities, of which christian journal for global health is a participant, seeks to 1. encourage “evidence literacy” among fbos, 2. communicate to faith communities the evidence already known about the “doability” of addressing extreme poverty, 3. share and promote the generation of evidence about the activity and impact of faith groups toward ending extreme poverty, and 4. encourage the exploration, measurement and communication of the distinctive faith assets that faith communities can bring. an on-line guide for evidence for faith groups has been initiated and is being developed. 14 it is hoped that there will be increased utilization of these measurement and evaluation tools, and more valuable contribution to the effort to earnestly seek what works best for health and human flourishing. references 1. innovations for poverty action. belief systems and poverty alleviation in the philippines [internet]. available from: http://www.povertyaction.org/study/belief-systems-and-povertyalleviation-philippines 2. united states agency for international development [internet]. center for faith-based and community initiatives. available from: https://www.usaid.gov/faith-based-and-communityinitiatives 3. the world bank group [internet]. faith and religious organizations. available from: http://www.worldbank.org/en/about/partners/brief/fait h-based-organizations 4. the international partnership on religion and sustainable development (pard) [internet]. available from: http://www.partner-religiondevelopment.org/ 5. wydick b. measuring hope. development impact [internet]. the world bank group. 18 april 2013. available from: http://blogs.worldbank.org/impactevaluations/measuri ng-hope-guest-post-by-bruce-wydick 6. the world bank group [internet]. global insights initiative (#wb_gini). behavioral and social change for development. available at: http://www.worldbank.org/en/programs/gini 7. woodberry rd. the missionary roots of liberal democracy. am polit sci rev. 2012 may;106:244-74 https://doi.org/10.1017/s0003055412000093 8. rambo lr, bauman sc. psychology of conversion and spiritual transformation. pastoral psychol. 2012;61(5): 879. https://doi.org/10.1007/s11089011-0364-5 9. sherman ac, simonton s, adams dc, latif u, plante tg, burns, sk, et al. measuring religious faith in cancer patients: reliability and construct validity of the santa clara strength of religious faith questionnaire . psycho-oncology.2001;10:436–43. https://doi.org/10.1002/pon.523 10. the light wheel: the learning and impact guide to holistic transformation. available from: http://guide.jliflc.com/resources/light-wheel-learningimpact-guide-holistic-transformation/ 11. hope quotient monitoring and evaluation survey [internet]. available from: http://www.hopeinternational.org/resources/resource/ hope-quotient-survey 12. asis mg,woolcock m. operationalizing the science of delivery agenda to enhance development results. world bank group. oct 2015, 2-6. available from: https://openknowledge.worldbank.org/bitstream/handl e/10986/23226/k8526.pdf?sequence=1 13. sidibé m. religion and sustainable development. rev faith int aff. fall 2016;14(3):1-4. https://doi.org/10.1080/15570274.2016.1215848 14. joint learning initiative on faith and local communities [internet]. evidence working group. guide to excellence in evidence for faith groups. available from: http://guide.jliflc.com/resource http://www.poverty-action.org/study/belief-systems-and-poverty-alleviation-philippines http://www.poverty-action.org/study/belief-systems-and-poverty-alleviation-philippines http://www.poverty-action.org/study/belief-systems-and-poverty-alleviation-philippines https://www.usaid.gov/faith-based-and-community-initiatives https://www.usaid.gov/faith-based-and-community-initiatives http://www.worldbank.org/en/about/partners/brief/faith-based-organizations http://www.worldbank.org/en/about/partners/brief/faith-based-organizations http://www.partner-religion-development.org/ http://www.partner-religion-development.org/ http://blogs.worldbank.org/impactevaluations/measuring-hope-guest-post-by-bruce-wydick http://blogs.worldbank.org/impactevaluations/measuring-hope-guest-post-by-bruce-wydick http://www.worldbank.org/en/programs/gini https://doi.org/10.1017/s0003055412000093 https://doi.org/10.1007/s11089-011-0364-5 https://doi.org/10.1007/s11089-011-0364-5 https://doi.org/10.1002/pon.523 http://guide.jliflc.com/resources/light-wheel-learning-impact-guide-holistic-transformation/ http://guide.jliflc.com/resources/light-wheel-learning-impact-guide-holistic-transformation/ http://www.hopeinternational.org/resources/resource/hope-quotient-survey http://www.hopeinternational.org/resources/resource/hope-quotient-survey https://openknowledge.worldbank.org/bitstream/handle/10986/23226/k8526.pdf?sequence=1 https://openknowledge.worldbank.org/bitstream/handle/10986/23226/k8526.pdf?sequence=1 https://doi.org/10.1080/15570274.2016.1215848 59 mar 2017. christian journal for global health, 4(1):55-59. competing interests: none declared. acknowledgments: stacy nam (jli), jean duff (jli) and lincoln lau (icm) provided some revisions and references for this report. the conference was sponsored by yale university, innovations for poverty action, joint learning initiative for faith & local communities, and international care ministries. correspondence: daniel w o’neill, christian journal for global health, dwoneill@cjgh.org cite this article as: o’neill dw. what works? evidence on the role of faith in poverty reduction. christian journal for global health. mar 2017; 4(1): 55-59. © o’neill d w this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:dwoneill@cjgh.org https://creativecommons.org/licenses/by/4.0/ guest editorial july 2017. christian journal for global health, 4(2):3-9. communities of faith and the global family planning movement: friends or foes? rebecca oasa a phd, associate director of research, center for family and human rights (c-fam), new york, ny, usa within the christian community, diverse views exist on the theological and moral dimensions of family planning, and specifically of contraception. discussion of these issues frequently focuses on family planning as a collection of methods and commodities used to space or limit pregnancies. often missing from the discussion is the notion of family planning as a social and political movement, and the degree to which this movement’s philosophy and goals are compatible with christian theology. nevertheless, faith-based aid organizations, including those with no objection to contraceptive use, must seriously grapple with the moral and practical implications of partnering with institutions that promote an approach to family planning that is at odds with christian values. for purposes of this discussion, the international family planning movement is taken to consist of the network of organizations whose primary purpose is advocacy for and provision of family planning. in contrast to many international aid groups, christian and otherwise, which seek a variety of solutions to the specific problems of a given country or region, the dominant discourse within this family planning movement has tended to advance one type of solution—contraception, often with abortion as a backup, although the rationale for doing so often changes. over the last century, the dominant discourse of the family planning movement has shifted multiple times, from a focus on eugenics and population control to a focus on women’s rights and empowerment, and then to a public health rationale aiming to reduce maternal and child deaths.1 more recently, the case for fertility reduction for its own sake has begun to reappear in connection with the global concern about climate change and environmental sustainability.2 while family planning advocacy invokes a wide range of problems, the proposed solution remains the same. you shall not kill (exodus 20:13) for leading family planning organizations including the international planned parenthood federation and marie stopes international, advocacy for abortion as well as contraception is a defining aspect of their work. nevertheless, according to international consensus among un member countries, as well as u.s. law, family planning is explicitly defined as excluding abortion.3,4 this agreed definition made it possible for the delegation of the holy see to accept the conclusions of the international conference on population and development at cairo in 1994, albeit with reservations clearly stating their unchanged position on artificial contraceptive methods and the immorality of abortion independent of its legality.3 this conference, convened by the un, and its resulting program of action which guides the work of the united nations population fund, not only separated the definition of family planning from abortion, but stated that the legality of abortion was a matter for individual governments to determine and not an international human right. 4 oas july 2017. christian journal for global health, 4(2):3-9. to the extent that family planning is understood to exclude abortion, some christian aid organizations have been able to justify providing family planning methods, inasmuch as the methods they offer are otherwise deemed morally acceptable. but for christian groups that oppose abortion, the dominant discourse within the family planning movement may not be tolerant of silent recusal. philanthropist melinda gates drew criticism from many within the movement for “stigmatizing” abortion by not directly supporting it.5 at the same time, gates provides support to organizations that also advocate for abortion and was critical of u.s. president donald trump for his reinstated and expanded mexico city policy which blocks federal funds to abortion-promoting organizations.6 for those within the christian community who view abortion as the intentional destruction of innocent human life, gates’ policy of silence on the abortion issue received some praise, but fell short of achieving her aim of “no controversy.” when combined with funding of family planning organizations who actively promote abortion, her silence arguably signaled not condemnation, but consent. again, a clear distinction must be drawn between family planning as methods to prevent pregnancy and the family planning movement as a global advocacy juggernaut with strong ties to abortion. determining what level of engagement christian agencies should have with organizations, governments, and multilaterals whose values conflict with christian values is a complex ethical question that requires in-depth biblical and ethical consideration. in december, 2014, usaid’s advancing partners and communities project (apc) supported a meeting by christian connections for international health (ccih) titled faith matters: international family planning from a christian perspective. its concluding report presented ccih’s definition of family planning as excluding abortion. it was perhaps commendable that ccih was able to articulate such a position and have it included, given the fact that the implementing partners of apc, john snow international (jsi) and fhi 360, had explicitly promoted abortion, if not as family planning per se, as part of their broader advocacy.7,8 the existing balance that enables christian groups to accept government funding—and ensures their eligibility for such grants—is supported by a combination of u.s. laws and policies and international standards that separate family planning from abortion. but these safeguards are under constant assault from many family planning organizations that oppose that separation. jsi, for example, has signed statements calling for both the repeal of the mexico city policy and the redefinition of the helms amendment to create exceptions in the ban on u.s. funding for overseas abortions. sneha barot of the guttmacher institute, which advocates for both abortion and family planning, is strongly critical of the helms amendment: “just on its face, the law is extreme and harmful.”9 elsewhere, barot acknowledges the “essential safety net” provided by faith-based organizations overseas, and the fact that in some areas, they may be the only providers of essential services. she notes that faith-based groups’ eligibility for u.s. family planning funding balances morally-based objections to particular methods against a requirement that they offer referrals to a wider range of services than they might be willing to offer directly10 if the guttmacher institute and its allies successfully advocate congress to repeal the helms amendment, christian aid organizations might find themselves pressured to refer for abortions as well, or be ineligible for u.s. funding, which could in turn jeopardize much-needed aid in fragile and poor settings. what is truth? (john 18:38) in recent decades, the dominant mostly western-based organizations within the family planning movement have been highly successful in convincing national and international institutions to adopt a range of definitions and measurements designed primarily as tools for family planning 5 oas july 2017. christian journal for global health, 4(2):3-9. advocacy. the concept of “unmet need” has been characterized as an “invaluable bridge” between demographic and rights-based rationales for promoting family planning.11 “unmet need” has been criticized by economists as better suited to advocacy than an actual measure of demand for products or services.12 furthermore, “unmet need” is frequently mischaracterized by organizations within the family planning movement as lack of access, despite the fact that far more women described as having a “need” cite personal opposition or concerns about health risks than cost or accessibility issues.13 as a result of the widespread misuse of “unmet need” by policymakers and advocacy groups alike, there is an illusion of high demand for family planning within developing regions. this in turn leads to costing projections like the 2014 adding it up report co-published by the united nations population fund and the guttmacher institute, which estimates that an annual $9.4 billion could meet the total “need” for family planning, based on the assumption “that all women with unmet need would use modern contraceptives.”14 this assumption gains little support from the guttmacher institute’s own analysis, which reveals that most contraceptive nonuse is a matter of personal choice rather than lack of access.13 yet modeling programs like the lives saved tool are used to estimate the impact of increased family planning use, for only the cost of providing commodities, in terms of averted deaths of women and children. in some cases, estimates of averted child deaths include children whose hypothetical deaths in infancy might be averted by preventing their conception. in the report acting on the call published by usaid, these were referred to as “child lives saved from demographic impact,” proposing an innovative way in which a life could be saved without leaving a survivor.15 it is likewise essential to consider the impact of definitions. while family planning may be considered to exclude abortion, it rarely excludes contraceptive methods that may have abortifacient effects, such as some types of intrauterine devices. such methods are classified as “contraceptive” if they prevent “pregnancy,” as defined as being established at implantation rather than conception.16 essentially, this definition not only redefines pregnancy but also entirely fails to consider when human life begins, which is arguably the more important question. similarly, while “contraception” and “family planning” are often used interchangeably, fertility awareness-based methods of family planning, the only methods permitted by catholic teaching, are morally permissible precisely because they are not contraceptive. in other words, they are not intended to render the act of sexual intercourse nonprocreative, or, in the words of the encyclical humanae vitae by pope paul vi, are not intended to separate “the unitive significance and the procreative significance which are both inherent to the marriage act.”17 while it makes sense on a semantic level to exclude these methods from classification as “modern contraceptive methods,” as has been proposed by some within the family planning community, the intent of this proposal is to classify such methods not as “non-contraceptive,” but rather as “non-modern.”18 this would have the effect of reducing funding and support for fertility awarenessbased methods of family planning within national and international policy, particularly as the current indicator for family planning within the sustainable development goals specifies that “need” for family planning be satisfied by modern methods. christian and other aid organizations would do well to critically examine the measurements and methodologies used by family planning groups, primarily as a means of advocacy, and frequently without internal consistency. for christian entities, the imperative to speak with honesty must be paramount, and a source of common ground between denominations divided over the contraceptive issue. if the goal is to ensure that women and children have better health outcomes in resource-limited settings, it is counterproductive to use measurements of progress designed to privilege family planning over other interventions. furthermore, if the goal is to 6 oas july 2017. christian journal for global health, 4(2):3-9. ensure that women have access to family planning, better measures of access are needed, preferably originating from entities that do not have a direct stake promoting particular forms of contraception and abortion. christian organizations might lead the way in this regard, but they may need to part company with many organizations in the family planning establishment, and even actively compete with them to set international norms and standards. be fruitful and multiply (genesis 35:11) central to the “sexual revolution” is the principle that the sexual act must be uncoupled from the potential for procreation. this goal, promoted by the development of modern contraceptives, has proven extremely difficult to accomplish, even with them. despite the fact that approximately 40% of pregnancies worldwide are designated as “unintended,” the international family planning movement continues to rely on definitions of pregnancy as “unintended,” “unwanted,” “mistimed,” and “unplanned,” all of which “assume that pregnancy is a conscious decision.”19,20 advances in global development and medicine have driven down maternal and child mortality, but gaps remain, linked to poverty and resource inequity. although africa is the global region with the highest rates of maternal and child mortality as compared with the number of live births (defined by the un as the maternal mortality ratio and the under-5 mortality rate), it is also the region with the lowest percentage of pregnancies classified as unintended (35%).21,22,19 it is important to note that the terminology of “intendedness” (and, similarly, of “wantedness”) originates from fertility surveys designed and intended to promote contraception and abortion, and which have no interest in promoting the acceptance of children whose conceptions were not “planned.” perhaps the best illustration of this point is the frequency with which attempts to measure “unintended” births refer to the problem of “retroactive rationalization”—that is, parents who not only come to accept their unexpected child, but deny having ever wished to avoid or postpone the pregnancy.23 this is typically regarded as an unfortunate flaw in the data that masks the true scale of the problem of unintended pregnancies, rather than evidence that the problem is, to an extent, selfsolving. furthermore, decades of studies seeking to demonstrate that “unintended” or “unwanted” children fare worse than their counter-parts have produced inconsistent and under-whelming findings, once confounding variables are accounted for. the third edition of the world bank’s disease control priorities stated in summary that “[i]nsufficient data exist to indicate whether unintended pregnancies carried to term are disadvantaged in health or schooling, compared with intended births.”24 within the international family planning movement, there is little acknowledgment that unplanned pregnancies or abortions might be addressed by any intervention apart from contraceptives. in a 2015 article in demography authors kathryn kost and laura lindberg, both of the guttmacher institute, clearly articulate this position: “[t]he public health goal is not to help mothers change their attitudes so that those unintended births become intended ones; the goal is to delay those pregnancies until women move into a life stage when they do want to have a baby . . . similarly, the negative consequences for an unwanted birth can be alleviated not by convincing mothers to want the births, but by preventing the unwanted pregnancies.”25 christian aid organizations, who are often a front line of assistance for women with crisis pregnancies both at home and abroad, have a duty to ensure that their message is one of hope and resilience for both mother and child. this mission is not only outside the agenda of many organizations in the international family planning movement, but it also starkly refutes many of their core principles. 7 oas july 2017. christian journal for global health, 4(2):3-9. bad company corrupts good morals (1 corinthians 15:33) many leading family planning organizations have made great strides in reaching out to the christian community to form partnerships, particularly around the goal of ending preventable deaths and reducing poverty. to the extent that religious leaders within local communities are seen as powerful gatekeepers, this may be a sensible strategic move. but whether christian organizations providing aid at the local, national, or international level stand to benefit from such partnerships—or can justify them at a moral and ethical level—remains to be seen. for all its attempts at outreach to faith groups, most organizations within the family planning movement have remained stubbornly committed to promoting abortion, whether they regard it officially as a method of family planning or not.26 they continue to push for institutional acceptance of definitions and measurements better suited to promoting the interests of their own organizations than the general public good. in recent years, the dominant discourse within the family planning movement has moved to favor “sexual and reproductive health and rights,” a construct that remains highly controversial within international institutions, and is typically defined as encompassing a set of norms that are on a direct collision course with a traditional christian concept of the dignity of the human person, sexual morality, and the nature of the family.27 christian organizations engaged in international family planning work face a choice with important moral implications: navigate their own course in parallel to or sometimes in competition with organizations in the family planning movement, or engage to speak prophetically and help guide the movement away from abortion as a solution and amoral principles which are antithetical to christian morality. however, this approach risks inviting organizations into their much-needed and faith-inspired efforts, which could dilute or challenge their moral beliefs. whatever choices christian groups ultimately make in this regard, they should be fully aware of the baggage the global family planning movement carries with it— and shows no indication of letting go. references 1. a good summary of these shifting rationales can be found in the discussion between former heads of the usaid’s office of population and reproductive health, held at the wilson center, washington d.c., on june 26, 2015. summary and webcast can be found at https://www.wilsoncenter.org/event/changing-theworld-how-usaids-50-years-family-planning-hastransformed-people-economies-and 2. aspen global health and development. the population-climate connection: why family planning is a win-win for women and the planet. global leaders council for reproductive health. aspen global health and development at the aspen institute. aspen institute, dec 2011. 3. report of the international conference on population and development (icpd), 18 october 1994. a/conf.171/13. available from: www.un.org/popin/icpd/conference/offeng/poa.html 4. usaid, global health legislative & policy requirements, updated may 2017. available from: https://www.usaid.gov/what-we-do/globalhealth/cross-cutting-areas/legislative-policyrequirements 5. kohn s. a plea to melinda gates: stop stigmatizing abortion. the daily beast. 5 june 2014. available from: http://www.thedailybeast.com/articles/2014/06/05/aplea-to-melinda-gates-stop-stigmatizing-abortion 6. trump's 'global gag rule' could endanger millions of women and children, bill and melinda gates warn. the guardian. 14 february 2017. available from: https://www.theguardian.com/globaldevelopment/2017/feb/14/bill-and-melinda-gatestrumps-global-gag-rule-endangers-millions-womengirls-us-funding 7. faith matters: international family planning from a christian perspective. christian connections for international health. 2014. available from: https://www.wilsoncenter.org/event/changing-the-world-how-usaids-50-years-family-planning-has-transformed-people-economies-and https://www.wilsoncenter.org/event/changing-the-world-how-usaids-50-years-family-planning-has-transformed-people-economies-and https://www.wilsoncenter.org/event/changing-the-world-how-usaids-50-years-family-planning-has-transformed-people-economies-and http://www.un.org/popin/icpd/conference/offeng/poa.html https://www.usaid.gov/what-we-do/global-health/cross-cutting-areas/legislative-policy-requirements https://www.usaid.gov/what-we-do/global-health/cross-cutting-areas/legislative-policy-requirements https://www.usaid.gov/what-we-do/global-health/cross-cutting-areas/legislative-policy-requirements http://www.thedailybeast.com/articles/2014/06/05/a-plea-to-melinda-gates-stop-stigmatizing-abortion http://www.thedailybeast.com/articles/2014/06/05/a-plea-to-melinda-gates-stop-stigmatizing-abortion https://www.theguardian.com/global-development/2017/feb/14/bill-and-melinda-gates-trumps-global-gag-rule-endangers-millions-women-girls-us-funding https://www.theguardian.com/global-development/2017/feb/14/bill-and-melinda-gates-trumps-global-gag-rule-endangers-millions-women-girls-us-funding https://www.theguardian.com/global-development/2017/feb/14/bill-and-melinda-gates-trumps-global-gag-rule-endangers-millions-women-girls-us-funding https://www.theguardian.com/global-development/2017/feb/14/bill-and-melinda-gates-trumps-global-gag-rule-endangers-millions-women-girls-us-funding 8 oas july 2017. christian journal for global health, 4(2):3-9. http://www.ccih.org/faith-matters-fp-christianperspective.pdf 8. see the universal access project’s briefing card on “sexual and reproductive health and rights and the post-2015 development agenda” available from: http://www.unfoundation.org/what-we-do/campaignsand-initiatives/universal-access-project/briefingcards-srhr.pdf and the letter to president obama calling for expanded u.s. support for abortions abroad, co-signed by john snow, inc. available from: https://americanhumanist.org/news/2015-03-foreignaid-must-guarantee-access-to-reproductive-he/ 9. barot, s. abortion restrictions in u.s. foreign aid: the history and harms of the helms amendment. guttmacher policy review. 2013; 16 (3). 10. barot s. a common cause: faith-based organizations and promoting access to family planning in the developing world. guttmacher policy review. 2013; 16(4). 11. cleland j, harbison s, and shah, ih. unmet need for contraception: issues and challenges. studies in family planning. 2014; 45[2]: 105–122. https://doi.org/10.1111/j.1728-4465.2014.00380.x 12. ozler b. is there an 'unmet need' for birth control. development impact. the world bank. 7 april 2011. available from: http://blogs.worldbank.org/impactevaluations/is-therean-unmet-need-for-birth-control-0 13. sedgh g, and hussain, r. reasons for contraceptive nonuse among women having unmet need for contraception in developing countries. studies in family planning 2014; 45[2]: 151–169. 14. singh s, darroch je, ashford ls. adding it up: the costs and benefits of investing in sexual and reproductive health. new york: guttmacher institute and united nations population fund; 2014. available from: http://www.unfpa.org/adding-it-up 15. acting on the call: ending preventable child and maternal deaths report. usaid; 2014. available from: https://www.usaid.gov/sites/default/files/documents/1 864/usaid_actingonthecall_2014.pdf 16. gacek cm. conceiving pregnancy: u.s. medical dictionaries and their definitions of conception and pregnancy. the national catholic bioethics quarterly, autumn 2009. https://doi.org/10.5840/20099336 17. humanae vitae, encyclical letter of pope paul vi on the regulation of birth, 1968. 18. hubacher d & trussell j. a definition of modern contraceptive methods. contraception. august 2015; 92(5): 420 – 421. https://doi.org/10.1016/j.contraception.2015.08.008 19. sedgh g, singh s & hussain r. intended and unintended pregnancies worldwide in 2012 and recent trends. studies in family planning. 2014; 45(3): 301–314. https://doi.org/10.1111/j.17284465.2014.00393.x 20. santelli j, rochat, r, hatfield-timajchy, k, gilbert, bc, curtis k, cabral r, hirsch js, schieve l, and other members of the unintended pregnancy working group. the measurement and meaning of unintended pregnancy. perspectives on sexual and reproductive health. march/april 2003; 35(2). https://doi.org/10.1363/3509403 21. maternal mortality fact sheet, updated november 2016. world health organization. available from: http://www.who.int/mediacentre/factsheets/fs348/en/ 22. unicef, world health organization, world bank, united nations department of economic and social affairs population division, 2015. levels and trends in child mortality 2015. united nations children’s fund, new york. 23. a prominent example is jaffe fs. toward the reduction of unwanted pregnancy. science. 8 oct 1971; 174 (4005): 119-127. https://doi.org/10.1126/science.174.4005.119 24. black, r. e., r. laxminarayan, m. temmerman, and n. walker, editors. reproductive, maternal, newborn, and child health. disease control priorities, third edition, volume 2. washington, dc: world bank. 2016. 25. kost k and lindberg l. pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. demography. february 2015; 52 (1):83-111. https://doi.org/10.1007/s13524-0140359-9 26. the bulletin of the world health organization credits the founding of the modern family planning movement to the international planned parenthood federation and the population council, both of which remain firmly in favor of abortion. available from: http://www.who.int/bulletin/volumes/86/3/07http://www.ccih.org/faith-matters-fp-christian-perspective.pdf http://www.ccih.org/faith-matters-fp-christian-perspective.pdf http://www.unfoundation.org/what-we-do/campaigns-and-initiatives/universal-access-project/briefing-cards-srhr.pdf http://www.unfoundation.org/what-we-do/campaigns-and-initiatives/universal-access-project/briefing-cards-srhr.pdf http://www.unfoundation.org/what-we-do/campaigns-and-initiatives/universal-access-project/briefing-cards-srhr.pdf https://americanhumanist.org/news/2015-03-foreign-aid-must-guarantee-access-to-reproductive-he/ https://americanhumanist.org/news/2015-03-foreign-aid-must-guarantee-access-to-reproductive-he/ https://doi.org/10.1111/j.1728-4465.2014.00380.x http://blogs.worldbank.org/impactevaluations/is-there-an-unmet-need-for-birth-control-0 http://blogs.worldbank.org/impactevaluations/is-there-an-unmet-need-for-birth-control-0 http://www.unfpa.org/adding-it-up https://www.usaid.gov/sites/default/files/documents/1864/usaid_actingonthecall_2014.pdf https://www.usaid.gov/sites/default/files/documents/1864/usaid_actingonthecall_2014.pdf https://doi.org/10.5840/20099336 https://doi.org/10.1016/j.contraception.2015.08.008 https://doi.org/10.1111/j.1728-4465.2014.00393.x https://doi.org/10.1111/j.1728-4465.2014.00393.x https://doi.org/10.1363/3509403 http://www.who.int/mediacentre/factsheets/fs348/en/ https://doi.org/10.1126/science.174.4005.119 https://doi.org/10.1007/s13524-014-0359-9 https://doi.org/10.1007/s13524-014-0359-9 http://www.who.int/bulletin/volumes/86/3/07-045658/en/ 9 oas july 2017. christian journal for global health, 4(2):3-9. 045658/en/. in recent years, the clearest illustration of the family planning movement’s support for abortion can be seen in the near-universal opposition of family planning groups to the u.s. government’s mexico city policy. for example: https://www.plannedparenthood.org/files/9814/8486/ 3032/coalition_statement_opposing_the_global_g ag_rule.pdf. 27. nowicka w. sexual and reproductive rights and the human rights agenda: controversial and contested. reproductive health matters. 2011; 19:119–128. https://doi.org/10.1016/s0968-8080(11)38574-6 competing interests: none declared. correspondence: rebecca grace oas, center for family and human rights (c-fam), new york, ny, usa. rebecca@c-fam.org cite this article as: oas r g. communities of faith and the global family planning movement: friends or foes? christian journal for global health. july 2017; 4(2):3-9. https://doi.org/10.15566/cjgh.v4i2.183 © oas r g this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.who.int/bulletin/volumes/86/3/07-045658/en/ https://www.plannedparenthood.org/files/9814/8486/3032/coalition_statement_opposing_the_global_gag_rule.pdf https://www.plannedparenthood.org/files/9814/8486/3032/coalition_statement_opposing_the_global_gag_rule.pdf https://www.plannedparenthood.org/files/9814/8486/3032/coalition_statement_opposing_the_global_gag_rule.pdf https://doi.org/10.1016/s0968-8080(11)38574-6 mailto:rebecca@c-fam.org https://doi.org/10.15566/cjgh.v4i2.183 https://creativecommons.org/licenses/by/4.0/ case study nov 2018. christian journal for global health 5(3):35-42. principles to guide a volunteer humanitarian faith-based short-term medical mission in nepal: a case study rebecca houweling a , barbara astle b a bscn, rn, (msn student), school of nursing, trinity western university, langley, bc, canada b phd, rn, associate professor for school of nursing & director for the centre of equity and global engagement (cege), trinity western university, langley, bc, canada abstract global health inequities, natural disasters, and mass migration of refugees have led to an increase in volunteer humanitarian responses worldwide. while well intentioned for doing good, there is an increasing awareness of the importance for improved preparation for international volunteers involved in short-term medical missions (stmms). this case study describes the retrospective application of lasker’s (2016) principles for maximizing the benefits for volunteer health trips to international volunteers from two faith-based non-governmental organizations (ngos) in canada and the united states partnering with a faith-based ngo in nepal. these principles are intended to maximize the benefits and diminish challenges that may develop between the international volunteers and the host country staff. lessons from this case study highlight the importance of applying such principles to foster responsible stmms. in conclusion, there is an increasing call by host country staff for collaborative and standardized guidelines or frameworks for stmms and other global health activities. key words: short-term medical missions, guidelines, volunteers, global health, humanitarian, faith-based, international volunteering, nepal. introduction over the past several years, there have been numerous natural disasters and migration of refugees that have resulted in catastrophic disruptions in the health and wellbeing of those afflicted. 1,2,3,4 this has been associated with a mobilization of volunteer activities and humanitarian assistance worldwide. 2,5 while these international volunteer activities are well intentioned, they can often be misaligned with the host countries’ staff desires and preferences, particularly by focusing on downstream, episodic care. 6 this has the potential for unintended and harmful consequences for the host country and may exacerbate global health inequities. 7,8 on april 25, 2015, nepal suffered a 7.9 magnitude earthquake that killed 8700, injured 22,000, and displaced 2.8 million people. then, on may 12, 2015, nepal experienced a second devastating 7.3 magnitude earthquake. 9 in 2015, nepal had been ranked 158/188 in health performance in the world. 10 these natural disasters 30 houweling & astle nov 2018. christian journal for global health 5(3):35-42. exacerbated nepal’s already high burden of disease and magnified health inequity in one of asia’s poorest countries. 10,11 in response to these devastating earthquakes, there was an immediate outpouring from various international organizations to provide aid, disaster relief, and funds. 12 among others, three faith-based ngos responded to the call: (1) a canadian church ngo focusing on refugee relief, education, and human trafficking, (2) an american ngo focusing on disaster relief, and (3) a nepalese ngo primarily focusing on human trafficking, particularly of vulnerable children and youth. the invitation to the north american ngos from the nepalese ngo requested assistance with infrastructure projects and medical clinics after the earthquakes and has resulted in an ongoing partnership. the canadian and american ngos accepted the invitation to work alongside the nepalese ngo to support their goals and objectives. this included short term medical missions (stmms) to provide annual medical care and to help rebuild structures destroyed during the earthquakes. stmms have been described as a “grass-roots form of aid, transferring medical services rather than funds or equipment.” 13( in addition, others have described short-term global health trips as lasting from one day to two years, but most commonly two weeks. 14, 15 case study this case study describes the retrospective application of lasker’s (2016) principles for maximizing the benefits for volunteer health trips to international volunteers from two faith-based non-governmental organizations (ngos) in canada and the united states, partnering with a faith-based ngo in nepal. initially, this partnership between these three faith-based ngos was built as the result of the humanitarian crisis in nepal. the american based ngo provided medical teams to support host country staff in kathmandu and in remote villages located in the himalayan foothills. over the past three years, the canadian and american ngo volunteers have worked in partnership with the nepalese ngo to continue providing primary medical and dental care in these areas during their annual stmms. purpose the purpose is to describe the retrospective application of principles for international volunteers to a specific case study demonstrating how these principles maximize the benefits and diminish challenges that may develop between international volunteers and host country staff in a stmm. recently, there has been increased awareness of the importance of improving the preparation for international volunteers involved in stmms when serving under-resourced communities. 14 in this case study, no specific principles guided the volunteer stmm among the canadian, american, and nepalese faith-based ngos. to date, the preparation for the international volunteers has consisted of pre-departure team meetings. lasker emphasizes the importance of having, “a set of standards to guide global health efforts toward the best possible outcomes.” 5 lasker acknowledges that other guidelines for practice in global health exist, but their focus may vary due to expectations from volunteers. as a result, lasker developed nine principles, based upon her and others’ research, that, “would be most likely to have an impact in creating effective health-related volunteer programs.” 5 principles for maximizing the benefits for volunteer health trips 5 lasker’s principles are described and retrospectively applied and evaluated to the case study. the principles are as follows: (1) foster mutuality between sponsor organizations and hostcountry partners at every stage; (2) maintain continuity of programming; (3) conduct substantive needs assessment with host-community 31 houweling & astle nov 2018. christian journal for global health 5(3):35-42. involvement; (4) evaluate process and outcomes and incorporate the results into improvements; (5) focus on prevention; (6) integrate diverse types of health services; (7) build local capacity; (8) strengthen volunteer preparation, and (9) have volunteers stay longer. 5 the application of lasker’s principles may be a useful guide for describing and better understanding the strengths and limitations of the partnership between the three faith-based ngos described in the case study. the first principle, “foster mutuality between sponsor organizations and host-country partners at every stage,” 5 describes many types of international collaborations whereby mutuality is valuing of the knowledge of both the visiting and host perspectives. in this faith-based partnership, the host country staff’s knowledge of the community’s needs was integral to ensuring that optimal care was provided. from there, the nepalese ngo engaged in conversations with the individual community stakeholders as to where they would like their clinics to be located. this ensured that the canadian and american ngos provided aid and assistance in alignment with the preferences and needs of the nepalese host communities. in the beginning, the volunteers from north america operated the medical clinics along with nepali translators, but as this collaboration progressed into the second year, a nepali dentist joined the healthcare team. the addition of a host dentist and the continued relationship with the nepali translators created an opportunity for mutual learning, which enabled the visiting volunteers to better understand and appreciate the needs of the nepalese population. the second principle, “maintain continuity of programming,” refers to the consistency, predictability, and sustainability of a stmm. 5 continuity of programming holds the potential for better health outcomes as it leads to strengthening the collaboration between the international volunteers and host communities. lasker further advises, “without a plan and the possibility for continuity, billions of dollars of international development aid and global health assistance can be wasted.” 5 as these international volunteers have been serving the same community for a number of stmms, over time trust between the partners has been steadily growing. as a result, there is ongoing clarity of what the international volunteers are continuing to provide relative to medical and dental care, and the host staff are clearer of their roles and what they can offer to maintain the sustainability of care once the international volunteers have left. the ongoing planning between the international volunteers and the host staff community has allowed other programs to be instituted based upon the changing needs of the host community, for example, the offering by the nepalese ngo of human trafficking prevention seminars. next, lasker emphasizes in the third principle the need to “conduct substantive needs assessment, with host-community involvement.” 5 this principle involves a structured approach towards assessing the perceived and actual needs of the host community. this serves to provide the most benefit: the ultimate goal of the majority of stmms. 5,16 this principle is also acknowledged as important in the global health literature when addressing the needs of visiting student trainees and hosts. 17 throughout this partnership, the visiting ngos have actively sought and valued the involvement of the host staff and community. for example, the volunteers on the stmm have relied upon the host organization and community to conduct needs assessments to determine the optimal location for the medical and dental clinics. lasker’s fourth principle focuses on the importance of evaluating, “process and outcomes and incorporate[ing] the results into improvements.” 5 there are several reports of successful stmms, yet when lasker asked, “how do you know if your program is benefiting the host community?” there were few objective responses by the various programs. 5 it appeared that the success of a stmm is often based upon the assumptions and feelings of the visiting volunteers. 5 the current stmm did not use any formal evaluation processes, 32 houweling & astle nov 2018. christian journal for global health 5(3):35-42. however, they did ask the host organization to follow up on specific patient concerns. it could be argued that without sufficient medical follow-up, the efficacy of the health care provided may often remain unknown to the volunteers and the host community, which is a common issue amongst stmms. 5,7,17 in this particular case study, the canadian ngo evaluated the volunteer experiences by having them complete a survey. this is an example that illustrates the high priority placed upon volunteer experiences rather than the host community benefits. as a result, this reflects the need for a paradigm shift away from only assessing the volunteer experiences, and toward the inclusion of the host community experiences. 16 another aspect of the paradigm shift needed leads to lasker’s fifth principle of a “focus on prevention.” 5 lasker describes this as a move away from a traditional medical mission model and towards a population based model that addresses the underlying causes, which is in line with upstream thinking. 5,8,14,18 despite the many successful outcomes to date with these stmms, the partners have become increasingly aware that the current model of care in nepal is unsustainable due to the almost complete on-going reliance on the canadian and american ngos. thus, there has been discussion between the partnering ngos about a refocus on health development projects and host staff initiatives within nepal. lasker’s sixth principle describes how to “integrate diverse types of health services,” to avoid the issue of siloed care, which focuses on only specific diseases, areas of interest, or types of services. 5 the stmms provided primary medical and dental care, yet further integration of these and other services within the local nepalese health system should be considered. therefore, the integration and collaboration of a variety of services from volunteer and host organizations has the potential to move away from “isolated, episodic interventions” to a “global network of shared learning and positive innovation.” 16 the seventh principle to “build local capacity” emphasizes the importance of bidirectional learning and training. 5 in this case study, this could include training host country staff, including local community health care workers, to ensure the ongoing delivery of healthcare once the international volunteers have left. for example, currently, the stmm international volunteers work alongside local interpreters in nepal who assist them in communicating with the patients. in the future, for example, the nepali interpreters could be involved in the development and implementation of culturally appropriate health seminars. in addition, as a result of the relationships built during the many stmms, two of the nepali interpreters are now being sponsored by the international ngos to complete their nursing education in nepal. further, there is established local capacity in serving rural nepal through partnering with the female community health volunteer (fchv) program. 11,19,20 the fchv program has received recognition for their work towards advancing health equity and gender equality in rural communities of nepal. 11 more recently, there has been a call for restructuring this program to aid in the implementation of the sustainable development goals (sdgs). 11 in this case study, the redirection from aid to development aligns well for future capacity building with the fchvs program. the final two principles are “strengthen volunteer preparation” and “have volunteers stay longer.” 5 according to lasker, strengthening volunteer preparation, entails pre-departure training including information about the unfamiliar environment, culture, and work that the stmm volunteers may encounter. 5 many of the canadian and american ngo volunteers were returning to nepal, so less emphasis was placed upon volunteer preparation. however, before every stmm, four pre-departure meetings are held by the canadian ngo which include basic cultural and religious competencies, language, common diagnoses, and treatments. the lack of a structured and agreed training for volunteers for stmm remains a 33 houweling & astle nov 2018. christian journal for global health 5(3):35-42. significant issue for volunteers, particularly because of diverse backgrounds and global health competency levels. other scholars found that limited preparation about community development principles significantly impacts the volunteers “perceived effectiveness” of the stmm. 21 a call for structured volunteer preparation has the potential to strengthen health outcomes to meet sdgs and to have a greater understanding and ability to apply lasker’s principles. 5 in addition, in these faith based stmms, a deep understanding of the religious and political climate is important. for example, religious conversion is illegal and acts such as prayer can result in imprisonment for both the visiting volunteer and recipient of prayer. therefore, it is very important that the stmm purpose is clearly defined and understood by the volunteers. finally, “have volunteers stay longer” describes the need for long-term and more consistent stmm trips. 5 other scholars have also questioned the value and efficacy of trips under three weeks and even up to six months to one year. 21 in the past, this stmm has been two weeks in length. currently, this appears to have been welcomed by the nepalese host organization in that they have continued to invite the canadian and american ngos. this stmm, however, might be strengthened by ensuring that the host community in nepal be involved in open discussions about future stmm trips, including potential for the international volunteers to stay longer or come more frequently. discussion the above application of the principles developed by lasker has demonstrated one way in which a collaborative relationship between ngos may be guided by taking into consideration the host perspective. such principles may thus be viewed as a strength, with the intention to ensure that there is mitigation of harm and that benefits are maximized. critically considering the host community perspectives has increasingly been an emerging area of research. 7,16,17,21,22 others have explored host perspectives on student trainee competencies in a short-term experience and found that the host respondents rated respectful conduct and cultural awareness as important. 17 in addition, the majority of the host respondents stated that fluency in the local language was not as important. also stated was that the purpose for understanding competency expectations for trainees was to work towards improved global health curriculum design and pedagogy, to develop experiential learning, and to better meet host expectations and goals. 23 in addition, they emphasized the importance of working towards mutual trust and respect, ethical sharing of power, and creating a collaborative agenda. 22 a systems thinking approach to shortterm health missions is proposed to assist with the ongoing, iterative process of self-organization and mutual learning. 16 in a survey of a convenience sample of 288 volunteer partner organizations located in 68 countries, highly skilled volunteers working a shortterm abroad trip were found to be most effective at promoting nutrition and healthcare, followed by slightly less-skilled long-term volunteers. 21 in addition, they found that there was greater variation in the perceived effectiveness of the volunteers based upon their ability to speak the local language, followed by their skill level and length of service abroad. lastly, they found there was a perceived effectiveness if the volunteers had training in community development principles and practices. scholars also were interested in determining how organizer practices aligned with the host community preferences while on stmms. 7 they administered an online survey with 334 stmm organizers and conducted interviews to explore existing practices. similarly, with host community staff, they collected 49 survey responses and conducted 75 interviews. they found that organizer practices often did not align with host community preferences. this finding supports the importance 34 houweling & astle nov 2018. christian journal for global health 5(3):35-42. for stmm organizers to ensure their practices align with those of the hosts. building upon her work on the development of the principles, lasker and others conducted a scoping review of the literature, analyzing the implementation of 27 guidelines for stmms and how these guidelines relate to the desires of host country staff working with volunteers. 14 they found that most existing guidelines were predominately developed in sending countries of the global north and specifically addressed practitioners and educators. 14 there appeared to be general agreement for certain key principles, such as proper preparation and supervision of visitors, a need for effective, responsible, and ethical programs for host partners, adherence to pertinent ethical and legal standards, and needs assessment and evaluation. in addition, host country staff in these studies added that mutual learning and respect for the hosts were also extremely important. the findings of mutual learning and respect for the host community supports the aims of others researching in the area of host perspectives for trainees. 22 lessons learned the lessons learned from this case study highlighted the importance for using a guideline or a framework to foster mutuality between the visiting volunteers and host-country by maintaining continuity of programming, by including hostcountry involvement in what is required, by building capacity, and by preparing volunteers to have a positive global health volunteer trip. in conclusion, the retrospective application of these principles by lasker between three ngos provided additional beginning insights and understanding of how to approach volunteer global health trips, with the potential for fostering mutual learning towards the attainment of the sdgs. recommendations for the future using a guideline or framework such as the principles for maximizing the benefits of volunteer health trips can be a useful guide for the various stages involved in a stmm from the initial preplanning, volunteer preparation, participating on the ground, and post trip. the critical importance for including the host perspective in determining how best to align the volunteer activities with the host communities’ preferences has been acknowledged. the implementation of such guidelines would seek not simply to provide aid but to provide development, to move from a model of doing-for toward catalyzing and empowering the host community to be able to do so themselves. implementation would ensure moving away from a colonial or imperialist model, towards collaborative and effective standardized guidelines, focused on host preferences versus volunteer desires for stmms, and other global health volunteering. 23 references 1. united nations, office for disaster risk reduction [internet]. geneva. sendai framework for disaster risk reduction 2015 – 2030. [updated 2015, cited 2018 aug 20]. available from: https://www.unisdr.org/files/43291_sendaiframeworkf ordrren.pdf 2. development initiatives [internet]. bristol, uk. global humanitarian assistance report 2017: [updated 2017, cited 2018 aug 20]. available from: http://devinit.org/post/global-humanitarian-assistance2017/ 3. united nations [internet]. new york. international migration report. 2017. available from: http://www.un.org/en/development/desa/population/m igration/publications/migrationreport/docs/migration report2017_highlights.pdf 4. world health organization [internet]. geneva. migration and health: key issues. available from: http://www.euro.who.int/en/health-topics/healthdeterminants/migration-and-health/migrant-health-inthe-european-region/migration-and-health-key-issues 5. lasker j. hoping to help: the promises and pitfalls of global health volunteering. ithaca, ny: cornell university press; 2016. 6. loh lc, cherniak w, dreifuss ba, dacso nm, lin hc, every j. short-term global health experiences and https://www.unisdr.org/files/43291_sendaiframeworkfordrren.pdf https://www.unisdr.org/files/43291_sendaiframeworkfordrren.pdf http://www.un.org/en/development/desa/population/migration/publications/migrationreport/docs/migrationreport2017_highlights.pdf http://www.un.org/en/development/desa/population/migration/publications/migrationreport/docs/migrationreport2017_highlights.pdf http://www.un.org/en/development/desa/population/migration/publications/migrationreport/docs/migrationreport2017_highlights.pdf http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/migrant-health-in-the-european-region/migration-and-health-key-issues http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/migrant-health-in-the-european-region/migration-and-health-key-issues http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/migrant-health-in-the-european-region/migration-and-health-key-issues 35 houweling & astle nov 2018. christian journal for global health 5(3):35-42. local partnership models: a framework. globalization and health. 2015;11(50):1-7. https://doi.org/10.1186/s12992-015-0135-7 7. rozier md, lasker, jn, compton b. (2017). shortterm volunteer health trips: aligning host community preferences and organizer practices. global health action. 2017;10(1267957):1-8. https://doi.org/10.1080/16549716.2017.1267957 8. melby mk, loh lc, evert j, prater c, lin h, khan oa. beyond medical “missions” to impact-driven short-term experiences in global health (steghs): ethical principles to optimize community benefit and learner experience. academic medicine. 2016;91(5):633-638. https://doi.org/10.1097/acm.0000000000001009 9. world health organization [internet]. geneva. nepal earthquake 2015 – grade 3 emergency. 2016. [updated 2015 may 15, cited 2018 august 20]. available from: http://www.who.int/emergencies/nepal/en/ 10. gbc 2015 sdg collaborators. measuring the healthrelated sustainable development goals in 188 countries: a baseline analysis from the global burden of disease study 2015. lancet. 2016;(388):18131850. https://doi.org/10.1016/s0140-6736(16)31467-2 11. maru s, nirola i. thapa a, thapa p, kunwar l, wu w, maru d. an integrated community health worker intervention in rural nepal: a type 2 hybrid effectiveness-implementation study protocol. implementation science. 2018;13(53):1-11. https://doi.org/10.1186/s13012-018-0741-x 12. regan h. international aid to nepal ramps up. time. 2015, april 28. available from: http://time.com/3837688/nepal-earthquake-aid-reliefdonations/ 13. caldron ph, impens a, pavlova m, groot w. a systematic review of social, economic and diplomatic aspects of short-term medical missions. bmc health service research. 2015;15:380. http://doi.org/10.1186/s12913-015-0980-3 14. lasker jn, aldrink m, balasubramaniam r, caldron p, compton b, evert j, et.al. guidelines for responsible short-term global health activities: developing common principles. globalization and health. 2018;14:18. https://doi.org/10.1186/s12992018-0330-4 15. martiniuk al, manouchehrian m, negin ja, zwi ab. brain gains: a literature review of medical missions to low and middle-income countries. bmc health services research. 2012;12(1):134. https://doi.org/10.1186/1472-6963-12-134 16. swanson r, thacker b. systems thinking in shortterm health missions: a conceptual introduction and consideration of implications for practice. christian journal for global health. 2015;2(1): 7-22. https://doi.org/10.15566/cjgh.v2i1.50 17. cherniak w, latham e, astle b, anguyo g, beaunoir t, beunaventura j, et.al. visiting trainees in global settings: host and partner perspectives on desirable competencies. annals of global health. 2017;83(2):359-368. https://doi.org/10.1016/j.aogh.2017.04.007 18. astle b, barton s, johnson l, mill j. global health. astle bj & duggleby w. (cdn. eds.). potter pa, perry ag, stockert pa, hall ma. canadian fundamentals of nursing (6 th ed). toronto, on: elsevier; 2019. 19. ahmed sm, rawal lb, chowdhury sa, murray j, arscott-mills s, jack s, et.al. cross-country analysis of strategies for achieving progress towards global goals for women's and children's health. bulletin of the world health organization. 2016;94(5):351-361. https://doi.org/10.2471/blt.15.168450 20. målqvist m, pun a, raaijmakers h, kc a. persistent inequity in maternal health care utilization in nepal despite impressive overall gains. global health action. 2017;10(1356083):1-7. https://doi.org/10.1080/16549716.2017.1356083 21. lough bj, tiessen r, lasker, jn. effective practices of international volunteering for health: perspectives from partner organizations. globalization & health. 2018;14(11):1-11. https://doi.org/10.1186/s12992018-0329-x 22. myser c, astle b, cherniak w, latham e, anguyo g, beaunoir t, et.al. comparing high-income and low and middle-income country host perspectives on students’ short-term experiences in global health: a qualitative analysis [abstract]. the lancet global health. 2018;6(s40). https://doi.org/10.1016/s2214109x(18)30169-4 23. sullivan n. international clinical volunteering in tanzania: a postcolonial analysis of a global health business. global public health. 2018;13(3):310-324. https://doi.org/10.1080/17441692.2017.1346695 https://doi.org/10.1186/s12992-015-0135-7 https://doi.org/10.1080/16549716.2017.1267957 https://doi.org/10.1097/acm.0000000000001009 http://www.who.int/emergencies/nepal/en/ https://doi.org/10.1016/s0140-6736(16)31467-2 https://doi.org/10.1186/s13012-018-0741-x http://time.com/3837688/nepal-earthquake-aid-relief-donations/ http://time.com/3837688/nepal-earthquake-aid-relief-donations/ http://doi.org/10.1186/s12913-015-0980-3 https://doi.org/10.1186/s12992-018-0330-4 https://doi.org/10.1186/s12992-018-0330-4 https://doi.org/10.1186/1472-6963-12-134 https://doi.org/10.15566/cjgh.v2i1.50 https://doi.org/10.1016/j.aogh.2017.04.007 https://doi.org/10.2471/blt.15.168450 https://doi.org/10.1080/16549716.2017.1356083 https://doi.org/10.1186/s12992-018-0329-x https://doi.org/10.1186/s12992-018-0329-x https://doi.org/10.1016/s2214-109x(18)30169-4 https://doi.org/10.1016/s2214-109x(18)30169-4 https://doi.org/10.1080/17441692.2017.1346695 36 houweling & astle nov 2018. christian journal for global health 5(3):35-42. peer reviewed: submitted 25 july 2018, accepted 28 sept 2018, published 9 nov 2018 competing interests: none declared. correspondence: rebecca houweling, langley, bc, canada. rebecca.houweling@mytwu.ca cite this article as: houweling r, astle b. principles to guide a volunteer humanitarian faith-based short-term medical mission in nepal: a case study. nov 2018;5(3):35-42. https://doi.org/ 10.15566/cjgh.v5i3.235 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ editorial approaching death in a mission hospital: foundational experiences shaping health practice and life together ian campbella a mbbs, mrcp(uk), drcog, mftm (rcsp-glasgow), coordinator, affirm facilitation associates, london, uk the article death in a mission hospital by james v ritchie in this issue is highly relevant to christian health practitioners anywhere. very little systematic reflection on death related attitudes, beliefs, and practice of health staff in a mission hospital setting seems to be available that is practical and experientially rooted. in reading the article, and reflecting on 30 years of personal experience in global health and mission hospital support, some parts stood out for me as innovative, indicating the author’s experiential learning and practice. the article also provokes some questions and reflections that apply widely in and between different culture and faith settings, particularly in mission health facility contexts. local context in a mission hospital setting, or for that matter in the increasingly diverse cities of north america and europe, what do we know, and how do we learn about the local cultural context of faith and meanings of passing, legacy, ancestors, and understanding of future? how, in that context, is god, as seen through jesus, loving and redeeming? such acknowledgement may not discount, invalidate, negate, or diminish the meaning of god in christ being present in and through a particular local culture. “the grace of god has come with healing for all . . .” (titus 2:11, neb). two-way faith inspired illumination is a reality, in fact, in all parts of the world.1 it has a biblical foundation. our personal theological and anthropological framework can be deepened and clarified through face to face healing and dying and passing experiences that cross other cultures and faiths.2 we are reminded to respect, learn from, and appreciate the local context. we also need to be ready to discern, share faith, explore, inform, and act, always with inclusion.3 acceptable constraints how are acceptable constraints discerned relating to passing and inability to prevent death in a changing cultural and economic context? doing our best, whilst deferring ultimate responsibility is challenging. our faith and humanity is stretched because we need to “live” ethics in a technically advanced time with imposed technical limits. the reality is that we have to navigate unavoidable, and therefore acceptable, constraints. we learn how to do this in our normal practice setting and manage through agreed norms and standards. the challenge of doing without the “right” technology, and the clash of culture and often of faith expression, can confront a newly arrived health practitioner who has come to help healing happen. he or she faces experiences of what is thought to be preventable patient death, at least by normal western technical and ethical standards. finding the way, personally and together with local teams, can be a major element for grasping and comprehending the missional life. team culture is particularly needed by mission hospital based expatriates who, because of health practice formation in resource rich countries, might be tuned to provision of services and saving lives as the dominant themes.4 4 campbell nov 2017. christian journal for global health 4(3):3-5. the health worker as community counsellor how do health staff really listen and relate — being more a counselor in approach, particularly accompanying patients in their passing and death? the health worker needs to be part of a conversation, in effect, with the patient and family, and indirectly, the local community. in relational community settings, everything is noticed and passed on, if not verbally, then by feelings shared with affected others. the fact that an expatriate health person may be out of touch with local norms and word forms is not a reason to disengage from the wider connected story of patient and their relatives by defaulting to technical expertise as the core identity. relational listening is in fact a critical need in terms of patient and family care, anywhere, and particularly when we are outside of our normal culture. the inner (i.e., personal) permission by the doctor, for example, to move from advice to open questions, reflecting back, giving the question back, active listening, and other “counseling” skills, and weaving pastoral care as well, is not always intuitive, and not many health staff have specific counseling training. how do relational health approaches underpin responses to impending death, improved health outcomes, and shared growth in faith? quality of life for christians doing health work depends on more than service provision and sustaining life at all costs. family and neighborhood are conscious of incipient or actual death and often, therefore, a wideopen opportunity to expand the circle of conversation, counselling, pastoral care, and empathic faith communication.5 such insight and inclusion can often nurture trust that extends beyond the hospital bed to the family home and community group, positively influencing longer term health program design, and outcomes, and impact. who is the subject? is there still an expatriate dominance assumption by expatriate staff working in mission heath facilities that can undermine respectful and loving accompaniment of patient passing and death? local staff are often the key interpreters of life and death narratives to expatriate mission staff. there needs to be cooperation between expatriate staff adaptation and local leadership. greater clarity is needed on who is the subject, who leads, who advises, and who interprets local reality. passing, culture, and faith where and how is the inter-cultural learning potential amplified in a mission hospital setting in the face of unexpected passing and death? ritual and ceremony in death is a global phenomenon, with various approaches for passing to another state of being, to honor loved ones, and to respect autonomy of individual and community in decision making.6 if a passing ceremony is acceptable for christian patients and families, why would it not be equally valid for non-christian patients and their families navigated differently? well-being of all is the key. two-way learning, in a spirit of mutuality, is an imperative that helps avoid unconscious imposition and proselytization and allows space for the spirit to teach and nurture understanding and shape relationships of trust. the ceremony of life transition is a very helpful relational concept and practice. there are many forms in global christian faith and practice. looking at this from the “outside in,” do we respond often enough to invitations from family and community to attend their ceremony outside the mission boundaries and in other religious contexts? can more be explored, experientially, in passing and death of patients, outside of the formal christian community, that will help name the space and boundaries for the intersection of faith and health and local culture? how can we better discuss theological foundations for health and healing, and 5 campbell nov 2017. christian journal for global health 4(3):3-5. passing and death, that can link to intercultural and interfaith practice? we can reflect on healing and wholeness, and passing and death, as an encounter in grace and justice; on the quality of life nurtured by relational approaches, embracing family and neighbors and connected others in a shared realization of mortality as well as healing and salvation; on the connection of persons and family and local community brought out through shared immersion in death and passing experience; and on the link of counselling to the paraclete — the presence of the spirit. 7 how can we see christ in the environment of other faith and cultural norms where we are guests? while grief and fear of death are common across cultures, there are various models of dying throughout time and across cultures, making a universal approach elusive.8 acknowledgement of cultural, faith, and context variables that influence our navigation of the passing and death of people seeking help in christian health facilities can expand our personal understanding of the gospel, and of health and healing ministry. we see and feel more clearly that the gospel is expressed and illuminated by love in action, and we receive insight into jesus as the “word of god,” the healing grace that has come for all. references 1. the global and local community conversation. together — a journey of community conversations [internet; glocon; documentary film; launched at the salvation army international headquarters]. london: 2017 august 3. available from http://www.affirmfacilitators.org/together 2. o’neill dw. toward a fuller view: the effect of globalized theology on an understanding of health and healing. missiology. 2017 apr;45(2): 204-214. https://doi.org/10.1177/0091829616684863 3. ballenger i. missiological thoughts prompted by genesis 10. review & expositor. 2006;103:391-402. 4. campbell i, rader-campbell a, and chela c. a community development approach to aids care, prevention, and control [chapter 20]. in: lankester t, editor. setting up community health programmes, fourth edition. london: oxford university press; 2017. 5. salt (support and learning team) protocol [internet]. available from: http://www.affirmfacilitators.org/together 6. lobar sl, youngblut jmm, brooten d. pediatric nursing [internet]. pitman. jan/feb 2006;32(1):4450. available from: https://search.proquest.com/openview/f201d1dc3409 67634f5204505eb6d99c/1?pqorigsite=gscholar&cbl=47659 7. campbell, id, rader, ad. hiv counselling in developing countries — the link from individual to community counselling for support and change. brit j guid couns. 1995;23(1): 33-43. https://doi.org/10.1080/03069889508258058 8. robben a, editor. death, mourning and burial: a cross-cultural reader. malden, ma: blackwell; 2004. p. 1-15. competing interests: none declared. correspondence: ian campbell, affirm facilitation associates, uk. iancampbell11@aol.com cite this article as: ian campbell. approaching death in a mission hospital: foundational experiences shaping health practice and life together. christian journal for global health. nov 2017; 4(3):3-5. https://doi.org/10.15566/cjgh.v4i3.199 © ian campbell. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.affirmfacilitators.org/together https://doi.org/10.1177/0091829616684863 http://www.affirmfacilitators.org/together https://search.proquest.com/openview/f201d1dc340967634f5204505eb6d99c/1?pq-origsite=gscholar&cbl=47659 https://search.proquest.com/openview/f201d1dc340967634f5204505eb6d99c/1?pq-origsite=gscholar&cbl=47659 https://search.proquest.com/openview/f201d1dc340967634f5204505eb6d99c/1?pq-origsite=gscholar&cbl=47659 https://doi.org/10.1080/03069889508258058 mailto:iancampbell11@aol.com https://doi.org/10.15566/cjgh.v4i3.199 https://creativecommons.org/licenses/by/4.0/ conference report may 2016. christian journal for global health, 3(1):99-102. karawaci conference on christian response to global heath issues rev morris sing key a a representing the conference steering and organising committees conference the international conference on christian response to global heath issues co-hosted by biola university (usa) and the universitas pelita harapan (uph, indonesia) was held in the uph campus, karawaci, from december 2-4, 2015 in jakarta, indonesia. this conference was designed to bring together healthcare workers from a variety of backgrounds, ranging from chaplaincy, bioethics, academics, as well as those working with economic disparity and emerging healthcare issues. thus, christians involved in theology, bioethics, cutting edge technology, and research in prevention, cure, and quality of life improvement came to share and present their experiences. there was significant representation from major christian healthcare missionary organizations, internationally renowned theologians, and academics in bioethics and clinical pastoral care. christian healthcare workers from 13 different countries participated. around 300 fulltime and part-time delegates attended the conference over two days. the conference opened on the afternoon of dec 2nd, with the leaders prayerfully setting the tone for the conference with opening addresses that challenged the participants to think together on the importance of christ-centered healthcare in response to needs across the world today. this was followed by indonesian cultural entertainment by uph students and an opportunity for all delegates to meet one another informally over dinner. themes for key note addresses, oral presentations, breakout sessions, and panel discussions 1. christian response to emerging global health issues • emerging infections-ebola/resistant malaria/dengue • epidemics in resource-poor countries • response to natural and man-made disasters 2. christian response to medical care in resource constrained and economically-challenged environments • quality vs quantity • low cost effective care • appropriate innovations and technologies • compassion fatigue serving and working in remote and isolated areas 3. christian response to emerging technologies and treatment • stem cell research • human cloning • genetic engineering • artificial reproduction/surrogacy 100 sing key may 2016. christian journal for global health, 3(1):99-102. 4. christian response to incurable disease, pain and dying • cure vs healing • meaning of suffering • palliative care • care of the dying christian response to emerging global health issues dr ravi zacharias, followed by dr tim teusink, spoke on the importance of being human from a biblical perspective, i.e., man made in the image of god. dr ravi challenged our world view, through the eyes of god, where suffering and pain can be understood, and forgiveness and hope are possible. dr tim reminded us that our faith must transcend popular “individualism,” both secular or religious, to value people because of their intrinsic worth in god. that way, men, women, and children can all be honored: the sick are cared for and the elderly enabled to live and die with dignity; dissidents are heard; prisoners are rehabilitated; minorities are protected; and the oppressed set free; where workers are given fair wages and decent working conditions; and the gospel is taken to the ends of the earth. talks were followed by breakout sessions where speakers from 4 different countries covered the following:  emerging health issues: mental health, obesity, human trafficking  challenges and responses by christian healthcare professionals in:  natural and man-made disasters  compassion fatigue  christian education to prepare future workers the session concluded with a stimulating panel discussion on questions from attendees. christian response to medical care in resource-constrained and economicallychallenged environments how should christian healthcare organisations respond to these limitations? dr mike soldering and dr daniel o'neill laid out theological foundations for the church’s compassionate and effective response to an increasing burden of global disease in resourceconstrained regions. dr. soldering challenged us to abandon traditional professionally-guided territories and status and instead to fully harness the skills and strength of every member of the healthcare system to meet the needs of patients. this may mean that doctors may have to surrender some traditional roles to nurses or community healthcare workers. talks were followed by breakout sessions on diverse topics given by speakers from six different countries covering:  insights on how innovation and strategic thinking to involve students and non-healthcare professionals could address economicallychallenged and resource-constrained environments,  theological and ethnical frameworks in spite of constrained resources, learning from historic missionary examples and insights for the future. the session concluded with a stimulating panel discussion on questions raised by attendees. 101 sing key may 2016. christian journal for global health, 3(1):99-102. christian response to emerging technologies and treatment dr. john lennox spoke on god being the basis of our entire universe. all human discoveries must be governed by god’s divine perspective. dr. peter saunders laid out the theological foundations for how christians must assess all new technologies and treatment in light of the bible. both talks challenged us to defend our faith and to seek all available avenues via the legal system and the media to debate ethical issues related to research and new technology in human genetic engineering and manipulation. we were also encouraged to ponder the social and legal impacts of artificial reproduction, surrogacy, and other new biotechnologies and weigh them against biblical teaching. breakout sessions on diverse topics followed with speakers from five different countries covering:  emerging technologies discussed in the light of bio-ethnics: the hiv/aids pandemic, stem-cell research and therapy, and ‘child of choice’ technology,  the importance of collaboration among christians workers to voice our concerns on these ethnical issues, and  hallmarks of a christian healthcare professional and the importance of global coalitions in christian healthcare education. the session concluded with a stimulating panel discussion on questions raised by attendees. christian response to incurable disease, pain, and dying elizabeth styffe challenged all of us to go and be mobilised, to partner with poorer countries and communities, and to train and empower local christians to reach out to their communities via healthcare. dr reena george shared her personal journey in palliative care and offered important practical tips on managing pain in terminal patients. talks were followed by breakout sessions on diverse topics given by speakers from five different countries covering  a historic account of christian contributions in palliative care,  practical examples of palliative care models from indonesia and malaysia,  pastoral care of the dying, and  partnering with local churches to train lay volunteers to provide basic community healthcare services the rwanda model. the session concluded with a stimulating panel discussion on questions raised by attendees. closing ceremony and networking dinner the conference concluded on the evening of december 4th with a networking dinner, where fellow attendees enjoyed warm fellowship and a cultural performance by uph students. everyone expressed the great need for christians to meet to encourage one another in our vision and mission, possibly yearly. 102 sing key may 2016. christian journal for global health, 3(1):99-102. competing interests: none declared. correspondence: rev. morris sing key, msingkey@gmail.com acknowledgments: conference steering committee: chair: prof dr george mathew, co-chair: dr doug pennoyer, members: prof dr eka wahjoeprammo, rev morris sing key organising committee: chair: connie rasilim, members: anita prasetyo, indah kurniawati, christine l sommers, dr stevent sumantri, dr yusak, novel priyatna, dr diena lemy, esterina jonathan, esther i pubra, florianna sing key, marta oktaviani souhuwat, rosse mince hutapea, nursari lugito, titis pinasti cite this article as: key ms. karawaci conference on christian response to global heath issues. christian journal for global health (may 2016), 3(1): 99-102. © key ms. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:msingkey@gmail.com http://creativecommons.org/licenses/by/3.0/ the attitudes and activities of pastors and faith leaders in zimbabwe on the use of family planning methods among their members 66 | christian journal for global health 4(2) www.cjgh.org the attitudes and activities of pastors and faith leaders in zimbabwe on the use of family planning methods among their members moses alikalia a monitoring and evaluation officer, umc-health, zimbabwe abstract background: faith leaders are important gatekeepers in disseminating reproductive health messages and influencing positive behaviour change within communities. faith leaders are seen as the most powerful, visible, and reachable form of authority, even trusted more than governments or non-profit organizations. in addition to providing counsel and advice aimed at enhancing health and wellbeing of the worshippers, faith leaders also play an important role in advocating and influencing what is taught in schools and what services are provided in healthcare facilities. because of this influence, faith leaders often have an unparalleled opportunity—indeed, a moral obligation—to prioritize conversations about family planning, advocating, and closing the contraception gap. the overall objective of this study was to ascertain the attitude and activities of pastors and faith leaders in zimbabwe on the use of family planning methods among their members. the result revealed that some faith leaders believed that spreading information about family planning education was the responsibility of the government and tended to avoid such responsibility. however, through training on family planning advocacy, much can be achieved. methods: qualitative study methods were used to better understand the attitude and activities of pastors and faith leaders in zimbabwe on the use of family planning methods among their members. the participants of this survey were drawn from 8 of 10 provinces in zimbabwe, which include: bulawayo, harare, manicaland, mashonaland central, mashonaland east, mashonaland west, masvingo, and matabeleland north. paper-based questionnaires were answered by 24 pastors and 26 faith leaders in zimbabwe (table 1) through personal face-to-face meetings, while interviews were conducted with a select few pastors and faith leaders. the samples were drawn from randomly selected churches in zimbabwe. data was analysed using epi info 7 and microsoft excel. results: generally, the pastors and faith leaders understood the benefits of longer birth intervals for the health of their members and their children, and the need for them to be involved in family planning awareness. however, both seemed slow to incorporate family planning into their programs. the faith leaders indicated an interest in being a part of various forms of campaigns to promote family planning if they could be equipped with correct information on family planning. many strongly believed family planning to be of great importance to them and their families in situations where their financial incomes were low, and that family planning could reduce the rate of abortion. a majority agreed family planning was in agreement with their religious beliefs. some felt their members had basic information on family planning methods, but only 44 percent of the faith leaders actually counselled their members on family planning methods from time to time. although many would like to be part of those who create awareness in their various places of original article christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 67 worship, only 28 percent of them had the right information on family planning through training. conclusion: one major factor for the limited involvement of faith leaders in family planning awareness is their lack of correct information on family planning. the gap can be narrowed by organizing family planning advocacy training workshops. networks such as africa christian health association platform (achap), the islamic medical association of zimbabwe (imaz), zimbabwe association of church-related hospitals (zach), and zimbabwe council of churches (zcc) can also be leveraged to disseminate and accelerate the spread of family planning information. introduction zimbabwe was making progress in addressing the family planning needs of the people but progress has stagnated in recent years. according to the 2010–2011 demographic health survey, 59 percent of currently married women use a contraceptive method, virtually unchanged from 60 percent in 2005–2006. also since 2005–2006, the contraceptive prevalence rate (cpr) in urban areas has dropped from 70 percent to 62 percent.1 according to the united nations population fund (unfpa), contraceptives prevent unintended pregnancies, reduce the number of abortions, and lower the incidence of death and disability related to complications of pregnancy and childbirth. if all women with an unmet need for contraceptives were able to use modern methods, an additional 24 million abortions (14 million of which would be unsafe), 6 million miscarriages, 70,000 maternal deaths, and 500,000 infant deaths would be prevented.2 birth spacing is a key health intervention for reducing both maternal and infant mortality. when a woman spaces her pregnancies at least three years apart, she is more likely to have a healthy delivery, and her children are more likely to survive infancy. if a woman becomes pregnant too soon after giving birth, her body does not have time to recover and her risk for complications increases. to be able to space her pregnancies in the healthiest possible manner, a woman must have information on family planning methods. inadequate services, lack of knowledge of family planning, cultural barriers, religious barriers, and negative provider attitudes all prevent people from obtaining family planning services. zimbabwe’s cpr is one of the highest in sub-saharan africa. however, economic challenges in the last decade have led to a downward trend in some health indicators, including family planning use. following the decline of both the economy and the health system in 2008, the government of zimbabwe has relied on donor assistance to provide financial and human resources, including substantial support for commodities and service delivery. donor funds for population assistance, which includes funding for family planning, maternal health programmes, system-related costs, hiv-aids, and basic research/ data/policy analysis, have more than quintupled from us$50.8 million in 2008 to us$275.7 million in 2012 (unfpa 2014b).3 however, the level of knowledge, availability, and access to family planning services in reality is yet to justify the resources pushed into family planning projects. in addition to benefitting the health and well-being of people, increased investment in family planning contributes to broader development goals such as improvements in the overall status of women and reductions in poverty among families. quality family planning services provide enormous health and economic benefits to families, communities, and countries. according to the un development programme, for every $1 spent on family planning, governments can save up to $6 for other development priorities. alikali christian journal for global health | http://www.cjgh.org http://www.unfpa.org/publications/adding-it-2014 http://www.undp.org/ http://www.undp.org/ http://www.gatesfoundation.org/what-we-do/global-development/family-planning http://www.gatesfoundation.org/what-we-do/global-development/family-planning http://www.gatesfoundation.org/what-we-do/global-development/family-planning 68 | christian journal for global health 4(2) www.cjgh.org according to the latest zimbabwe national survey, 16 percent of young married women in that country reported having an unmet need for family planning, and 32 percent of sexually active unmarried women reported having an unmet need. • the proportion of women with unmet need translates into more than 103,000 women—an estimated 93,000 married and 10,400 unmarried women. • one outcome of high unmet need is unplanned pregnancies. in zimbabwe, 31 percent of pregnancies among married women between the ages of 15 and 24 are unplanned.4 recognizing the right to high-quality reproductive healthcare, and the link between population growths, gaps in family planning, and health and economic development, the government of zimbabwe made the following commitments (known as the fp2020 goals) at the 2012 london summit on family planning. • increase the cpr to 68 percent by 2020; • reduce unmet need for family planning from 13 percent to 6.5 percent by 2020; and • increase access to a comprehensive range of family planning methods, including long-acting and permanent methods (lapms).1 however, in most of these plans, the role of faith leaders is mostly ignored. the government, civil society organizations, and other policymakers must recognise that faith leaders and individual congregations are important gatekeepers in disseminating reproductive health messages and influencing positive behavioural change within communities. there has been a lot of improvement in the efforts of faith-based organizations (fbos) in creating awareness and educating women and men on family planning methods, particularly in zimbabwe. fbos are also one of the key messengers in reaching out to conservative religious and cultural communities. some fbos consider family planning to be central to their mission in supporting women, children, and families, and integral to their efforts in promoting global health based on evidence that birth spacing is critical to lowering the number of deaths and disabilities. as trusted messengers with deep roots in communities, fbos can and do play important— sometimes essential—roles in providing contraceptive services, raising awareness, and advocating for family planning. the united methodist church has been one of the strongest fbos supporting family planning globally, both theologically and in practice.5 fbos are one of the key healthcare providers in zimbabwe. for instance, the zimbabwe association of church-related hospitals (zachs), which has more than 60 member hospitals and 66 smaller healthcare institutions, has been providing family planning services in zimbabwe since 1982, including a range of contraceptive methods (such as injection, pill, implant and barrier methods). in 2009 alone, zachs had more than 40,000 first visits for family planning, more than 100,000 repeat visits, and more than 4,000 referrals.6 some of the factors possibly slowing down the efforts to expand knowledge and access to family planning in zimbabwe are the prevailing social/cultural attitudes and religious beliefs of community members. contraception is against the teachings of 28 percent of faith leaders in our study, and this prevents them from supporting positive actions around family planning. this makes it critical to win the support of faith leaders as they are likely to influence the perception of their followers. the direct and indirect benefits, however, of women planning their families are priceless and countless: smaller family sizes, better health for both children and mothers, less economic burden on the families, and women’s continued economic contribution to the greater community. by meeting all the unmet need for family planning, maternal mortality rates would drop by a third, and the need for abortion would be reduced significantly.7 faith leaders need to be sensitized on family planning to be able to embrace these community responsibilities, educate themselves about the various contraceptive options for couples, and engage their local alikali christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 69 governments and healthcare providers on the topic. local action is one of the major tools that can allow us to meet the family planning needs of millions and build a better world for future generations. the following organizations were engaged in planning and executing this study: the united methodist church episcopal areas zimbabwe health board, the united methodist church zimbabwe episcopal areas, and zimbabwe council of churches. methods the study employed a qualitative study method to better understand the attitudes and activities of pastors and faith leaders in zimbabwe on the use of family planning methods among their members. the participants of this survey were drawn from 8 provinces of 10 in zimbabwe, which include bulawayo, harare, manicaland, mashonaland central, mashonaland east, mashonaland west, masvingo, and matabeleland north. paper-based questionnaires were answered by 24 pastors and 26 faith leaders in zimbabwe through personal face-to-face meetings while interviews were conducted with a select few pastors and faith leaders (table 1). some of these faith leaders established mission hospitals and clinics. the samples were drawn from randomly selected churches in zimbabwe. the questionnaire was designed with support from the umc health board coordinator (mrs. hannah mafunda) and prof. ezra chitando. the data collection process took place smoothly with the support of the zimbabwe council of churches and other volunteers. to be eligible to participate in the study, the participant had to be a pastor or faith leader and agree to participate. data was analysed using epi info 7 and microsoft excel. table 1: respondents’ information number sex position age number sex position age 1 male pastor 40 26 female leader 23 2 male pastor 30 27 male pastor 22 3 male leader 42 28 female leader 24 4 female leader 25 29 male leader 40 5 male pastor 34 30 female pastor 24 6 male pastor 36 31 male pastor 24 7 male leader 40 32 female leader 22 8 male pastor 43 33 male leader 24 9 female leader 38 34 male pastor 35 10 female leader 38 35 female leader 60 11 female pastor 30 36 male leader 47 12 male pastor 41 37 male leader 45 13 male pastor 50 38 male pastor 47 14 male leader 44 39 male pastor 44 15 male pastor 50 40 female leader 41 16 male leader 24 41 female leader 49 17 female leader 48 42 male pastor 37 18 male leader 28 43 female leader 36 19 male pastor 52 44 male pastor 33 20 female leader 33 45 male pastor 40 21 male pastor 44 46 male pastor 27 22 female leader 31 47 male pastor 41 23 male leader 50 48 female pastor 30 24 male leader 41 49 male pastor 35 25 female leader 37 50 male pastor 33 alikali christian journal for global health | http://www.cjgh.org 70 | christian journal for global health 4(2) www.cjgh.org results generally, the pastors and faith leaders understood the advantages of longer birth intervals, the health benefits for their members and their children, and the need for them to be involved in family planning awareness. however, both groups seemed slow to incorporate family planning into their programs. the results of this study revealed that some faith leaders believed that spreading information about family planning education was the responsibility of the government, and they tended to avoid such responsibilities. however, they indicated an interest in being a part of various forms of campaigns to promote family planning if they could be well equipped with correct information on family planning. the gap between family planning knowledge and faith leaders could be narrowed by organizing family planning advocacy training for religious leaders in zimbabwe on how to effectively construct and deliver family planning messages. networks such as africa christian health associations platform (achap), zach, and zimbabwe council of churches (zcc) can also be leveraged to disseminate and accelerate the spread of family planning messages. family planning and its benefits ninety-six percent of the respondents strongly believe family planning is of great importance to them and their families, and 92 percent agree that the number of children one has should correlate with their financial income. (figure 1). they understand the benefits of longer birth intervals for the health benefits of their members and their children. when women and couples are empowered to plan whether and when to have children, women are better enabled to complete their education and their earning power is improved. this strengthens their economic security, their well-being and that of their families. it was observed that women that are on family planning have a better nutritional status with a higher average weight and body mass index. their children weigh more and were more likely to be immunized for diphtheria, pertussis, and tetanus (dpt); polio; and measles. families using family planning methods are more likely to have higher incomes, greater savings and assets, higher educational achievements, and improved access to water. family planning and abortion/religious beliefs eighty-two percent of the respondents agree that family planning can reduce the rate of abortion, while some think family planning encourages abortion. seventy-two percent agree family planning is in agreement with their religious beliefs, while 28 percent say family planning is not in agreement with their religious beliefs. this explains the role of others influencing their views on family planning (figure 2). figure 1 alikali christian journal for global health | do you think family planning is good? the number of children one has should correlate with financial income. http://www.cjgh.org www.cjgh.org july 2017 | 71 people tend to learn the myths of family planning from others in their communities. these people often get inaccurate information or are directly counselled by others not to engage or use family planning. as mentioned earlier, some of the factors possibly slowing down the efforts to expand knowledge and access to family planning in zimbabwe are the prevailing socio-cultural attitudes and religious beliefs of community members. contraception is against the teachings of 28 percent of religious leaders in this study, and this prevents them from supporting artificial methods. however, some of them support natural methods and would encourage those who want to practice them. this makes it critical to win the support of religious leaders as they are likely to influence the perception of their followers. in addition to the myths described above, many also mention real side effects as a barrier to use. the most common side effects expressed by the respondents are weight changes, bleeding, lack of sexual desire, headaches, and high blood pressure. family planning counselling and people’s knowledge of family planning it was discovered from the study that only 62 percent of the faith leaders felt their members have basic information on family planning methods and only 44 percent of the faith leaders actually counsel their members on family planning methods from time to time (figure 3). religious leaders need to be sensitized on family planning in order to embrace these community responsibilities, educate themselves about the various contraceptive options for couples, and engage their local governments and healthcare providers on the topic. local action is one of the major tools required to meet the family planning needs of millions and build a better world for future generations. figure 2 figure 3 alikali christian journal for global health | is fp in agreement with your religious beliefs?does fp reduce the rate of abortion? do your members have info on fp? do you counsel your members on fp? http://www.cjgh.org 72 | christian journal for global health 4(2) www.cjgh.org willingness to create awareness on family planning seventy-six percent of the faith leaders understand the importance of family planning and would like to be part of those who create awareness in their places of worship, but are handicapped as only 28 percent of them have the right information on family planning through training (figure 4). lack of knowledge is one of the major barriers to the use of family planning, with many women not understanding when they are able to fall pregnant, not knowing what family planning methods are available, or having incorrect perceptions about the health risks of modern methods. religious leaders are important gatekeepers in disseminating family planning messages and influencing positive behavioural change within communities, and need to be well equipped with correct information on family planning to be able to deliver the message effectively to the people. discussion these findings demonstrate that people’s perceptions and knowledge of family planning determines whether or not they will use it. those that have information on the benefits of family planning are likely to use contraceptive methods, as will those who perceive that family planning will help them to improve their standard of living. furthermore, this analysis suggests that there is a strong relationship between attitudes toward family planning and contraceptive use, faith leaders’ knowledge of family planning methods, and counselling of their members. the study also shows the impact social support can have on contraceptive use. faith leaders who are important gatekeepers in disseminating family planning messages have influence and positive effects on their members’ contraceptive behaviour. therefore, it is important to identify those influential faith leaders who can act as social change agents and to increase their support for contraception. their endorsement of family planning may thereby increase contraceptive use among their members and other community members. finally, it is also very important to leverage the support of religious networks such as achap, zach, imaz, and zcc to disseminate and accelerate the spread of family planning messages. recommendations in order to gain the full benefit from the engagement of pastors and faith leaders in the efforts to promote family planning in zimbabwe, government, civil society organizations, and other policymakers will need to consider equipping and engaging faith leaders in their efforts. below are some of the practical interventions to engaging faith leaders on the issues of family planning: organize family planning advocacy training for selected influential faith leaders in zimbabwe to equip them with correct information, communicaalikali christian journal for global health | figure 4 have you attended any training on fp? do you like to be part of faith leaders who talk about fp in their place of worship? http://www.cjgh.org www.cjgh.org july 2017 | 73 tion skills, appropriate language for family planning awareness, and training to overcome barriers to the use of family planning. develop family planning manuals for faith leaders to guide them on the appropriate language to use when communicating with their members. there are a number of challenges to improving access to family planning information and services. efforts to increase access must be sensitive to cultural and national contexts, and must consider economic, language, geographic, and age disparities within countries. organize communication programs for various media outlets to involve trained faith leaders in optimizing their voices beyond the pulpit. the media communication program could be on radio, television, social media, and other forms of communication, including those in local languages, particularly to reach out to those in rural areas. various myths and barriers will be addressed on these platforms. hopefully, these positive messages will lead to a change of attitude toward family planning and even compel policymakers to act positively. networks such as achap, zach, imaz, and zcc can be leveraged to disseminate and accelerate the spread of family planning messages. fbos are one of the key healthcare providers in zimbabwe. for instance, zach has more than 60 member hospitals and 66 smaller healthcare institutions that have been providing family planning services in zimbabwe since 1982, including a range of contraceptive methods (such as injection, pill, implant, and barrier methods).8 conclusion faith leaders are trusted and respected in zimbabwe. women, men, and youths rely on them for guidance on many personal and family matters, including life-cycle, reproductive health, and family planning decision-making. they share opinions about the acceptability and advisability of family planning, birth spacing, and other reproductive health topics, and help their followers make important life decisions through individual and premarital counselling, and through weekly sermons. essentially, religious leaders play an active role in the dissemination of accurate information about family planning. access to family planning information is also central to achieving gender equality. when women and couples are empowered to plan whether and when to have children, women are better enabled to complete their education, women’s autonomy within their households is increased, and their earning power is improved. this strengthens their own and their family’s economic security and well-being. cumulatively, these benefits contribute to poverty reduction and development. lack of knowledge is one of the major barriers to the use of family planning methods, with many people not understanding the importance of family planning, not knowing what family planning methods are available, or having incorrect perceptions about the health risks of modern methods. faith leaders are important gatekeepers in disseminating family planning messages and influencing positive behavioural change within communities. this makes it critical to win the support of faith leaders as they are likely to influence the perception of their followers, empowering and equipping them with relevant skills to effectively disseminate family planning messages. alikali christian journal for global health | http://www.cjgh.org 74 | christian journal for global health 4(2) www.cjgh.org references 1 resource requirements for family planning in zimbabwe. health policy project, usaid. june 2014. available from: https://www.healthpolicyproject.com/pubs/332_ resourcerequirmentsforfpinzimbabwefinal.pdf 2 adding it up: the costs and benefits of investing in sexual and reproductive health. united nation population fund. 2014. available from: http://www.unfpa.org/adding-it-up 3 evaluation of the unfpa support to family planning services. unfpa. 2008-2013. available from: http://www. unfpa.org/sites/default/files/admin-resource/final_family_ planning_country_note_zimbabwe_0.pdf 4 youth reproductive health: satisfying unmet need for family planning. population reference bureau. september 2015. available from: http://www.prb.org/pdf15/unmetneed-factsheet-zimbabwe.pdf 5 barot s. a common cause: faith-based organizations and promoting access to family planning in the developing world. guttmacher policy review. december 10, 2014. available from: https://www.guttmacher.org/gpr/2013/12/ common-cause-faith-based-organizations-and-promoting-access-family-planning-developing 6 kaiso rev canon g, ragab a r. leap of faith: why religious leaders have a moral duty to promote family planning. the citizen. january 17, 2016. available from: http:// allafrica.com/stories/201601181555.html 7 maternal health: the church’s role. the book of resolutions of the united methodist church. the united methodist publishing house. 2012. available from: http://www. umc.org/what-we-believe/maternal-health-the-churchs-role 8 faith-based organizations as partners in family planning: working together to improve family well-being. institute for reproductive health. georgetown university. august 2011. available from: http://irh.org/wp-content/ uploads/2013/04/irh_faith_report.oct_.5.reduced.pdf peer reviewed competing interests: none declared. acknowledgements: the author gratefully acknowledges the efforts of zimbabwe council of churches and the following people: prof. ezra chitando, theology consultant for the ecumenical hiv and aids initiatives and advocacy (world council of churches)/ department of religious studies, university of zimbabwe; mrs. hannah mafunda, zimbabwe united methodist church episcopal area health board coordinator; rev. dr. kenneth mtata, general secretary zimbabwe council of churches; mr. simon mafunda, zimbabwe east annul conference lay leader; miss rutendo m. chapwanya, medical laboratory sciences student at university of zimbabwe; mr. tapiwa blessing kanengoni, global mission fellow (2016-2018) serving in brazil. correspondence: moses alikali, mosesalikali@gmail.com cite this article as: alikali m. the attitude and activities of pastors and faith leaders in zimbabwe on the use of family planning method among their members. christian journal for global health. july 2017; 4(2):66-74; https://doi.org/10.15566/cjgh.v4i2.188. © alikali m. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ alikali christian journal for global health | http://www.cjgh.org https://www.healthpolicyproject.com/pubs/332_resourcerequirmentsforfpinzimbabwefinal.pdf https://www.healthpolicyproject.com/pubs/332_resourcerequirmentsforfpinzimbabwefinal.pdf http://www.unfpa.org/adding-it-up http://www.unfpa.org/sites/default/files/admin-resource/final_family_planning_country_note_zimbabwe_0.pdf http://www.unfpa.org/sites/default/files/admin-resource/final_family_planning_country_note_zimbabwe_0.pdf http://www.unfpa.org/sites/default/files/admin-resource/final_family_planning_country_note_zimbabwe_0.pdf http://www.prb.org/pdf15/unmetneed-factsheet-zimbabwe.pdf http://www.prb.org/pdf15/unmetneed-factsheet-zimbabwe.pdf https://www.guttmacher.org/gpr/2013/12/common-cause-faith-based-organizations-and-promoting-access-family-planning-developing https://www.guttmacher.org/gpr/2013/12/common-cause-faith-based-organizations-and-promoting-access-family-planning-developing https://www.guttmacher.org/gpr/2013/12/common-cause-faith-based-organizations-and-promoting-access-family-planning-developing http://allafrica.com/stories/201601181555.html http://allafrica.com/stories/201601181555.html http://www.umc.org/what-we-believe/maternal-health-the-churchs-role http://www.umc.org/what-we-believe/maternal-health-the-churchs-role http://irh.org/wp-content/uploads/2013/04/irh_faith_report.oct_.5.reduced.pdf http://irh.org/wp-content/uploads/2013/04/irh_faith_report.oct_.5.reduced.pdf mailto:mosesalikali@gmail.com https://doi.org/10.15566/cjgh.v4i2.188 editorial mar 2017. christian journal for global health, 4(1):1-2. supplement on health-related education, healing and sustainable development we continued to receive submissions related to health-related education that could not all be accommodated in our november 2016 issue. to afford their timely publication, we present a supplementary issue enhanced by two conference reports and a book review. two original articles grace this issue. training in clinical skills for medical students can be demanding of staff and teaching time, especially in settings where senior clinicians face competition for their time from their own practice and administrative duties. dr. cheryl snyder and rose chisenga developed a training program for senior medical students who then taught clinical skills to fourth year students. this was followed up with an assessment that compared perceived preparedness and confidence levels with historical controls. the use of the senior students in peer-assisted learning significantly boosted the students’ sense of preparedness and confidence as they began their fifth year clinical rotations. the second original article is by dr. jeany kim jun and colleagues. during three yearly short term mission trips to cambodia they collected data on the types of diseases seen and medications and diagnostic tests needed. this enabled them to prepare formularies and tests to more efficiently prepare for future trips with possible extension to other similar efforts. the journal aspires to be a venue for open discussion of areas where global health practitioners might disagree. consequently, we have published a submission from dr. mark crouch who offered pushback on one of the november conference proceedings. dr. crouch argues for clinical practice having a continuing role in global health despite doubts regarding its sustainability. he notes that clinical experience is foundational for effective teaching in medically indigent areas because nothing in a western medical education can prepare one for these types of challenges. his article is a vigorous riposte to the teaching-only cadre. two other articles round out the healthrelated education supplement. one documents a multi-disciplinary continuing education effort in tanzania that provides a yearly conference focused on quality improvement. dr. john kvasnicka and colleagues explain how the conference is set up, run, and paid for and offer an evaluation of the most recent one in 2016, suggesting this may be a model that could be used in other contexts. short term servicelearning continues to be popular for medical students, but there are pitfalls to be avoided. kristen sessions, supported by two of her mentors, describes her experience in uganda tested against the existing literature and offers some very practical advice. global health is an immense field of endeavor, and one way for the editors to stay abreast is to attend as many of the relevant conferences as possible. dr. daniel o’neill attended a conference examining evidence for the role of faith in poverty reduction at yale university last september, and reviews the interchanges between faith-based organizations and secular and government organizations. there appears to be movement towards greater recognition of the role of faith in development on the one hand, and recognition of a need for measurement and documentation on the part of faith-based organizations. the second conference report is from the christian connections for international health (ccih) annual conference and is reported on by kathy erb in the current issue. ccih is an http://journal.cjgh.org/index.php/cjgh/article/view/152 http://journal.cjgh.org/index.php/cjgh/article/view/152 http://journal.cjgh.org/index.php/cjgh/article/view/156 http://journal.cjgh.org/index.php/cjgh/article/view/156 http://journal.cjgh.org/index.php/cjgh/article/view/157 http://journal.cjgh.org/index.php/cjgh/article/view/157 http://journal.cjgh.org/index.php/cjgh/article/view/129 http://journal.cjgh.org/index.php/cjgh/article/view/129 http://journal.cjgh.org/index.php/cjgh/article/view/147 http://journal.cjgh.org/index.php/cjgh/article/view/158 http://journal.cjgh.org/index.php/cjgh/article/view/159 2 editors mar 2017. christian journal for global health, 4(1):1-2. organization that seeks to bring together christians working across the public-private landscape. the 2016 theme was the relationship between christian faith and sustainable development. last, but by no means least, is a review of healing in the gospel of matthew: reflections on method and ministry by walter t. wilson, submitted by professor brian labosier. theological perspectives on health, healing, and wholeness are encouraged to frame global health approaches. the editors commission some reviews, but are often pleased to receive uncommissioned reviews relevant to our focus. though we send calls for papers, we continue to seek submissions of any content. as you read please keep us in mind and send links of relevant articles to interested colleagues. www.cjgh.org http://journal.cjgh.org/index.php/cjgh/article/view/161 case study jun 2017. christian journal for global health, 4(2):87-94. a historic humanitarian collaboration in the pacific context robert bradley mitchell a, nathan john grillsb a phd, ceo, anglican overseas aid, australia b mbbs, mph, dphil, nossal institute of global health, university of melbourne, australia the purpose of this article is to report on a historic collaboration between australian faithbased development agencies and their partners in the pacific. the collaboration is called the church agencies network disaster operations (can do), comprising a group of eight australian church-based development organisations, each comprising established relationships with counterpart churches in the pacific. the formal collaboration began in mid-2016, and program activity between members is in its infancy. the context for can do was the recognition that climate change was damaging health and wellbeing in pacific communities – especially in terms of climate-related disasters – and that churches had a unique role within the civil society in the region. specifically, can do participants had recognised that more could be achieved by acting together than alone and by moving beyond traditional “siloed” denominational relationships. this case study aims to describe this unique inter-denominational collaboration and to explore the factors that have led to its formation. vulnerability of pacific to climate change in its fourth assessment report, the intergovernmental panel on climate change (ipcc) identified the pacific region, especially small island states, as being one of the most exposed areas in the world to the adverse implications of climate change.1 for several low-lying coral island states, climate change represented an existential threat, and the prospect of climate-induced migration was in view.2 for other parts of the pacific, the impact was felt in lost revenue from agriculture, the strain on water resources, and degradation of infrastructure through disasters. evidence from the fifth ipcc assessment reports growing evidence of the link between global warming and the frequency, intensity, and spatial extent of extreme weather events.3 in the pacific, this is experienced not only as tropical cyclones and typhoons, but also as periods of prolonged drought due to changes in weather patterns. for example, cyclone pam, in vanuatu in 2015, was immediately followed by a period of drought, which defeated attempts to replant damaged crops and compounded risks to food security. in terms of health impacts, the who (world health organisation) has comprehensively assessed climate-sensitive health risks in the pacific. risks identified include trauma from extreme weather events, heat-related illnesses, compromised safety and security of water and food, and vector-borne diseases.4 comparatively, pacific island countries are among the most vulnerable societies in the world to the health impacts of a changing climate.5 the remote nature of pacific island communities and the limited resources available to their governments for adaptation and prevention are exacerbating the risks. against this background, civil society organisations have an added responsibility. the role of churches within pacific societies historical context to understand the dominant role of churches in pacific societies, it is necessary to reflect briefly on their colonial history. in most other colonial contexts, the interface with the rest of the world 88 mitchell & grills jun 2017. christian journal for global health, 4(2):87-94. came primarily as the result of securing economic or other national interests of the colonial power. the pacific, in general, presented fewer opportunities. it was seen as a high-cost and relatively inaccessible context with fewer natural resources suitable for exploitation. in addition, it was distant from the military or strategic concerns of many european powers. for this reason, the pacific was conceptualised by colonialists more as a mission field than as a place to secure other types of interests. the oxford handbook of global religions summarised, “when one considers processes of globalisation in the pacific islands, one is struck by the extent to which religion has been central to them. there are grounds to argue that religion, and christianity in particular, has been the single most powerful globalising force. . . ”6 churches were central to that engagement, pursuing their missionary and social goals by inculcating outposts of “civilisation” (as they saw it) right across the region. initiatives associated with missionary endeavour were also the precursors to many modern development programs, although recognition for this has been somewhat belated. clarke blames their invisibility on the development sector itself in failing to recognise the importance of religion within its largely secular worldview.7 even after independence, many educational, social, and welfare facilities have continued to be run by the churches.7 relevantly for can do, the international denominational linkages have endured through formal association with corresponding indigenous churches. present day christianity remains the dominant religion across the region and most people claim a specific christian faith.8 there are high levels of church attendance, and the place of religion is integrated into the functioning of many aspects of the society. religious belief is not held separately from other domains of life such as economics or politics.6 in many pacific countries, church-based institutions engender more trust and reliance for ordering interpersonal and societal relationships than does the state.8 the churches have high levels of legitimacy and public support, and claim a moral authority that has largely diminished in the west.9 in the pacific, christianity has been singled out as constituting “the one set of ideas that is both widely shared and highly valued by the majority of citizens of each state,” making it a natural focus for nation-building efforts.6 the statistics bear out the dominance of christianity in the region. the most populous part of the pacific is the subregion of melanesia (which includes the nations of papua new guinea, solomon islands, and vanuatu). melanesia identifies as 90% christian, with some areas as high as 95%.10 it has been reported that when the settler nations of hawaii and new zealand are excluded, the rest of the pacific islands are 99% christian.6 there are elements of nominalism and syncretism in many communities, but christianity and its institutions continue to have a profound social resonance. geography and government capacity while a significant role fell to the churches under colonial administrations, it is also important to understand the ongoing influence of the region’s geography. power structures tend to be more localised than centralised because of remoteness. nations like vanuatu, solomon islands, and tonga are spread across large island groups and archipelagos, many of which are uninhabited. some islands are hundreds of kilometres from the capital, and may only be accessed infrequently by boat. in places like papua new guinea (png), the mountainous and dense forest terrain creates remoteness of a different kind. the fact that there are over 800 indigenous languages in png indicates that many communities have developed in relative isolation from each other. against this background, the footprint of the central government has often been significantly reduced beyond the capital city. historically, churches have helped to bridge the gap, carrying out activities like health care and education, which in other settings are often the responsibility of government. for example, clarke notes, “there 89 mitchell & grills jun 2017. christian journal for global health, 4(2):87-94. was an almost entire dereliction of duty by the dual-ruling french and english colonial powers within vanuatu with direct involvement in the provision of health and education services not occurring until the mid-1960s.”10 (page 5) these activities were seen by the churches as consistent with their theological mandate for social care, and were usually a welcome adjunct to their physical presence. recognition of faith-based actors the australian government recognises that faith-based actors are well placed to contribute to development goals in the pacific context. the church partnership program (cpp), a part of its official aid program, commissioned a case study reviewing its progress. the report sets out succinctly some of the arguments supporting working through churches in png: working with the churches in png is highly relevant for the png context. with strong legitimacy among the population, which is more than 95% christian, churches can contribute to public policy in png, enhance government transparency and account-ability, support social justice and peace building, and develop social capital. in addition, the churches in png play a crucial role in service delivery—some 50% of health services and 40% of the schools in png are run by the churches. in the context of png, where the government is relatively fragile with very little capacity, the role of the churches is especially important. the churches them-selves have strengths in their legitimacy, widespread presence, and ability to shape social capital but can benefit from stronger structures, systems, and development practice. such capacity development is the highly relevant focus of the cpp.11 many of the same considerations apply in the humanitarian sector, especially in work that is focussed on building community resilience, disaster risk reduction, and emergency response planning. more broadly, there is a growing recognition of the particular value that faith-based organisations can bring to the humanitarian sector.12 multilateral agencies, including those attached to the un, have in recent years specifically affirmed the contribution of faithbased actors. in 2013, the united nations high commissioner for refugees (unhcr) published a document, welcoming the stranger, drawing on affirmations of various faith leaders and religions setting out important humanitarian principles.13 in 2014, the un development program published the formal guidelines for engaging with faith-based organisations and religious leaders.14 similarly, the unhcr has now published a practice note providing guidance on partnering with faith-based organisations in the humanitarian sector.15 this is highly relevant because there has been a historic reluctance for secular organisations and governments to engage with faith-based organisations.16 that position has changed and changed relatively quickly. the can do consortium is one of a number of consortia and other organisations seeking funding from the australian government under its humanitarian partnerships program. a related and equally important trend is the movement towards localisation in humanitarian practice. this refers to a greater commitment to local in-country organisations, especially grassroot organisations, being involved in the design and implementation of humanitarian programs. the trend towards localisation was championed at the 2016 world humanitarian summit.17 it acknowledged that local actors knew their context the best and had an essential role in designing and embedding initiatives affecting their own communities. global commitments were made to fund and capacitate this important devolution of power. establishing can do these brief reflections indicate that the time was right for a consortium like can do to take shape. with climate change posing as a major regional social challenge, there was an existing set of relationships that could be effectively leveraged, 90 mitchell & grills jun 2017. christian journal for global health, 4(2):87-94. notably in the context of a more enlightened approach to funding faith-based consortia by government. while the last point is a welcome development, it should be noted that the can do consortium was established with a commitment by members to use their own funds. that an additional source of funding is now in prospect is felicitous because it will allow added scale, but it was not a factor in establishing the consortium. that said, it is a significant achievement that can do has formed because there has never been a programmatic collaboration on this scale by australian church-based development agencies. presently there are eight participating organisations. they are act for peace, adventist development and relief agency, anglican board of mission, anglican overseas aid, australian lutheran world service, caritas australia, transform aid international (baptist world aid), and unitingworld (uniting church). it should be noted that not every church denomination in australia has its own aid and development organisation. some churches choose to support the work of can do member act for peace, which is the development arm of the national council of churches in australia. in this way they are represented through can do. reaching an agreement with these many actors, each of differing sizes and capacities, for an undertaking that is both complex and ambitious is of itself noteworthy, so is the breadth of theological traditions represented within the group. this raises some interesting questions about how consortia are formed at the level of organisational theory. one important factor in establishing can do was capitalising on the strong sense of collegiality that existed between the various participating agencies, all of which were members of the church agencies network in australia (a group of international development organisations affiliated with churches or church bodies). that sense of collegiality stemmed from a shared sense of identity as christian faith-based ngos and was made explicit in the can do memorandum of understanding that stated as its first guiding principle, “faith matters. can do and its partners are guided by christian values and identity.”18 shared christian identity appears to be the basis of trust between the can do members. several published case studies have indicated the importance of common identity or faith in network development.19,20 in uttarakhand, north india, one of the authors analysed the genesis of a network between faith-based health and develop-ment organisations.19 a “broadly similar faith understanding” was identified as being the most significant factor determining the “ties” that bound members in the network. such findings are consistent with social network theory that identifies homophily, or the tendency of individuals to associate and bond with similar “nodes”, as important in facilitating network development.21-24 homophily is often associated with strong interpersonal relationships and a strong sense of trust. on the basis of their common faith, the ceos of can do members have been meeting together regularly for over a decade. in more recent years, staff representatives from each agency have formed practice groups for the purpose of sharing knowledge in specialist areas, including programming and humanitarian response. these kinds of interactions have helped develop a shared history and mutual respect. the salient point is that collaborations, like can do, do not come out of a vacuum. a long-term structure has been in place to facilitate the cooperation that is now bearing fruit. in addition to the programmatic foundations for can do discussed above, the participants have realised that there is a range of other advantages from working in collaboration. these advantages are reflected in literature that describes how networks can increase effective-ness, capacity, and reach, and ultimately give rise to responses to wicked (complex and interdisciplinary) public health problems.19,21 for example, one factor in motivating the network formation was the desire to achieve programmatic coverage of as many pacific island communities as possible. the presence and spread of denominations across different parts of the pacific tend to reflect historic patterns of missionary activity. the breadth of the can do 91 mitchell & grills jun 2017. christian journal for global health, 4(2):87-94. consortium means that most areas of the pacific are touched by one church partner or another. it is also important in disaster preparedness that key messages are reiterated and understood as broadly as possible. this is especially the case in disseminating information about disaster risk reduction and in planning for emergencies. when key messages are socialised beyond one’s coreligionists, this provides a helpful consistency and a useful reinforcement. this is a good example of how a network approach can be used to tackle an important social challenge. collaboration creates the capacity to produce resources suitable for use across all churches. can do partners will have a central role in developing these resources, with the goal of building a sense of ownership and enhancing their ultimate utilisation. it has been observed that . . . the language of faith, the religious idiom, frequently better reflects the cultural norms in which the poor and marginalised operate. they are better able to draw such individuals and communities into global discourse of social justice, rights and development, without recourse to the often distancing language of secular development discourse.25 given the faith-infused nature of the pacific society, this observation is especially apt. also, given the similarities between the faith-based providers, this consortium is in a good position to facilitate the development and communication of appropriate messaging. a final point is that, in theory, the network approach can keep costs for each participant to a minimum because each agency has committed to make its affiliated partner network available to the group. thus, time and money are not wasted in replicating communication channels in-country (if that were in fact possible). the participants also have an appreciation of the possibilities made available to them by partnering together, including being able to engage multilateral agencies, national governments, and public and private funds. various studies have highlighted such a benefit from networking.20,26 subtler advantages in their discussions, can do members have anticipated some advantages of a less tangible nature. one is the symbolic message about christian unity projected by can do to a range of stakeholders. can do sees the group of agencies as proudly celebrating their overarching unity as christian faith-based agencies by way of practical action while at the same time respecting their diverse traditions. this is a counterpoint to the sectarian tensions and suspicion that have sometimes existed between denominations at different points in australia’s church history. they also note the possibility of building and strengthening forums for ecumenical co-operation among in-country church partners. historically, there are some clear examples of ecumenical cooperation for the sake of the public good between pacific churches. one is the role of churches in response to the civil conflict in the solomon islands from 1999 to 2003. during and after this period, “it was the churches [that] provided space for brokering peace and facilitating ongoing dialogue between different ethnic groups.”27 it has been reported that undoubtedly, “had the churches split along denominational lines, the conflict would have been far worse.”27 more recently, the solomon islands christian association has committed to developing a theology of gender to help combat high levels of domestic violence. these types of examples provide a high level of confidence about church cooperation to combat climate change and prepare for disasters. risks and concerns can do is in its infancy, and it is acknowledged that much could go wrong. the picture painted is sanguine, reflecting initial enthusiasm for the task ahead. careful management of several issues will be necessary to ensure that the program of work, and organisational relationships, stay on track. one issue is the complexity of the consortium structure, with a relatively large number of direct participants and a layer of in-country partners also engaged in program development and delivery. 92 mitchell & grills jun 2017. christian journal for global health, 4(2):87-94. larger consortia are notoriously fragile, often because a sustainable balance cannot be achieved between the objectives of the consortium as a whole and the member’s or partner’s own interests.28 a transparent and objective decisionmaking process is essential along with an efficient conflict-resolution process. another complicating feature of can do is the different capacities that exist within its membership. some organisations are much larger and better resourced with a depth of specialist experience. others are smaller but are anxious to learn through the process of collaboration itself. whilst this has significant potential to build the capacity of smaller players, it raises the issue of how respective contributions of participants will be valued whilst maintaining program quality throughout. at the outset, there is a clear and shared understanding that the work being undertaken is part of god’s mission. it is hoped that the spirit of goodwill this imbues will enable the consortium to succeed in the longer term. it is important that the actual results of the consortium are monitored over the coming years, so that the lessons learned can be shared. it is proposed to provide a report back when there is a sufficient body of field work and experience that can be meaningfully analysed. concluding reflections it is a significant achievement to get eight church-based development organisations, representing a diverse range of denominations, together for a programmatic collaboration of this kind. while caution is required, there is real cause for optimism. at one level, can do was negotiated relatively quickly, over a few short months beginning late in 2015. viewed in another light, however, can do has had a gestation lasting over ten years. as it begins its life, the potential benefits from this collaboration are significant. the consequence of climate change is a pressing concern throughout the pacific, and a compelling case exists for responding through the churches. however, as this consortium unfolds, it is hoped that can do will provide an inspiration and direction in other contexts. a final thought is that can do reminds church agencies of their tendency to sometimes pay too much attention to orthodoxy rather than orthopraxy in its broader sense. while by no means wanting to discount the importance of orthodoxy, when attention falls exclusively on questions of correct doctrine this can lead to unhelpful divisions, defensiveness and disunity. this makes collaborative actions much harder. orthopraxy, on the other hand, refers to christian practice, including how christian faith should be expressed in practice and action. a unity based on orthopraxy is easier to achieve. there is little disagreement about god’s call to reach out and serve the world as a vital expression of christian faith. opportunities to collaborate in the exercise of justice, compassion, and solidarity abound, and debates about doctrine need not stifle the common commitment to god’s mission in the world.29 references 1. the international fund for agriculture development. climate change impacts pacfic islands. 2011 2. locke j. climate change-induced migration in the pacific region: sudden crisis and long-term developments’. the geographical journal. 2009;175 (3):171-80. https://doi.org/10.1111/j.1475-4959.2008.00317.x 3. seneviratne i, nicholls, n., easterling, d., goodess, c., kanae, s., kossin, j., luo, y., marengo, j., mcinnes, k., rahimi, 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http://www.unhcr.org/en-au/protection/hcdialogue%20/51b6de419/welcoming-stranger-affirmations-faith-leaders.html http://churchagenciesnetwork.org.au/assets/documents/can-do-memorandum-of-understanding.pdf http://churchagenciesnetwork.org.au/assets/documents/can-do-memorandum-of-understanding.pdf http://churchagenciesnetwork.org.au/assets/documents/can-do-memorandum-of-understanding.pdf https://doi.org/10.1186/1472-6963-12-206 https://doi.org/10.1186/1472-6963-14-297 https://doi.org/10.1093/jopart/mun013 https://doi.org/10.4135/9781446294413 https://doi.org/10.1057/9780230371262 94 mitchell & grills jun 2017. christian journal for global health, 4(2):87-94. and practice. 2012;18(5):1-13. https://doi.org/10.1097/phh.0b013e31823a815c 27. clarke m. “god i givim ples ya long yumi" (god has given us this land): the role of the church in building pacific nations’ in mission and development: god’s work or good works. london: continuun; 2012. https://doi.org/10.5040/9781472549129.ch-005 28. kreuter m, lezin na., young, la. evaluating community-based collaborative mechanisms: implications for practitioners. health promot practice. 2000;1(1):49–63. https://doi.org/10.1177/152483990000100109 29. mitchell b. faith-based development. new york: orbis books (usa); 2017 peer reviewed competing interests: none declared. correspondence: robert bradley mitchell, bmitchell@anglicanoverseasaid.org.au cite this article as: mitchell r b, grills n j. a historic humanitarian collaboration in the pacific context. christian journal for global health. july 2017; 4(2):87-94. https://doi.org/10.15566/cjgh.v4i2.160 © mitchell r b, grills n j this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1097/phh.0b013e31823a815c https://doi.org/10.5040/9781472549129.ch-005 https://doi.org/10.1177/152483990000100109 mailto:bmitchell@anglicanoverseasaid.org.au https://doi.org/10.15566/cjgh.v4i2.160 https://creativecommons.org/licenses/by/4.0/ historical review article nov 2018. christian journal for global health 5(3):3-11 christ as physician: the ancient christus medicus trope and christian medical missions as imitation of christ christoffer h. grundmanna a m.th., d.th., professor in religion and the healing arts, valparaiso university, valparaiso, indiana, united states of america abstract only a few people will know that as early as the second century ad, christ was called a physician. not being scriptural, this nomenclature originally reflected the looming rivalry with the pagan asclepius cult very popular in hellenistic times. yet, despite its polemic background, that designation grew into an accepted rhetorical trope for christians since it was regarded as well-suited to illustrate the corporeality of salvation. it implied that redemption is as corporeal as the work of medical practitioners, an aspect crucial for christian medical missions. this article first provides a sketch of the early occurrences of the christus medicus trope documenting only some of the crucial texts (i). in the second part, the article addresses the imitatio christi motif, that is, the call to imitate christ, because imitatio christi had become somewhat typical for arguing the cause of medical missions in their nascent stage. this had to do with breath-taking developments in medicine beginning in the latter part of the nineteenth century, which suddenly empowered physicians to effectively heal diseases plaguing people from time immemorial. pious doctors, thus, felt urged to imitate christ by going out on missions to share the good news and to heal (ii). concluding remarks plead for reckoning the unique vocation and ministry of medical missions within and for the church, namely to hold fast to the corporeality of salvation. key words: christus medicus, imitatio christi, medical missions, asclepius, hippocrates, disinterested benevolence, healing, physician, church. introduction it might not be known to many outside the academy that in early christianity the work of christ was — among others — likened to, nay, identified with that of a physician. at a first glance, such comparison seems more than obvious given that jesus went about galilee “healing every disease and every sickness.” (mt. 9:35)1 on a second look, however, things turn out to be not as plain as initially assumed since the trope speaks about christus medicus, not jesus medicus. further, unlike god’s self-designation in ex. 15:26 as “the one who heals,” jesus is never referred to as “doctor” nor did he declare himself a “healer” despite several other allusions to who he is, notably so in the gospel 4 grundmann nov 2018. christian journal for global health 5(3):3-11 according to john.2 rather than appealing to jesus’ healing ministry, the christus medicus trope implies reference to god’s ultimate redemptive sacrifice on the cross in christ and his resurrection while simultaneously insinuating that redemption is as corporeal in nature as is the work of medical practitioners, an aspect pointedly caught by the north-african church father tertullian (ca. 160 – 220) in his famed phrase: “the body is the pivot of salvation.”3 yet, while christians throughout the ages and churches everywhere engaged in sometimes remarkable works of charity, they nonetheless increasingly lost sight of the bodily dimension of salvation.4 they narrowed their focus on the rescue of an undying soul from eternal damnation, regarding the frail, decaying body not fit for life everlasting — an attitude heavily indebted to philosophical concepts held by (neo)platonism and stoicism, not to scripture. such an approach, however, was challenged to its core with the emergence of medical missions in the nineteenth century. but, unfortunately, that challenge was seldom realized and rarely properly understood.5 what follows attempts to remedy this crucial blind spot by first providing an informative sketch of the christus medicus trope (i) before dealing in a second part with the call to imitate christ — typical for medical missions in the early days and important for comprehending the corporeality of salvation more adequately (ii). the exposition of the two topics — christus medicus and imitatio christi — will be followed by brief conclusions. i. christus medicus — interpreting the redemptive work of christ as healing it is telling that as early as the second century, christians could refer to christ as “physician” (cristo.ς ivatro,ς / christus medicus). even though this designation is found nowhere in the new testament and, albeit, hippocratic/galenic medicine was regarded a pagan art6, this title, nevertheless, stuck. originally prompted by apologetic confrontation with the prevalent healing cult of asclepius, speaking of christ as physician became a frequently used rhetoric trope in latter centuries until it fell into oblivion during the eighteenth century.7 the first mention of the trope occurred in a letter to the ephesians ascribed to bishop ignatius of antioch who died a martyr in rome in 107 ce. the text stated, “there is one physician who is... god existing in flesh... jesus christ our lord.”8 the same document also spoke of the lord’s supper as “the medicine of immortality, the antidote to prevent... from dying... that we should live forever in jesus christ,” a phrase still used in the eucharistic liturgy of christian eastern orthodox churches today.9,10 in an apologetic treatise written later that century, theophilus of antioch (ca. 169-190) asserted: “this [i.e., ignorance of god] is your condition, because of the blindness of your soul, and the hardness of your heart. but, if you will, you may be healed. entrust yourself to the physician, and he will couch the eyes of your soul and of your heart. who is the physician? god, who heals and makes alive through his word and wisdom.”11 irenaeus of lyon (ca. 135-200) in his extensive against heresies argued that “the lord came as the physician of the sick,” and declared, “himself... saying, ‘they that are whole need not a physician, but they that are sick; i came not to call the righteous, but sinners to repentance’.”12 here irenaeus, who like ignatius, called the eucharistic host the “bread of immortality” (panis immortalitatis), made the first-time reference to lk. 5:31 thereby establishing that verse (and its parallel in mt. 9:12 while mk. 2:17 did not figure at all) as the cardinal reference for the christus medical trope.13 for theologians of the third century, the healing brought about in christ aimed mainly at the cure of the passions of the soul, a topic of philosophical discourses of their day. the medicus thereby becomes an expert who cares for the wellbeing of the soul. clement of alexandria (ca. 150215) writes: “our instructor, the word... cures the unnatural passions of the soul by means of 5 grundmann nov 2018. christian journal for global health 5(3):3-11 exhortations. for... the help of bodily diseases is called the healing art — an art acquired by human skill. but the paternal word is the only pæonian [i.e., godly] physician of human infirmities, and the holy charmer of the sick soul;... the all-sufficient physician of humanity, the saviour, heals both body and soul.”14,15 origen (ca. 185-254) holds that christ is the supreme physician: “for although, in the diseases and wounds of the body, there are some which no medical skill can cure, yet we hold that in the mind there is no evil so strong that it may not be overcome by the supreme word and god. for stronger than all the evils in the soul is the word, and the healing power that dwells in him; and this healing he applies, according to the will of god, to every man.”16 another third century church father, cyprian of carthage (ca. 200-258), praises god’s philanthropy thus: “many and great... are the divine benefits... for our salvation” because christ “humbled himself... was wounded that he might heal our wounds;... for when the lord at his advent had cured those wounds which adam had borne, and had healed the old poisons of the serpent, he gave a law to the sound man and bade him sin no more.” and tertullian decrees: “the lord had come... to save that which had perished; a physician necessary to the sick more than to the whole... who among men perishes, who falls from health, but he who knows not the lord? who is safe and sound, but he who knows the lord?”17 speaking of jesus’ healings, tertullian insists that these were corporeal indeed, because, “he [i.e., jesus] did himself before long touch others, and by laying his hands upon them — hands evidently meant to be felt — conveyed the benefits of healing, benefits no less true, no less free from pretense, than the hands by which they were conveyed. consequently, he is the christ of isaiah, a healer of sicknesses: he himself, he says, takes away our weaknesses and carries our sicknesses.”18 tertullian, thus, augments the already established reference to lk. 5:31 with isa. 53:4 (surely, he has borne our infirmities and carried our diseases.), something which stuck with the christus medicus trope ever since. theologians of the fourth century — eusebius of caesarea (260-339), athanasius (295-373), cyrill of jerusalem (313-387), gregory of nazianz (ca. 326-390), ambrose of milan (333-397), basil of caesarea (329-378), and his brother gregory of nyssa (ca. 331-394), had no hesitation to call christ “physician”, even a “spiritual hippocrates.”19 they spoke of the word of god as “medication for life eternal” and listed repentance, baptism, the eucharist, and, yes, martyrdom as other “means of healing.” convinced that christus medicus accomplished his mission in the church through the priests’ ecclesial office, they compared the pastoral ministry to activities of doctors, too, who had to administer bitter medicines, and, especially, to surgeons, who had to cut and burn, pierce, and amputate in order to bring about healing; such comparisons not only referred to actual surgical practices of the day, but also to cruel tortures martyrs had to endure.20 around this time, it now became possible explicitly to compare christ with asclepius, something consciously avoided by previous authors due to the lingering conflict in hellenistic times with asclepius’ popular healing cult. thus, athanasius remarked: “[w]hat man ever healed such diseases as the common lord of all? or who has restored what was wanting to man's nature, and made one blind from his birth to see? asclepius was deified... because he practiced medicine and found out herbs for bodies that were sick... but what is this to what was done by the savior, in that, instead of healing a wound, he modified a man's original nature, and restored the body whole.”21 cyril, archbishop of jerusalem, agreed with others before him in diagnosing sin as “the sorest disease of the soul.”22 cyril also advised sinners to turn to the great physician: “thine accumulated offences surpass not the multitude of god’s mercies: thy wounds surpass not the great physician’s skill. only give thyself up in faith: tell the physician thine ailment.”23 to justify addressing christ as medicus, 6 grundmann nov 2018. christian journal for global health 5(3):3-11 cyril explained that “jesus... means according to the hebrew ‘savior,’ but in the greek tongue ‘the healer;’ since he is physician of souls and bodies, curer of spirits, curing the blind in body, and leading minds into light, healing the visibly lame, and guiding sinners’ steps to repentance... if, therefore, any one is suffering in soul from sins, there is the physician for him... if any is encompassed also with bodily ailments, let him not be faithless, but let him draw nigh; for to such diseases also jesus ministers, and let him learn that jesus is the christ.”24 for augustine (354-430), who “easily holds the first place among those patristic writers of the west who made use of the christus medicus figure,” christ is not only mankind’s “physician and savior,”25,26 but also the one who, “in healing man has applied himself to his cure, being himself healer and medicine [medicus et medicamentum] both in one.”27 augustine thereby transformed the christus medicus trope into a soteriological statement. on the whole, however, to perceive of christ as a physician for body and soul had become a well-established figure of speech by the fifth century. sermons and theological discourses played with variations of the already known without saying anything really new. hence, there is no need to go into further detail. suffice it to mention that the writings of augustine were instrumental in transmitting the christus medicus trope to theologians of the middle ages, first and foremost to bede the venerable (ca. 673735), anselm of canterbury (1033-1109), bernhard of clairvaux (1090-1153), peter lombard (10961160) and also to hildegard of bingen (1098-1179). ii. medical missions as imitation of christ (imitatio christi) medical missions as the purposeful integration of professional medical, surgical, and health-care services into the mission of the church represent a very specific vocation. as much as they are an expression of charity to show forth god’s unconditional love and mercy like other such endeavors — soup-kitchen, orphanage, shelter — medical missions target a realm of human existence often experienced as life-threatening — disease — to prevent untimely death and assist in sustaining life by providing treatment in cases of acute infections or medication for chronic diseases. on the other hand, trying to heal or alleviate ailments and being concerned about disease prevention today is not distinctively christian, because — thanks be to god — other humanitarian organizations do the same, as doctors without borders or medical missions run by secular agencies and national health-care systems.28 what is unique about christian medical missions is the context in which such activities are performed: the church. this requires some explanation. church, first and foremost, does not refer to any organizational local, national, or global support system that commissions medical missions nor to associations of well-intending, caring christian individuals engaging therein. church (with the capital “c”) refers to the body of baptized christian believers past and present who heed the word of god. church refers to the “cloud of witnesses” (heb. 12:1) for god’s revelation in christ as testified to in scripture by the holy spirit. this church is universal, while the amazing multitude of churches and christian traditions that currently exist are only dimmed, almost blind mirrors (1. cor. 13:12) of the true community of saints that the church is called to be (col. 3:12; eph. 2:19).29 therefore, to properly grasp what church is, requires honestly acknowledging and overcoming the attitude of celebrating individual achievements and personal accomplishments. instead, a new identity must be acquired, an identity beyond personal goals and communitarian loyalties, a genuine christian identity which glorifies god, and god alone, by living an authentic personal response to the gift of salvation gracefully granted in christ. glorification of god everywhere at every time and in communication with everyone is not only the content of a genuine christian life. the soli deo gloria [to god alone be glory] focus is, at the same time, a key criterion to shield against all kinds of vested interests 7 grundmann nov 2018. christian journal for global health 5(3):3-11 pursued by churches or groups, by strategic masterplans or humanitarian ideologies. how does one acquire an identity genuinely christian? the answer given to this question since new testament times is: imitate christ, for did the lord not say: “if any want to become my followers, let them deny themselves... and follow me” (mt. 16:24)? and did jesus not admonish his disciples “learn from me; for i am gentle and humble in heart” (mt. 11:29)? paul told the corinthians: “be imitators of me, as i am of christ” (1. cor. 11:1; 4:16). the ephesians were emboldened to become “imitators of god... and live in love as christ loved us” (eph. 5:1), and a first century congregation threatened by persecution and martyrdom was counselled “to look to jesus the pioneer and perfecter of... faith... so... not [to] grow weary or lose heart” (heb 12:1-3). to explain what imitation of christ means, church father gregory of nyssa alluded in the fourth century to the art of painting, likening virtues to colors: “[i]t is possible for the virtues’ pure colors skillfully combined with each other to imitate beauty that we might be an image of the image [that is: christ], expressing through our works the prototype’s beauty by imitation.” looking to christ we “imitate those qualities we can assume while we venerate and worship what our nature cannot imitate.”30 this is to say, imitation of christ can never mean endeavouring to become a replica of christ since christ had “qualities” — being of god and without sin (heb 4:15) — “which our nature cannot imitate.” imitation, rather, means to live a life which is translucent for christ as the lord. hence, the call to imitate christ asks for authentic personal piety bearing as untainted a witness to christ as possible. many devout christians heeded this appeal from the church’s beginnings through the middle ages up to modern times and, somewhat surprisingly, those engaging in medical missions did as well.31 this is remarkable in so far as christian missions conventionally justify their activities with the “great commission” (mt. 28:18-20) not with imitatio christi. however, that medical missionaries perceived their work as an imitation of christ had to do with developments in theological thinking as well as with medical discoveries. when the influential north american theologian samuel hopkins (1721-1803) expounded the meaning of imitation for christians, he did it along the lines of utilitarian tenets of doing good rather than christ-likeness. hopkins claimed that christians “are called upon to imitate... that love which god exercised... in giving his son” and maintained that “the holy love of god is represented as consisting in disinterested benevolence and goodness... and in nothing else.”32 declaring imitatio christi synonymous to disinterested benevolence and doing good left its mark. it “fashioned the missionary character of the american churches” by giving “birth to a passion to minister to the physical needs of people.”33 it is, therefore, not surprising that american christians were among the first to advocate and engage in medical missions. in 1833, an appeal by dr. john scudder to pious physicians in the united states appeared ending on the note: “no mission... should be sent out without one, who like his adorable master, will go about ‘preaching the gospel of the kingdom, and healing all manner of sickness and all manner of disease’ among people.”34 missionaries working in china lectured their home-boards in 1838 to “imitate him whose gospel you desire to publish to every land. like him, regard not as beneath your notice the opening of the eyes of the blind and the ears of the deaf, and the healing of all manner of diseases.”35 at edinburgh, students of medicine, potential medical missionaries, were told by one of their eminent professors in 1848: “every medical practitioner... is... to be an imitator of the lord jesus christ... this great physician! this vanquisher of death!”36 further, when applying for medical missionary service, david livingstone (1813-1873) declared: “i am a missionary heart and soul, god had an only son, and he was a missionary and a physician. a poor, poor imitation of him i am, or wish to be.”37 another person from britain, a 8 grundmann nov 2018. christian journal for global health 5(3):3-11 colleague of livingstone, admitted: “deep in the make-up of [a] true medical missionary is implanted that divine urge to reproduce in his own life... a pattern of the great physician, albeit in an alien culture.”38 and as recently as 2013, a seasoned medical missionary from the u.s. published an insightful book by the title heal in imitation of christ: conversations on medical missions.39 reference to imitating christ, however, waned once medical missionaries were accepted as legitimate co-workers in the missionary enterprise. other, more pragmatic arguments replaced it, especially strategic ones. this had to do with breathtaking developments in medicine empowering physicians effectively to heal diseases plaguing people since time immemorial. discovery of anaesthesia in 1846 and of asepsis the next year led to the rise of safe surgery. by 1859 the importance of public sanitation to curb, even prevent, epidemics came to be understood correctly, followed by detection of cellular pathology and bacteriology as reliable diagnostic tools, thanks to which many disease-causing agents were discovered and, subsequently, potent drugs developed. discovery of x-rays in 1895 paved the way for non-invasive diagnostics, and the identification of mosquitos as transmitters of malaria in 1897 allowed for effective means of protection in tropical countries.40 in short, during the brief period of only fifty years, medicine turned from an art into a rational, effective science, proving by results its superiority over indigenous medical systems in places elsewhere, at least as diagnosis, surgery, and medication were concerned. unlike their colleagues serving ex-patriate populations in trading colonies and ports abroad, medical missionaries often worked as pioneers in remote interior regions of host countries. their skill and medicines drew crowds of sufferers in search for relief whom native healers could not help. since these patients were regarded by many as potential converts, mission societies began to support such work in the hope to win people otherwise not reached. but once home-boards realized the enormous and ever-growing cost of running medical missions and the minimal number of neophytes actually won that way, they withdrew sponsorship for this “auxiliary,” redirecting funds to missionary work “proper,” namely to the care for “lost souls.”41 this, however, was opposed by some in the field who argued that medical mission work was “a constant corrective to the type of religion which is apt to think only of ‘precious souls’ and forget the medium by which alone those souls can express themselves and so become precious.”42 unfortunately, this objection did not find a hearing even though persuasive. john mott (1865-1955) also declared that: “medical missionary work is the climax of the integrity of [the] all-inclusive gospel. it gives us the most vivid apprehension of the real meaning of the incarnation and likewise the life of our lord and savior.”43 conclusions not fully grasping the unique ministry of medical missions as witness to the corporeality of salvation in christ, societies and boards still continue to justify their respective engagement with strategic arguments or claim that the commitment of the devoted staff makes such work a tangible experience of god’s love. while well-intending personal commitment to the task is precious and must be honoured, it does not compensate for lack of means or poor professional performance, be it in a primary health care program, a small regional or an upscale teaching hospital in the south, north, east, or west. christians cannot hide behind their devoted commitment as an excuse for failure in professional performance. also, while it is difficult to maintain excellence when working within the confines of a shoestring budget, christian medical missionaries should be aware that more funds do not necessarily warrant the christian character of their doings. further, faith-based institutions nowadays not only compete in almost every country with secular agencies; they also have to meet the standards of the professions set by secular boards not concerned 9 grundmann nov 2018. christian journal for global health 5(3):3-11 about christian values. therefore, christian medical missions cannot sufficiently be justified by personal devotion and commitment to the task nor with strategic considerations. considerations like these fail to notice that exploiting human suffering as opportunity for evangelization and church growth compromises the integrity of both, medicine and the gospel. working under false pretence is neither reconcilable with professional ethos nor with christian standards, one of which is refusing “to practice cunning” (2 cor 4:2). granted that national governments, local churches, and private initiatives have taken over what once was begun by medical missionaries, one may ask if that branch of missionary work has not become obsolete today.44 this, however, got disavowed resolutely by physicians and theologians who met for a conference addressing that very issue organized by the lutheran world federation and the world council of churches at tübingen, germany, 1964. the participants “were led,” to their own surprise, as they repeatedly said, to acknowledge that the “christian church has a specific task in the field of healing” which cannot be surrendered “to other agencies.” reaffirming healing as, “an integral part of its [i.e., the church’s] witness to the gospel,” because healing is, “an expression of salvation,” and recognizing “that to ask whether or not the time has come for the church to surrender its work in medicine... is to ask a theological question,” they demanded from all involved — churches, seminaries, hospitals, medical staff — to give “particular attention” to studying the topic of “health and salvation.”45-47 to bring about healing, christians cannot ignore medicine. they must avail of it in such a way that all their medical activities and the churches’ health-care institutions become translucent for christ and bear credible witness to the corporeality of salvation. beyond that, christian medical personnel have the potential to articulate this unique contribution — corporeality of salvation — to medicine at large and to all the health-care professions. not that they know more about healing than others; they probably may not. but those engaged in medical missions as the medical agency of the church know — thanks to the gospel — something essential for putting health-care and medical efforts into proper perspective since they glorify god, the giver of life, as christus medicus, the sustainer and preserver of life. this is the sole, genuinely christian, motivation for doing medical missions. references 1. all scripture passages are quoted from the new revised standard version (nrsv), 1989. 2. see john 6:35, 41, 48, 51 “i am the bread of life.” / 8:12; 9:5 “i am the light of the world.” / 10:7, 9 “i am the gate for the sheep.” / 10:11 “i am the good shepherd.” / 11:25 “i am the resurrection and the life.” / 14:6 “i am the way and the truth and the life.” / 15:1, 5 “i am the true vine.” 3. evans e. tertullian’s treatise on the resurrection. london: s.p.c.k.; 1960. p. 26. [in its original latin, the phrase reads “caro cardo salutis,” a pun playing with homophones.] 4. laboa jm. caritas — the illustrated history of christian charity. new york / mahwah (nj): paulist press; 2014. 5. grundmann ch. sent to heal! – emergence and development of medical missions. lanham (md): university press of america; 2005. p. 220-21. 6. the hippocratic oath sworn by professional doctors was sworn after all by the greek gods apollon and asclepius, and by the goddesses hygiea, panacea “and all the other gods.” see hippocrates, vol. i. jones whs, withington et editors. cambridge (ma): harvard university press:; 2015. p. 298. see also temkin o. hippocrates in a world of pagans and christians. baltimore (md)/london: the johns hopkins university press; 1991. p. 109-248. 7. the lutheran book of concord of 1580 echoes the christus medicus trope in the solid declaration of the formula of concord, i,5 for instance. allusions to the topic one also finds in church-cantatas by j. s. bach (1685-1750), see bwv 25, (3rd & 4th movement), bwv 48 (5th movement), bwv 135 (2nd movement). 10 grundmann nov 2018. christian journal for global health 5(3):3-11 8. the apostolic fathers with justin martyr and irenaeus. schaff p,editor. vol. i, american edition. chronologically arranged, with brief notes and prefaces by coxe ac. grand rapids (mi): eerdmans, 1886, reprint 2001. p. 76. 9. ibid. p. 85. 10. calivas a. holy communion: the gift of eternal life. [internet]. goarch.org [cited 2018 august 9]. available from: https://www.goarch.org/-/holycommunion-the-gift-of-eternallife?inheritredirect=true. 11. ante-nicene fathers. vol. 2. fathers of the second century. grand rapids (mi): eerdmans;1885, reprint 2004. p. 91. 12. the apostolic fathers, vol. i. (see en 8). p. 418. 13. ibid. p. 521. 14. paean: according to homer the physician of the gods in greek mythology. 15. clement of alexandria, the instructor [paedagogus], i, 2. in: ante-nicene fathers, vol. 2 [see en 11]. p. 210. 16. contra celsum, viii,72. in: ante-nicene fathers. [see en 8] vol. 4. fathers of the third century: tertullian, part fourth; minucius felix; commodian; origen, parts first and second. p. 1565.— in one of his writings, origen actually entitles jesus christ, ἀρχιατός, that is: chief medical director. 17. on modesty, ix, 12+13. in: ibid. p. 83. 18. adversus marcionem, evans e, editor & translator. oxford, uk: oxford university press; 1972. p. 285. 19. quoted by pease s. medical allusions in the work of st. jerome. harvard studies in classical philology. 1914:75. 20. see gregory of nazianz in his de beatitunidibus [on the beatitudes] viii. the same is also found in writings by clement, origen, and tertullian. 21. oratio de incarnatione verbi [on the incarnation of the word], 49, 1-2. in: schaff p. wace h, editors. nicene and post nicene fathers, series ii, vol 4. grand rapids(mi): eerdmans; 1891. p. 63. 22. the catechetical lectures of s. cyril, archbishop of jerusalem, ii,1. in: nicene and post nicene fathers, series ii, vol. 7. cyril of jerusalem, gregory nazianzens. grand rapids (mi): eerdmans; 1893. p. 8. 23. ibid. ii, 6. p. 6. 24. ibid. x, 13. p. 61. see also xii, 1. ibid. p. 72. 25. arbesmann r. the concept of christus medicus in st. augustine. traditio. 1954;10:2. 26. exposition of psalm 130. in: the works of saint augustine. a translation for the 21st century. expositions of the psalms (ennarationes in psalmos 121-150), translation and notes by boulding m. hyde park (ny): new city press. 2004. p. 144. 27. on christian doctrine, i,14,13. in: schaff p, editor a select library of the nicene and post-nicene fathers of the christian church, vol. 2. st. augustin’s city of god and christian doctrine. grand rapids(mi): eerdmans; 1887. p. 526. 28. the official name of the organization is médecins sans frontières (msf). founded in 1971 in the aftermath of the biafra war in nigeria by french physicians. it is an international non-governmental organisation (ngo) today working in conflict zones and regions affected by endemic diseases with 30.000+ (2015), mainly local personnel. 29. for a comprehensive survey of present-day christianity see johnson tm. ross kr, editors. atlas of global christianity. edinburgh: edinburgh university press; 2009. and barrett db. kurian gt. johnson tm. editors. world christian encyclopedia: a comparative survey of churches and religions in the modern world. oxford: oxford university press; 2001.2nd ed. 30. on perfection by gregory of nyssa. greek orthodox theol rev. 1984:29(4):349-79. 31. see thomas à kempis (1379-1471). de imitatione christi. 1425 (thomas á kempis. the imitation of christ. (de imitatione christi, 1425). [trans by benham w. london]. forgotten books; 2007). this became, after the bible, the most widely read book, enjoying overall more than 5,000 editions. 32. an inquiry into the nature of true holiness. in: the works of samuel hopkins, vol. iii. boston: doctrinal tract and book society; 1852. p. 41. 33. chaney cl. the birth of missions in america. south pasadena (ca): william carey library; 1976. p. 82f. 34. the missionary herald, 1833;29:271. 35. the medical missionary society in china — address with minutes of proceedings. canton: office of the chinese repository; 1838. p. 21; original emphasis. 36. wilson g. the sacredness of medicine as a profession. in: lectures on medical missions. edinburgh / london: thomas constable; 1849. p. 230. https://www.goarch.org/-/holy-communion-the-gift-of-eternal-life?inheritredirect=true https://www.goarch.org/-/holy-communion-the-gift-of-eternal-life?inheritredirect=true https://www.goarch.org/-/holy-communion-the-gift-of-eternal-life?inheritredirect=true 11 grundmann nov 2018. christian journal for global health 5(3):3-11 37. letter of february 5, 1850. quoted in blaikie wg. the life of david livingstone. london: j. murray; 1908 (12th ed.). p. 104. 38. chesterman cc. in the service of suffering. london: the carey press; 1940. p. 135. 39. kuhn wt. sisters (or): trusted books; 2013 (2014 2nd ed.). 40. for a more detailed survey see grundmann ch. sent to heal! (see en 5). p. 45-51. 41. on this hotly debated topic see allen r. the place of medical missions. world dominion press. 1930;3(1). p. 34-42. chesterman cc. in the service of suffering. (see en 38). 42. chesterman cc. ibid. p. 99. 43. medical missionary enterprise – the outlook to-day. quarterly paper of the edinburgh medical missionary society. 1930;17:570. 44. making men whole — the theology of medical missions. london: medical missionary association/christian medical fellowship; 1990. p. 15. 45. the healing church. geneva: world council of churches; 1965. p. 34–5. 46. germany ch. the healing ministry — report on the tübingen consultation. int rev mission, 1964; 53(212):470-71. https://doi.org/10.1111/j.17586631.1964.tb03004.x 47. the healing church. (see en 45). p. 43 peer reviewed: submitted 13 aug 2018, accepted 1 oct 2018, published 7 nov 2018. competing interests: none declared. correspondence: christoffer h. grundmann, vöchtingstr. 31 d 72076 tübingen, germany. christoffer.grundmann@valpo.edu cite this article as: grundmann, c.h. christ as physician: the ancient christus medicus trope and christian medical missions as imitation of christ. christian journal for global health. nov 2018;5(3):3-11. https://doi.org/10.15566/cjgh.v5i3.236 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1111/j.1758-6631.1964.tb03004.x https://doi.org/10.1111/j.1758-6631.1964.tb03004.x mailto:christoffer.grundmann@valpo.edu https://doi.org/10.15566/cjgh.v5i3.236 http://creativecommons.org/licenses/by/4.0/ original article ______________ nov 2018. christian journal for global health 5(3):23-28. equipping african medical students with ethical decisionmaking skills: a case-based method from burundi eric mclaughlina & alyssa pfisterb a md, faafp, professor of family medicine, hope africa university, burundi b md, faap, dtm&h, professor of pediatrics, hope africa university, burundi abstract in addition to medical ethical issues faced in every context globally, many african contexts have the challenge of additional ethical scenarios particular to african culture, resource limitation, and more varied levels of professional expertise. in an effort to equip medical trainees with the knowledge and skills to confront these situations well and from a particularly christian vantage point, we developed a bioethics module for african medical students in burundi that began with a didactic ethics lecture and spent most of the time on student-led, facilitated case discussions. the cases were designed to highlight problems specifically created by the particularities of our rural, african, under-resourced context. five rounds of implementing this module have shown a positive and interactive reception, with students critically thinking about the problems, engaging in personal application, and being willing to disagree with each other. evaluation after each module has resulted in some cases being discarded and others modified. facilitation of case discussions has been especially aided by structuring cases that specifically force the making of a difficult ethical decision, soliciting an articulation of any disagreements existing within the presenting group, and exploring permutations of each case in order to see if that changes opinions and to clarify the underlying ethical principles at play. in our setting, the creation of bioethical case scenarios that are specifically applicable to the context of our african learners has been helpful in making a module with useful content capable of growing the ethical decision-making capacity of the participants. key words: medical ethics, medical education, east africa, burundi, case-based ethics. introduction medical ethics touch every context of our world on a daily basis. many situations surround issues of current controversy, but many others are shrouded in everyday scenarios that are so common as to be rendered invisible by their familiarity. it has been long recognized that case scenarios are a preferred tool for teaching bioethics, and learners from diverse backgrounds have expressed this preference.1,2 east african learners, in particular, 24 mclaughlin & pfister nov 2018. christian journal for global health 5(3):23-28. have stated their desire for more practical case studies.3 however, curricula indiscriminately applied across a broad international base risk a lack of applicability to the learners, which can lead to confusion, unusable knowledge, and even cultural imperialism.4 in order for case scenarios to be effective, they must be real to the learners, which requires contextualizing the case to the real learning environment.1 though there are examples of cases developed for western students going to east africa on elective rotations, there is a lack of published information about cases designed for the particularities of an east african health context.5 in addition to the universal questions encountered everywhere, many african contexts have the challenge of additional ethical scenarios particular to african culture, resource limitation, and more varied level of professional expertise. to give a few examples, traditional african family cultures can be more patriarchal or (possibly at the same time) collectivist, which may create nuances in approaches to autonomy and confidentiality. the significant resource limitations in many african contexts create increased tension for questions of justice and stewardship, as wall highlights in her discussion of medical ethics in developing countries.6 lack of sufficient professional expertise in other contexts can pose heightened questions of beneficence and non-maleficence. these unique features may render imported ethics curricula from wealthier and/or non-african contexts either insufficient or irrelevant to african learners, thereby hindering the development of necessary ethical decision-making capacities in medical professionals. there is an ongoing need for bioethics teaching that is compatible both with the learner’s worldview and their medical practice context. materials and methods at hope africa university, a burundian christian medical school, we designed a module for teaching and practicing medical ethics based on cases inspired from the same context. the module began with a two-hour interactive, didactic lecture on ethical principles and their applications. the first four principles discussed were beneficence, nonmaleficence, autonomy, and justice, as first postulated by beauchamp and childress in principles of biomedical ethics.7 these were described as secular principles, but the biblical support of each was also discussed. this was followed by a discussion of (and the biblical support for) several uniquely christian principles with bioethical importance, including the sanctity of life (in association with the imago dei), stewardship of creation, the fall, suffering and death, miracles, the sovereignty of god, grace and mercy, compassion, and hope. this list had been loosely adapted from medical ethics and the faith factor by robert orr.8 the didactic portion of the module concluded with several case examples explored as a group that demonstrated how specific situations brought different ethical principles into tension with one another and how to define those tensions. the subsequent majority of the bioethics module was spent in facilitated student-led discussions of case studies created for this context. our faculty developed the cases based on our knowledge of our particular rural, african, underresourced context, oftentimes drawing from reallife experiences. cases were designed to highlight certain ethical principles, but also certain unique elements of our context. four of the ten cases used are included here. (the principles and context highlighted by the cases were not given to the students who were to present them.) (table 1) 25 mclaughlin & pfister table 1. case examples case example #3 (highlighting autonomy and hope in the context of african family culture) “secret terminal cancer” a 75-year-old man presents with epigastric pain and severe anemia. he is transfused and endoscopy shows an inoperable gastric cancer. before rounds the next day, the patient’s son comes and asks you if his father has cancer and if the problem is treatable. you explain what you found, and he asks you to tell neither his father nor his mother, saying that it will cause them to “lose hope”. what do you do? if the son refuses to inform his parents, do you inform them directly? case example #2 (highlighting justice and stewardship in the context of severe resource limitation) “not enough oxygen” a 45-year-old woman presents in a coma and requires oxygen therapy. the next day, a head ct shows massive hemorrhage and recovery is impossible. when trying to wean her off oxygen, she rapidly becomes hypoxic and apneic. the hospital has one other oxygen concentrator, which is shared by two children with severe bronchiolitis. there is no other source of oxygen in the hospital. do you continue oxygen therapy for the comatose woman? what if another child with severe bronchiolitis arrives? case example #1 (highlighting beneficence and non-maleficence in the context of insufficient professional expertise) “in over your head” you are the only doctor present at a rural hospital who just admitted a pregnant woman at 38 weeks gestation with a hemorrhage, and you suspect placenta previa. fetal heart tones are 170 per minute. you are new at this hospital and you are being trained to do c-sections. up until now, you have only observed several times, but you have never done one alone. the patient’s bp is 70/30, and she continues to bleed despite every other intervention. it takes 3 hours to get to the next nearest hospital that can do a csection. the ambulance is available. do you transfer the woman or try to save her life by doing a c-section alone? case example #4 (highlighting autonomy and beneficence in the context of resource limitation and african family culture) “who decides?” a mother of 8 children is hospitalized for a cesarean for baby #9 while baby #8 is hospitalized for severe acute malnutrition due to inadequate food supply at home. the mother agrees to have a tubal ligation. however, the father refuses, not for religious reasons, but because he says that “a large family is the truest blessing.” the mother asks you secretly to do the tubal anyway and to not inform the father. what do you do? 26 mclaughlin & pfister nov 2018. christian journal for global health 5(3):23-28 student groups were given a step-by-step framework to follow in developing and presenting their case. this framework was loosely adapted from scott rae’s model for making moral decisions (from moral choices).9 after several days of preparation, each group had 15 minutes to make their presentation followed by 15 minutes to respond to questions from their colleagues and the faculty facilitator. a summary of the framework used is included in table 2. table 2. student framework for presenting a bioethics case (adapted from rae9) results the module, as described above, has been implemented for five consecutive classes, with a total of over 170 students, usually in their final year of training. the average group size for a case presentation has been 4-5 students. discussion has been invariably lively and interactive, with students showing a willingness to engage the scenario as applicable to their lives and to express disagreement with their colleagues when felt. additionally, students have demonstrated an increased ability to think critically about ethical principles. after each of the five successive modules, small alterations to the cases as well as the presentation framework were made based on difficulties with their utilization. to cite examples, a case similar to #2 above had been used involving a mechanical ventilator instead of oxygen supplementation. the absence of mechanical ventilators in our learners’ context hindered them from being able to relate to the situation and thus engage the ethical principles. another case involving patients being required to pay in advance for services in order to improve organizational sustainability was discarded after finding that the student perspective invariably related to the patient in front of them instead of the sustainability of the system, thus rendering the case less useful for discussion purposes. the facilitation of the discussion of these cases has yielded several themes that are worth mentioning. first, cases needed to be structured to force the necessity of a difficult decision, since the learners invariably would choose any exit that enabled them to avoid the difficult decision. so, in an example like #2 above, the option of transferring the patient to another facility needed to be explicitly excluded. this tendency to avoid facing the ethical question is as universal as it is natural, but for the purposes of learning to think critically about bioethics, it is unhelpful. second, though the students presented the cases in groups, we systematically asked each group if there were differences of opinion among the group members. this was to help foster 1. gather all relevant and available facts. what other information would possibly change the ethical situation, if known? 2. identify the main ethical question of the case. 3. identify the role of the principles of non-maleficence, beneficence, justice, and autonomy in this case if they are present. 4. identify the distinctively christian ethical principles that apply to this case, including biblical references if possible. 5. list the possible courses of action. 6. evaluate the pros and cons of each option in light of the ethical principles. 7. make a decision. 27 mclaughlin & pfister nov 2018. christian journal for global health 5(3):23-28 discussion and to allow for disagreement. our particular cultural context was generally quite collectivist (at least compared to western cultures), yet we often found learners willing to express differences of opinion that helped to delineate the ethical principles at play. third, we often found it useful to propose a slight permutation of the case to the presenting group in an effort to see if the permutation would change their opinion. this often helped to elucidate the driving forces in the decision-making process. for example, case #3 above involves an elderly father and the request of his son. changing the case to a middle-aged son who has a terminal cancer and the request of his elderly father not to tell the son revealed very interesting cultural values about family, but again there were often differences of opinion (see preceding paragraph). in another case about two patients requiring blood transfusion when only one unit was available, it was useful to modify the case afterwards to where one recipient was a convicted murderer. the response of the learners to that permutation demonstrated an important distinction between simple stewardship of biological life and the sanctity of human life as marked by the image of god. discussion the willingness and ability to face difficult ethical situations and to make a wise and courageous decision is undoubtedly the process of a lifetime. the presence of conscientious and compassionate role models seems likely to play the most central role in the development of such skills in the lives of learners. however, we hope and believe that a specific content module such as the one described above can play a useful role in lending a common vocabulary and a structured thought process to this lifelong process. additionally, we maintain that the creation of bioethics case scenarios specifically applicable to the context of our african learners has been instrumental in making such a content module useful in growing the ethical decision-making capacity of the participants. a similar process could be useful for contextualizing cases to other cultures, including many developed societies, which are often pluralistic and may have similar variables present. references 1. macklin r. teaching bioethics to future health professionals: a case-based clinical model. bioethics. 1993;7:200-206. https://doi.org/10.1111/j.1467-8519.1993.tb00285.x 2. greenberg ra, kim c, stolte h, hellman j, shaul rz, valani r, scolnik d. developing a bioethics curriculum for medical students from divergent geo-political regions. bmc med educ. 2016;16:193-198. https://doi.org/10.1186/s12909016-0711-4 3. mathooko jm. bioethics teaching in african institutions of higher learning. proceedings of the international conference on bioethics; 2008 aug 12-14; egerton, kenya. egerton: unesco; 2009. 4. piasecki j, dirksen k, inbadas h. erasmus mundus master of bioethics: a case for an effective model for international bioethics education. medicine, health care and philosophy. 2018;21:3-10. https://doi.org/10.1007/s11019-017-9814-x 5. white m, evert j. developing ethical awareness in global health: four cases for medical educators: developing ethical awareness. developing world bioethics. 2014;14:111-116. https://doi.org/10.1111/dewb.12000 6. wall ae. ethics for international medicine: a practical guide for aid workers in developing countries. hanover, n.h.: dartmouth college press; 2012. 7. beauchamp tl, childress jf. principles of biomedical ethics. 7th ed. new york: oxford university press; 2013. 8. orr rd. medical ethics and the faith factor: a handbook for clergy and health-care professionals. grand rapids, mich.: william b. eerdmans pub. co.; 2009. 9. rae sb. moral choices: an introduction to ethics. 2nd ed. grand rapids, mich.: zondervan publishing house; 2005. https://doi.org/10.1111/j.1467-8519.1993.tb00285.x https://doi.org/10.1186/s12909-016-0711-4 https://doi.org/10.1186/s12909-016-0711-4 https://doi.org/10.1007/s11019-017-9814-x https://doi.org/10.1111/dewb.12000 28 mclaughlin & pfister peer reviewed: submitted 28 june 2018, accepted 19 july 2018, published 6 nov 2018 competing interests: none declared. correspondence: eric mclaughlin, hope africa university, bujumbura, burundi. drsmcl@gmail.com cite this article as: mclaughlin e, pfister a. equipping african medical students with ethical decision-making skills: a case-based method. christian journal for global health. nov 2018; 5(3):23-28. https://doi.org/10.15566/cjgh.v5i3.229 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:drsmcl@gmail.com https://doi.org/10.15566/cjgh.v5i3.229 http://creativecommons.org/licenses/by/4.0/ original article mar 2017. christian journal for global health, 4(1): 3-12. impact of a pre-clinical skills course with peer assisted learning (pal) on preparedness and confidence levels of medical students in africa cheryl snyder a , rose chisenga b a ma, do, associate professor and chair of the science department, san diego christian college, united states b mb chb, junior resident medical officer, university of zambia, zambia abstract background: many benefits of pre-clinical medical skills training have been documented in technologically advanced nations, and in the past decade these courses have been introduced to developing countries. curriculum that can prepare and build confidence in medical students must be cost effective, evidence-based, and culturally sensitive in places where there are severe resource limitations. in 2013, an initial pre-clinical skills course without assessments was introduced to medical students in zambia. later that year, a more developed course was launched to a second cohort integrating peer assisted learning (pal) and assessments. these trainers were prepared in advance with instructions in standardized skills, learning theory, effective feedback techniques, and use of rubrics to insure good inter-rater reliability in teaching and assessments. methods: a quantitative study surveyed 108 students utilizing convenience sampling and a written questionnaire. data collected compared preparedness and confidence in performing clinical skills of the intervention cohorts with the control group (medical students who preceded pre-clinical skills training). results: preparedness responses increased from 36.1% of the students in the control group to 90.9% in the intervention group who had been exposed to the pal course with assessments (p value <0.001). student confidence levels in history taking, physical exam skills, procedures, and the application of critical thinking skills diagnostically also showed improvement from 11.5-29.5% range in the control group to 77.3-86.4% range in the pal cohort (p value <0.001). conclusions: exposure to pre-clinical training program especially utilizing pal with assessments had a positive impact on the sense of preparedness and confidence levels for medical students beginning their clinical training years at the university of zambia. integration of pal influenced academic development, clinical procedural standardization, appropriate curriculum additions, transitional support, and program sustainability. pal may have beneficial application extending to basic science lab instruction in resource limited environments. recommendation for future research would be integration of qualitative triangulation and reduction of variables in confidence data reporting. 4 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. introduction the benefits of pre-clinical skills training during the medical school years are well researched in technologically advanced nations and include the following: reduced workload for clinical faculty, decreased anxiety for the student, and improved patient safety. 1-5 curriculum that is cost effective, evidence-based, and culturally sensitive is a critical consideration throughout the world but even more so in developing countries where there are severe human and financial resource limitations. 6-8 by 2012, pre-clinical medical skills training had been introduced into other african nations, however a literature search failed to report on cost-effective curriculum or evidence-based methodology. sub-sahara africa in general and zambia specifically have experienced high rates of poverty and health challenges. the human immunodeficiency virus (hiv) is listed as the most common cause of death (20%) according to the center for disease control (cdc) statistics for this nation. 9 the ministry of health (moh) addressing the deans of zambian medical schools in 2012 estimated the country to have a physician shortage of at least 2000 and encouraged increased medical school enrollment. in response, the university of zambia, school of medicine (unza som) expanded the medical class size from 60 students per year (class of 2014) to approximately 170 students per year (class of 2019). the tasks of training, supervising, and assessing students’ clinical skills became even more onerous for the already over-worked clinical faculty. in addition, the students typically lacked any formalized preclinical skills training when they began their clinical years working with the “sickest of the sick” at a tertiary referral center, the university teaching hospital (uth) in lusaka. unza som has a seven-year medical school curriculum, and students are introduced to their first clinical experience with patients at the beginning of their fifth year of medical school. prior to september 2013, students were oriented to the expected skills by whoever was available for that specialty (consultants, residents, interns, fellow students, etc.). at most clinical rotation sites, students reported their orientation experience to be “unstructured” and “inconsistent.” clinical rounds took place with up to 30 students gathered around a patient’s bedside to observe a physical exam. physician supervision of individual students performing exams and procedures was rare. objective standardized clinical exams (osces) were just being introduced on some of the clinical specialty rotations for assessment of skills. patient exams occurred primarily in a discussion format (patient remaining in a chair) and physicians demonstrated limited physical exam and diagnostic skills. in addition to insufficient supplies and patient delays in seeking medical care, mortality rates were high with the average life expectancy in 2010 estimated at only 58 years compared to 78 years in the usa. 10 in an attempt to rectify some of these concerns at unza som, a new curriculum component was introduced in january-march 2013 as a pre-clinical skills course (32 contact hours). the ratio was one experienced physician to train 96 fourth-year medical students (group 1). two-hour didactic classes introduced the basics of history taking, physical exam, differential diagnosis development, and procedures (intravenous and foley catheterization, nasogastric tube placement, and lumbar puncture), and a summative didactic exam was given. lab sessions lasted 2-4 hours per week where students practiced skills on simple, non-electronic manikins and classmates. however, due to the lack of examiners, skills assessments did not occur. students, consequently, still reported a lack of confidence as they prepared to enter their clinical years. in an effort to improve the curriculum and bolster confidence in unza som students transitioning from the pre-clinical to clinical training levels, peer assisted learning (pal) was introduced. this methodology involved the 5 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. recruitment and training of sixteen volunteers, more senior (5 th, 6 th-, and 7 th year) medical students who were provided an 80-hour program. concepts of learning theory, inter-rater reliability, mentorship, and providing quality feedback were introduced. trainees were expected to demonstrate standardized clinical skills (procedural and physical exams) in both the student and teacher roles. feedback and evaluations in a 360-degree manner (supervising physician, peers, and the trainee themselves) were given throughout the program to help develop the expected supportive culture for this new role. these peer educators were required to assist with the development of procedural rubrics and writing of culturally appropriate standardized patient histories. after a mock psychomotor assessment, the training group compared rubric scores in a discussion format. trainers learned to identify if they were either too strict or too lenient in their assessment skills (and modify when necessary). subsequently, a second pre-clinical skills course was offered to the second cohort of 36 fourth-year students (group 2). the course was slightly longer than the first, spread over eight weeks (50 student contact hours). there were combined classroom didactic lectures in the mornings given by the training physician and senior peer educators with supervised practice lab sessions required in the afternoons. students were expected to practice physical exam skills with one another during the evenings and weekends. in addition to the initial skills of intravenous and foley bladder catheterization, lumbar puncture, and nasogastric tube placement, more advanced skills were introduced including airway management, cardiopulmonary resuscitation, and one standardized patient encounter. research on the impact of the pre-clinical course on student preparedness and confidence levels as well as the specific impact of pal with assessments on the second cohort is described below. after the initial two shorter courses, a full year course was launched in august 2013-may 2014 and a second year-long course the subsequent year. materials and methods the research design utilized a convenience sampling, quantitative approach comparing the intervention groups (1 and 2) with a control group that had not received skills training. the study focused on student perception of preparedness and confidence levels. ethical approval as an exempt research project was granted by unza biomedical research ethics committee (unza brec) and also by the institutional review board at the university of new england, usa. data was collected from a printed questionnaire that took students approximately five minutes to complete. an explanation of the purpose of the survey and ethical considerations of this volunteer-dependent research was provided verbally. the participants were informed that the results would be treated confidentially and used for curriculum development (i.e., specifically not impacting grades, advancement, or employment). the research questionnaire had two portions, demographics and the research questions. the basic demographic information included date, current year of study (5th, 6th or 7th), gender, the specific rotation that occurred as the first clerkship of the 5th year (internal medicine, pediatrics, surgery, or obstetrics/gynecology), and timing when the preclinical skills course was taken (options were “not taken,” “jan-march 2013,” or “june-august 2013”). the five survey questions were as follows: 1. how prepared were you for your first patient encounter? 2. on your first days on the ward as a clinical student, how confident were you about your history-taking skills? 3. how confident were you with physical examination skills during your first days on the ward as a 5th year? 4. how confident were you with the various clinical procedures, e.g., iv cannulation, lumbar puncture, and foley catheterization? 6 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. 5. how confident were you at investigating patients, determining a diagnosis, and differentials? the response options were in a three-point likert scale to simplify the process and reduce the time required at the recommendation of the peer trainer involved in question development. the instructions were to circle the appropriate response with three categories of choices as potential answers: 1. “fully prepared” or “very confident” 2. “prepared/confident” 3. “not prepared”/”not confident” the setting of the survey was at the university teaching hospital (uth) in lusaka, zambia, a tertiary facility and the primary clinical teaching site for 5 th , 6 th , and 7th year unza som medical students. the convenience sampling of the students (intervention and control group) was based on the availability of the participants at uth during one specific week (october 2013) and their willingness to participate in taking the anonymous survey given by preselected academic assistants. the targeted sample sizes for the control and intervention groups were 33% of the potential pool of respective participants. typically, due to responsibilities of these students in patient care areas or being at home post call, less than 50% would actually be available during random time blocks at the uth site. demographics of the prospective pool placed them primarily in the 2030-year-old range, mixed gender with ratios of approximately two male students to one female student, 95% of african ethnicity, and 5% a mix between east indian and middle eastern ethnicities. the survey was anonymous and had no personal identifying information beyond demographics mentioned above. peer educators were excluded from the survey due to potential bias. after collecting the completed questionnaires, the surveys were divided as follows based on student’s exposure to pre-clinical skills training: control group: the control group included 61 participants (potential pool of 139), 6 th and 7 th year students, without any exposure to the pre-clinical skills course. group 1: this was an intervention cohort of 23 participants (potential pool of 96), 5 th -year students exposed during their 4 th year to the initial preclinical skills course during january-march 2013. skills included physical exam, intravenous and foley bladder catheterization, nasogastric tube placement, and lumbar puncture). no assessments were required. group 2: another intervention cohort included 22 participants (potential pool of 36), fifth-year students, exposed to the second pre-clinical skills course during june-august 2013. skills included those listed above as well as airway management, cardiopulmonary resuscitation, and one standardized patient encounter. this cohort also had pal, and clinical skills assessments were required during a summative exam. a total of 108 questionnaires were completed and returned, two were excluded based on criteria (5 th year students who had not attended the course). sixty-one (43% of the potential pool) of the returned surveys were from the control group (6 th and 7 th -year students who had not experienced preclinical training) and forty-five (34% of the potential pool) were from the intervention groups (combined). data were grouped from the three-point subjective likert scale into a binary model to better view change versus no change. “prepared” and “very prepared” responses were summed and compared with the “not prepared” responses. likewise, the number of “very confident” and “confident” responses were summed together and compared to the “not confident” responses. question 3 was not answered by one student in group 2; this was noted but the rest of the survey responses were complete. statistical analysis was conducted using epi info version 3.5.4 stat calculator utilizing chisquared test (mantel-haenszel method) on the tabulated data. 7 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. results the pre-clinical skills course positively influenced the students’ sense of preparedness and confidence levels with the most dramatic changes in confidence seen in the second cohort exposed to pal methodology with assessments. question 1 indicated only 36.1% of the students in the control group acknowledged a sense of preparedness for their first patient encounter, compared with 90.9% reported by the intervention group exposed to the pal course (p value <0.001 table 1). student confidence levels in performing the various benchmarks of history taking, physical exam skills, procedures, and the application of critical thinking skills diagnostically also showed positive improvement after the introduction of the course. the control group reported 11.5-29.5% range in confidence in those skills compared to 77.3-86.4% range in the intervention group 2 after pal methodology was introduced with assessments (p value <0.001 questions 2-5 table 1). table 1: impact of pre-clinical skills training and the addition of pal on preparedness and confidence in medical students (p <0.001 on each question) control group intervention group 1 intervention group 2 pre clinical skills program description (no pre clinical training) 61/139 (n/pool) basic pre clinical program: 2 hours/week didactic lectures and 4 hours of lab/week (32 contact hours over 6 weeks) basic physical exam: demonstrated (limited supervised practice) procedures: intravenous & bladder catheterization, nasogastric tube placement, lumbar puncture no pal didactic testing no skills assessments 23/96 (n/pool) improved program: 6-8 hours/week of morning lectures and afternoon labs (50 contact hours over 8 weeks) basic physical exam: practiced with supervision procedures: intravenous & bladder catheterization, nasogastric tube placement, lumbar puncture. airway management, cpr, standardized patient encounter pal didactic testing skills assessments 22/36 (n/pool) questions: control n (%) intervention 1 n (%) intervention 2 n (%) 1. how prepared were you for your first patient encounter? 22 (36.1) (very) prepared 22 (95.7) (very) prepared 20 (90.9) (very) prepared 2. on your first days on the ward as a clinical student, how confident were you about your history taking skills? 10 (17.4) (very) confident 14 (60.9) (very) confident 19 (86.4) (very) prepared 8 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. 3. how confident were you with physical examination skills during your first days on the ward as a 5 th year? 7 (11.5) (very) confident 11 (47.8) (very) confident 17 (81) (very) prepared 4. how confident were you with the various clinical procedures e.g. cannulation, lumbar puncture, catheterization? 9 (14.8) (very) confident 8 (34.8) (very) confident 17 (77.3) (very) prepared 5. how confident were you at investigating patients, determining a diagnosis and differentials? 17 (29.5) (very) confident 10 (43.5) (very) confident 17 (77.3) (very) prepared the data indicates that the initial student cohorts exposed to the course were more confident than those who had no course. however, the second cohorts who participated in the pal methodology with assessments during the pre-clinical skills course were the most confident in their skills starting out in their clinical rotation (figure 1). figure 1. impact on pre-clinical skills training and the addition of pal on preparedness and confidence in medical students. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 5. how confident were you at investigating patients, determining a diagnosis and differentials? 4. how confident were you with the various clinical procedures e.g. cannulation, lumbar puncture, catheterization? 3. how confident were you with physical examination skills during your first days on the ward as a 5th year? 2. on your first days on the ward as a clinical student, how confident were you about your history taking skills? 1. how prepared were you for your first patient encounter? control group intervention group 1 intervention group 2 9 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. discussion the short initial pre-clinical skills course was effective in generating a sense of preparedness in the zambian medical students consistent with the findings by researchers in developed countries. 11-16 falk et al. specifically documented improved confidence in clinical skills of students preparing for surgical internships and though not taught initially, suturing was the skill most appreciated by students as the program developed into a full-year course. improved student confidence influenced academic progression, clinical procedural standardization, and development of a more culturally sensitive curriculum. 13 the medical students found transitional support between the preclinical and clinical training areas. ultimately, those confident students who became peer educators invested their time to sustain the pre-clinical skills program, despite increasing numbers of junior students and decreasing resources. peer educator training was initiated prior to teaching the second cohort of junior students and continued weekly throughout the school year. retention of these trainers was high through the years, and they reported how the program helped them to develop mastery of basic skills. this is consistent with previous research on tutors in other countries. 14 an extensive literature review on clinical skills training by bugaj and nikendi, published in 2016, referred to miller’s learning pyramid that distinguishes four levels of competence or training objectives knows, knows how, shows how, and does. as the student transitions from cognitive understanding to competence in performing the psychomotor skills on patients, it is beneficial to not only learn the skill but to demonstrate their abilities. this reinforces the need for practical skills training with assessments. 15 confident peer educators frequently reported a desire to pursue academics after completing their initial medical degree, a difference from their initial intentions. they reported how they enjoyed the “sense of family” that developed amongst the peer trainers as they worked together for the good of their future colleagues. wenrich et al. specifically researched the impact of a training program on clinical educators over a five-year period of time and noted significant improvement by the faculty in giving feedback to students and understanding their developmental needs. they also reported development of teaching tools and strategies for a more inclusive team approach. 16 in time, peer educators assisted with more clinical procedural standardization and culturally appropriate curriculum development. clinical students who had experienced the pre-clinical skills lab, either as only a student or a student and a peer educator, carried guidelines with them into their clinical years. during the full-year program, residents were also incorporated into the preclinical training program and later used these training rubrics for their clinical assessments on more senior students providing consistency between the two areas. truly sensitive and culturally appropriate preclinical curriculum would not have been possible without the involvement of the developing student educators. zambia is very culturally diverse with over 72 tribal/cultural groups. by integrating diverse trainers (who represented various tribal groups), a common bridge was established between the pre-clinical program and clinical training sites with appropriate transfer of knowledge. this was essential in the areas of development of standardized patients’ scripts for ‘“telling bad news’ and gender-based violence, differential diagnoses, and appropriate patient diagnostic work ups. for example, common presenting illnesses in an emergency department in zambia were malaria, hiv, and tuberculosis rather than myocardial infarctions, strokes, and obesity-related disorders which are more typically seen in the usa. the peer educators frequently suggested additional skills needed to better prepare medical students for the clinical experience. for example, when the nurses went on strike, the medical students were responsible for injections but had not received any previous formal training. neonatal 10 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. resuscitation was another skill introduced later in the training year after hearing of the shortage of nurse midwives and obstetricians to supervise the increasing number of hospital deliveries. neonatal resuscitation training utilizing a rubric provided a tool to practice skills safely before they found themselves in a critical life or death clinical scenario. transitional support was a byproduct of the pal methodology and helped students transition from the theoretical academic years into the challenging reality of the clinical experience with more confidence. these stark realities can be dauntingly incongruent as described by previous researchers in resource-limited countries. 12 despite the stress of working without common supplies or sufficient staff in the clinical area, students reported an improved sense of confidence when they saw the familiar face of a more senior peer educator. ultimately, through pal, the pre-clinical training program was sustainable. typically in a us medical school, pre-clinical skills are provided in small group settings (i.e., one experienced physician to 8-10 students). as previously stated, in zambia, the program was launched with one experienced physician for 96 students. utilizing paid, experienced physicians for lab instruction was cost and resource prohibitive, thus the mandatory introduction of the more cost effective pal methodology. as they took on the role of peer educators, they were empowered to continue making improvements in the program to better prepare their junior colleagues whether in the pre-clinical lab or at the bedside of the patient. this extension of the impact into the clinical setting has been described in plack et al’s research studying the impact of a fellowship program at a us institution. 17 in zambia, many additional skills were introduced including multiple standardized patient encounters, triage and disaster response, suturing, skills for pediatric evaluation, pelvic exam, and objective standardized clinical exam (osce) in subsequent years. as peer-educators’ ownership grew, so did the sustainability of the program. this was evident less than three years after the initial pre-clinical skills course was launched when they successfully trained 40 additional peer educators, followed by 169 fourth-year students during the 2015-2016 school year. this was the largest cohort of students in the medical school’s history and was supervised by national residents independent of expatriate involvement. pal is a valuable methodology and could be used beyond pre-clinical skills with proven application in a multitude of other settings where there is a shortage of trainers. research by sammaraiee et al. demonstrated this resource application to basic science labs and shiozawa, et al. specifically showed improved student learning of dissection skills. 18,19 resource limited nations such as zambia could benefit greatly with pal methodology in other lab areas to help with sustainability and encourage academic advancement for the trainers. one limitation of this study includes the paucity of objective testing results that could corroborate the more subjective data. during the time of initiation of this research, 5 th -year osce scores from the clinical programs were not collated and available. in 2013, some departments still had not launched this type of assessment during the clinical years. however, clinical faculty verbally reported “improvement” when comparing the intervention groups with previous students (without pre-clinical training). uncontrolled variables were additional limitations that could have influenced students’ reported preparedness and confidence levels. considerations include variation in personality, recall bias of the control group, previous curriculum exposure (nursing experience), and actual early clinical encounters and how they correlated with skills taught and attrition of skills. for example, the time between completing the training and beginning the patient encounters for group 1 was 6 months and for group 2 was less than 3 weeks. the use of a 11 snyder, chisenga mar 2017. christian journal for global health, 4(1): 3-12. three point likert scale on the questionnaire was time efficient and easy to answer, but limited the accuracy of the range of confidence responses. recommendations for future studies assessing the impact of a pre-clinical course include accessibility to correlated clinical osce scores, reducing recall bias, increasing qualitative triangulation, and improved specificity in the questionnaire. self-impression of preparedness and actual readiness based on skills performance can be two entirely different realities and altered with time in the clinical wards. the use of qualitative triangulation has proven beneficial in the research of plack et al. and suggests that improved preparedness reporting could be obtained through the process of correlating input from clinical faculty, trainers, and the student. 17 conclusions exposure to a pre-clinical training program, especially utilizing pal with assessments, had a positive impact on the sense of preparedness and confidence levels for medical students beginning their clinical training years at the university of zambia. integration of pal influenced academic development, clinical procedural standardization, appropriate curriculum additions, transitional support, and program sustainability. pal may have beneficial application extending to basic science lab instruction in resource-limited environments. recommendation for future research would be the integration of qualitative triangulation and reduction of variables in confidence data reporting. references 1. ali 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course to prepare students for clerkship assignment: tutees' and tutors' perspectives. bmc med educ. 2014;apr 4(14):71. http://www.dx.doi.org/10.1186/1472-6920-14-71. 15. bugaj t, nikendei c. practical clinical training in skills labs: theory and practice. gms j med educ. 2016 aug 15;33(4):doc63. http://dx.doi.org/10.3205/zma001062 16. wenrich m, jackson m, maestas r. from cheerleader to coach: the developmental progression of bedside teachers in giving feedback to early learners. acad med. 2015. nov 90(11).s91-s97. http://dx.doi.org/10.1097/acm.0000000000000901 17. plack m, goldman e, wesner m, manikoth n, haywood y. how learning transfers: a study of how graduates of a faculty education fellowship influenced the behaviors and practices of their peers and organizations. acad med.2015.march;90(3): 372-8. http://dx.doi.org/10.1097/acm.0000000000000440 18.sammaraiee y, mistry r, lim j, wittner l, deepak s, lim g. peer-assisted learning: filling the gaps in basic science education for preclinical medical students. physiol educ. 2016 sep;40(3):297-303. http://dx.doi.org/10.1152/advan.00017.2015. 19. shiozawa t., hirt b, lammerding-koeppel m. the influence of tutor training for peer tutors in the dissection course on the learning behavior of students. ann anat. 2016 jul 28;s0940-9602(16)30127-3. http://dx.doi.org/10.1016/j.aanat.2016.07.001. peer reviewed: competing interests: none declared. correspondence: cheryl snyder, san diego christian college, united states. clinicalskillsprof@yahoo.com cite this article as: snyder c, chisenga r. impact of a pre-clinical skills course with peer assisted learning (pal) on preparedness and confidence levels of medical students in africa. christian journal for global health. mar 2017; 4(1): 3-12. © snyder c, chisenga r this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.educationforhealth.net/text.asp?2010/23/3/339/101478 http://www.educationforhealth.net/text.asp?2010/23/3/339/101478 http://dx.doi.org/doi%2010.1007/s11845-009-0306-8 http://dx.doi.org/doi%2010.1007/s11845-009-0306-8 https://www.ncbi.nlm.nih.gov/pubmed/?term=blohm%20m%5bauthor%5d&cauthor=true&cauthor_uid=24708782 https://www.ncbi.nlm.nih.gov/pubmed/?term=krautter%20m%5bauthor%5d&cauthor=true&cauthor_uid=24708782 https://www.ncbi.nlm.nih.gov/pubmed/?term=lauter%20j%5bauthor%5d&cauthor=true&cauthor_uid=24708782 https://www.ncbi.nlm.nih.gov/pubmed/?term=huber%20j%5bauthor%5d&cauthor=true&cauthor_uid=24708782 https://www.ncbi.nlm.nih.gov/pubmed/?term=weyrich%20p%5bauthor%5d&cauthor=true&cauthor_uid=24708782 https://www.ncbi.nlm.nih.gov/pubmed/?term=herzog%20w%5bauthor%5d&cauthor=true&cauthor_uid=24708782 http://www.dx.doi.org/10.1186/1472-6920-14-71 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https://www.ncbi.nlm.nih.gov/pubmed/?term=lammerding-koeppel%20m%5bauthor%5d&cauthor=true&cauthor_uid=27476505 http://dx.doi.org/10.1016/j.aanat.2016.07.001 mailto:clinicalskillsprof@yahoo.com https://creativecommons.org/licenses/by/4.0/ letter to the editor july 2018. christian journal for global health 5(1):50-52. medical education as mission j dwight phillipsa and james d smithb amd, professor of pediatrics, department of pediatric and adolescent medicine, mayo clinic, rochester, minnesota, usa bmd, professor emeritus, otolaryngology, oregon health and science university, portland, oregon, usa we appreciate the insightful commentary of dr. mark crouch in his article the propper college,1 some of which was stimulated by our articles in an earlier issue of cjgh.2 in fact, we heartily agree with dr. crouch and add these additional comments to further emphasize some of the important points he raised. first, clinical medicine has value! no matter how excited we are and become about medical education as missions, we agree with dr. crouch’s plea: “don’t forsake clinical medicine.” as crouch clearly pointed out, jesus preached and healed. life is multi-faceted. ministry is multi-faceted. jesus saw crowds with compassion and urged his disciples to pray for more laborers — laborers who would compassionately work to help needy people. jesus himself demonstrated the value of clinical medicine as he saw the opportunity to heal as an emergent reason to “break” a sabbath law, and as he linked spiritual healing and physical cure as concurrent activities in patients who sought him. god directs each of us to balance many opportunities—teaching medicine, preaching the gospel, healing the sick, caring for the dying, studying existing problems. we show our multi-faceted love for god as we love him with our heart and soul and mind and strength. education is important, and some of us get to concentrate a lot of time and effort on education; but, this does not in any way decrease the importance of practicing clinical medicine. second, humility matters! crouch wisely said that those who take on “the mantle of teacher” are required to demonstrate humility. indeed, every christian, health worker or not, is called to humility. examples abound of well-intentioned missionaries who caused unintended harm due to arrogance. readers of the poisonwood bible as well as readers of when helping hurts are graphically reminded of the importance of humility in medical missions. we all need to grow in humility. we must, as crouch clearly states, recognize the limitations of our training and knowledge. we must keep learning about local illnesses, about cultural variations, and about effective ministry. we must daily avoid power differentials whereby “we” hold the power over “them,” be it by “us” being healthier or wealthier or more educated or taller or whiter or louder. god, through paul, calls us to be transformed by the renewal of our minds; we must humbly keep learning. we must recognize limitations. we must be willing to learn, even from those we came to serve. third, teaching must be relevant! we each have the privilege of teaching in many parts of the world, and we do not repeat the same “lessons” in each setting. medical training must be adapted and relevant based on local disease epidemiology, diagnostic means, and feasible treatment resources. some basic science facts remain relevant across geographic boundaries, but the application of scientific knowledge must be made relevant in various situations. in addition, treatment must be communicated clearly across cultural and linguistic barriers. effective teaching requires adequate understanding of local situations. one visiting short-term medical missionary knew that her young age and female gender might not be respected in the male-dominated area she was visiting. a man 51 phillips & smith july 2018. christian journal for global health 5(1):50-52. entered the exam room with a clinic card on which the chief complaint, “swelling in groin,” was written. she greeted the man and asked him to drop his pants. he stared at her, incredulous. prepared for being disrespected, she firmly explained, “i am the doctor. drop your pants.” her words had to be repeatedly translated before he complied. she then carefully examined his genital anatomy and explained, “everything is normal. there is no problem.” “of course,” he exclaimed, flabbergasted and still naked, pointing across the room to his son saying, “he’s the patient.” in clinical care and in educational ministry, we must always understand local situations before imposing our knowledge on others. fourth, focus properly! jesus is building his church, and he calls us to participate relationally with individuals and with groups of people. it is not necessarily our responsibility to build institutions. the goal is to see people grow to true whole-person health: physically, emotionally, mentally, and spiritually. the goal is not to sustain institutions but, rather, to help people as jesus builds his eternal institution. very few medical institutions are financially sustainable; essentially, all either depend on governmental help or philanthropic donations to continue functioning. the call to appropriate stewardship of resources is wise, but service is the goal, not sustainability. crouch wisely urges us to keep our focus, whether caring or educating, on people rather than on institutional structures. we affirm this, even as the institution where one of us works (mayo clinic) says, “the needs of the patient come first.” patient centricity has been effective as mayo clinic has grown to be a leading medical institution in the world, with a highly ranked medical school and active research activities. focus on people! finally, modeling matters! we have heard details about the work of mark crouch in asia. we have observed as he taught in the united states. we have read and re-read his helpful writing in cjgh. mark crouch is a role model, and, we should all be role models. we teach by our actions. true education is much more than the transmission of information; it involves changing lives as people learn how to act based on proper information. jesus taught in sermons, through stories, and while serving. care and education should benefit whole persons, and models such as prime3 are helpful in guiding learners toward whole person care. all education should be multi-faceted. teachers living by the “medical education as mission” framework espoused in cjgh will communicate factual knowledge. they will help learners understand new information, and they will model the implementation of improved patient care. we are grateful for the comments of mark crouch, comments to keep educators relevant and real, humble and helpful, and compassionate and kind. like crouch, and like jesus, we can all join in ministry around the world, ministry that involves a personalized mix of clinical care and educational expertise. references 1. crouch m. the proper college. christian journal for global health 2017;4(1):30-3. https://doi.org/10.15566/cjgh.v4i1.157 2. smith jd, holland rp, phillips jd, falkenheimer sa. mobilizing and training academic faculty for medical mission: current status and future directions. christian journal for global health 2016;3(2):168-75. https://doi.org/10.15566/cjgh.v3i2.134 3. morgan h. prime partnerships in international medical education — restoring a christian ethos to medical education worldwide. christian journal for global health 2016;3(2):134-9. https://doi.org/10.15566/cjgh.v3i2.127 https://doi.org/10.15566/cjgh.v4i1.157 https://doi.org/10.15566/cjgh.v3i2.134 https://doi.org/10.15566/cjgh.v3i2.127 52 phillips & smith july 2018. christian journal for global health 5(1):50-52. competing interests: none declared. correspondence: j dwight phillips, department of pediatric and adolescent medicine, mayo clinic, united states of america. jdwightphillips@gmail.com cite this article as: phillips j d, smith j d. medical education as mission. christian journal for global health. july 2018; 5(1):50-52. https://doi.org/10.15566/cjgh.v5i1.214 © phillips j d, smith j d. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:jdwightphillips@gmail.com https://doi.org/10.15566/cjgh.v5i1.214 http://creativecommons.org/licenses/by/4.0/ historical review june 2014. christian journal for global health, 1(1):16-25. faith and health: past and present of relations between faith communities and the world health organization the rev. canon ted karpf a a th.m. former partnerships officer, who headquarters 2003-2010, and retired priest living in rural new mexico abstract relationships between faith communities and international multi-lateral organizations can be complicated. while there is potential for synergy between the two, different values often characterize the approach of each. the history of these relationships is illustrative. this review describes collaboration between the world health organization (who) and faith-based organizations (fbos) in the implementation of primary health care, the role of spirituality in health, community responses to the hiv pandemic, and definitions of quality of life containing spiritual dimensions. however, important gaps persist in the appreciation and measurement of the contribution of faith communities to health assets on the part of governments and the who. fbos can still draw from the nine points developed in the 1960s as a timetested viable agenda for current and future operations. introduction it seems to be time for the christian community of health care providers and the international multi-lateral organizations to work together, again! we’ve been here before. this “revolutionary” movement of service provision or resource sharing among governments, ngos, and faith-based organizations is not new but has quite a history of periodic relating and long-term neglect. since the middle ages, the establishment and maintenance of institutions to care for the sick has been the priority for the western christian church. in his book, sent to heal!, christopher grundmann describes that in the 16 th and 17 th centuries the jesuits and franciscans sent missionaries to the new worlds: africa, asia, and the americas, where they practiced medicine, surgery, and pharmacy. 1 christian polities of other colonizing nations soon followed suit. english missionary, samuel marsden, founder of the church missionary society’s mission to the maori in new zealand in 1819, used the term “medical missionary” in a letter where he requested physicians to assist him in mission. 1 the term “medical missions” occurs formally for the first time in the official records of the edinburgh medical missionary society in 1842. the ecumenical movement and the rise of christian health services the christian approach to health improvement as mission work was born out of the belief that there is something peculiarly christian about the business of health and healing. jesus healed. the beneficiaries of his ministry were not primarily the rich or the strong, although these were by no means excluded. they were the poor, the sick, the stigmatized, and the disabled. when missionaries observed the needs for both improved hygiene and basic medical services and 17 june 2014. christian journal for global health, 1(1):16-25. responded to both, the interrelationship between mission, public health, and health care delivery began. in the 1960s, the ecumenical movement and widespread christian engagement with missions and health care services came together to give rise to the creation of the christian medical commission (cmc). cmc became a forum through which theologians, christian missionaries, and health care service providers explored the meaning of their work in the context of the broad social justice movements emerging around the globe. diane smith brilliantly compiled the history of cmc, documenting the seminal tubingen consultations and the initial world council of churches/world health organization collaboration. the reader is encouraged to consult smith’s history, which was published in the last double issues of the world council of church’s magazine contact in the summer of 1998. 2 highlights include discussions of the following: the role of christian health care providers, the relationship of role and mission, the process by which religious institutions came to work with other entities to extend their influence, and the broad range of health services that religious institutions had come to provide in the countries where they had missions. smith’s history is notable for its honesty. most christian medical missions tended to make the same mistakes that other aid groups made in their inability to fit themselves to local circumstances, to nimbly scale up or down, and to assume their cultural mindset matched the local reality. a great contribution of this seminal latetwentieth century work was the recognition that collaboration across denominations or sectors of influence (health, government, faith-based organizations) was usually more effective than competing for scarce resources or than operating in isolation. as both the christian medical commission and the world council of churches became more articulate about their distinctive contribution to the delivery of quality preventive and curative health services across the globe and as more former missionaries entered leadership roles in health agencies (such as the u.s. centers for disease control and the world health organization), it became possible for religious and secular agencies to dialogue about common problems and to develop joint strategies to solve them. christian medical commission and primary health care as smith recounts, on 22 march 1974, dr. halfdan mahler, director-general of the world health organization (who), called together senior staff for a joint meeting with all five senior staff of the cmc. as a result of this meeting, a joint committee was set up to explore the possibilities of collaboration and cooperation in “matters of mutual concerns.” in spite of the disparity in size, the relationship between the two organizations turned out to be exceptionally fruitful. the most significant result of the cmc/who relationship was the formulation by who, in 1975, of the principles of primary health care (phc). this marked a radical shift in who priorities, with massive implications for health care systems everywhere. at who’s 1976 assembly, dr. mahler called for the use of primary health methodology to make health services available to all by the year 2000 and offered the facilities of who to analyze the problems of each country, so as to enable development of health policies and targets which would help national governments achieve this goal. the proposal was adopted and became the subject of the international conference on primary health care held in alma ata in the ussr (today almaty, kazakhstan) in september 1978. cmc was closely involved in planning and many presenting came from members of the cmc family. this moment was a zenith for the work of cmc and its constituents. 18 june 2014. christian journal for global health, 1(1):16-25. in this process, who was trying to develop a simple and easily understandable methodology which could be replicated and which carried a stamp of approval that might make it acceptable to governments. however, making phc universal through governmental programs created its own problems. the original vision of phc had been a force for liberation and empowerment through the promotion of health care. once it had been watered down to methodology acceptable to governments, it could no longer address key issues such as corruption and oppressive systems. governments interpreted placing “maximum reliance on available community resources” as a means of saving costs. meanwhile, cmc and other ngos made every effort to promote the original concept emphasizing the need for community involvement and the need to draw in other sectors, such as agriculture and education. however, gradually phc came to be a topdown government approach, rather than bottom-up people’s initiative. 2 a parting of the ways within a year, who and wcc-cmc parted company, heading in different directions. dr. charles elliott, a priest and economist, addressed the cmc annual meeting with his talk, “is primary health care the new priority? yes, but . . . .” meanwhile, james mcgilvray wrote in contact in the same year that phc was all but dead and decried the top-down philosophy. while there was no formal disagreement per se in terms of relations between who and wcc, there was clearly a cooling of relations. elliott’s words seem to sum up the dilemma and opportunity. we have a lot in common with who, but our ultimate aims are not the same. for a christian organization to ignore the importance of the spiritual dimension of health is for it to ignore the really crucial input it has to make to the debate about the nature of healing. health is more than medicine. it is to do with the way you live and way you die, the quality of life and the quality of death. the ultimate answer to disease lies in a way of life – a life of surrender and obedience that leads to wholeness. 2 where wcc represented the ecumenical movement with the ambition and dream of christian unity, the who serves government as the world’s public health agency. the tensions about government and the traditional secular/sacred debate, not to mention the christian view of the world versus many other religions or cultures, were real and often intractable. collaborating in an environment in which the dream of primary health care was subverted to a government program was, in itself, enough to quell enthusiasm if not end most collaborations and meetings of concern. but like many governmental and faithbased health care service provider relationships, they never expanded and deepened to meet the hopes and expectations of the various parties, and they never went away completely enough to ignore. they simply co-existed while change and development moved forward or backward depending on which country and the state of government relations at any specific time. hiv/aids the gathering storm of a worldwide hiv/aids pandemic through the 1980s and 1990s created both a crisis and an opportunity for those interested in the intersection between christianity and health mission work. without going into detail, it is safe to say that there was great division in christian churches about hiv/aids. debates raged about sin and sickness, justice and decency, sexual activity and god’s judgment, the theology of disease, and the role of guilt. such debates broke out in all quarters within and without christianity and through organized religion as a whole. many communities of faith stepped up to provide basic support services to people living with hiv/aids, and some faith-based health service providers re19 june 2014. christian journal for global health, 1(1):16-25. ported systems at near breaking points in the face of such a health threat. larger polities and denominations also began to engage with aids mission work led often by individuals dedicated to meeting human need. in the mid-90s, as the wcc was preparing for its world assembly at harare, a long issue of cmc contact was devoted to hiv/aids. wcc also commissioned a report for harare that was widely researched. it reported on what christian communities were doing around the world to support those living with hiv/aids. this author was one of those interviewed for that report in a full day seminar at the us national council of churches in new york. the report cited extensive hiv/aids ministries supported by larger polities difaem (german institute for medical mission and founding member of the cmc), lutheran world service, and the anglican communion through their respective member churches or dioceses, united methodist board of global ministry aids program, christian aid in the uk, norwegian churches, and agencies like aus aid. in more challenging and developing world societies, repeated attempts by the wcc and by national ecumenical and local church councils were slowly succeeding in creating local, indigenous, and more generous responses to hiv/aids. but the long separation between theology and health care at the congregational level left the clergy unknowing about matters relating to health care, basic biology, and the process of disease and, thus, unable to speak in coherent meaningful ways to either their congregations or those infected with hiv. thanks to the treatment literacy growing out of aids activism, those infected often had a better understanding of their disease than their families, community, or the congregation, and, too often, their personal stories and witness outside the community invited others to take action in their behalf. quality of life, and spirituality, religious and personal beliefs during that same period, the littlepublicized department of mental health of the who published a report from the who consultation on quality of life and spirituality, religiousness and personal beliefs (srpb) held june 22-24, 1998 in geneva. the objectives for the meeting were as follows:  to explore the meaning of srpb as it relates to the quality of life and health.  to define, as clearly as possible, potential facets of srpb.  to review existing facets and propose additional facets to the who qol.  to suggest facets which may apply to some religious groups and not others (in the same way that national items have been included in the who qol-100).  to begin to draft some items.  to produce a broad protocol for followup work at country level to produce a module. 3 the whoqol is an instrument developed for measuring quality of life. from the manual, “these instruments have several uses, including use in medical practice, research, audit, health services and outcomes evaluation, and in policy making”. 3 the document goes on to say, until recently the health professions have largely followed a medical model, which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and faith (in healing, in the physician and in the doctorpatient-relationship). this reductionism or mechanistic view of patients as being only a material body is no longer satisfactory. patients and physicians have begun to realize the value of elements such as faith, hope and compassion in the healing process. the value of such ‘spiritual’ elements in health and quality of life have led to research in this field in an attempt to move towards a more holistic view of health that includes a nonmaterial dimension emphasizing the connectedness of mind and body. research in such areas as psychoneuroimmunol20 june 2014. christian journal for global health, 1(1):16-25. ogy, for example, has shown the linkage between how we feel and how our physical health, in this case the immune system, can be affected. examples of mind body relations are the essence of psychosomatic medicine. 3 while the report was published and circulated, it bears the standard who disclaimer,“ this document is not a formal publication of the world health organization and all rights are reserved by the organization.” 3 in order to provide an exhaustive understanding of the great traditions, the document included background essays by hindu, buddhist, muslim, christian, and jewish scholars and health professionals to ensure that the spiritual traditions and ethics of each tradition was included and explored. this was a first for who exploring the values and role of faith from the health perspective. another historical note is found in the introduction on page 4 stating: since the1983 world health assembly, the issue of dealing with the ‘nonmaterial’ or ‘spiritual’ dimension of health has been discussed extensively. a resolution of the 101 st session of the executive board in 1998 requests the director general to consider an amendment to the constitution of the who defining health as “a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity.” 3 this resolution was considered at the fiftysecond world health assembly in may 1999 and was tabled without a concluding vote. thus, this issue remains on the table of the assembly to be reconsidered at any time. hiv and qol finally, regarding hiv/aids, the same report included a summary of a who global program on hiv/aids consultation was held in the previous year, 1997, which attempted to describe facets to be added to the srpb domain. these were generated for a module created for people with hiv/aids in order to provide a starting point for a more general srpb module. a review of the seven areas focused upon in this meeting were as follows: meaning of life, forgiveness, beliefs, spiritual connectedness, personal spiritual experience, feeling of harmony with past, present, and future, death and dying. 3 these same thematic areas remained a focus throughout the worldwide hiv/aids pandemic and helped form a foundation for the who hiv/aids program of outreach to faith communities and a touchstone for the hiv/aids program from 2004-2011. with the advent of the “3 by 5” initiative, created in 2003 by the late who directorgeneral dr. j.w. lee, led by dr. jim kim, and endorsed by the who assembly in 2004, a target was set that three million hiv+ persons should be in treatment by the close of 2005. that would be a virtual doubling of the number of persons in treatment in three years. it was a noble goal that was missed in 2005, but reached in 2006! for the first time in many years, though, the self-conscious attention of the who turned again to faith communities, which both operated health services and offered hope, help, and potential resistance in meeting this target. the lack of government response and enthusiasm in both prevention and treatment of hiv/aids made it evident that other allies were needed beyond the treatment communities of the infected and international ngo providers like médecins sans frontières – msf (doctors without borders), aids action, persons living with hiv/aids, and other coalitions worldwide. health agencies seek faith-based partners again at the same time, unaids saw a remarkable opportunity in many countries to bring together grassroots coalitions and communities to support and expand upon the “3 by 5” initiative. securing the leadership of ms. sally smith, a nurse and former medical missionary in nepal, unaids undertook grassroots organizing workhttp://www.doctorswithoutborders.org/ http://www.doctorswithoutborders.org/ 21 june 2014. christian journal for global health, 1(1):16-25. ing alongside former candidate for holy orders and danish gay rights activist, mr. calle almedal. smith, specifically, reached out to faith communities with a dynamism that became an instant hallmark of the unaids program. the ongoing work of documentation and consultation became the style undertaken by ms. smith, but it was evident then that the aids effort needed faith communities to promote aids prevention and education, along with their ongoing work to create healthier communities and nations. who, likewise, perceived the necessity of sending an envoy to communities outside of their usual national public health constituency to reach out to communities of people with hiv/aids as well as to faith-based organizations and faith communities and to business and trade unions. i was recruited among several activists for the program as a long-time aids advocate who was a missionary canon for hiv/aids in southern africa through the anglican communion and supported by usaid. i served in the us public health service as the nation’s first hiv/aids liaison specialist, recruited by kim to be that envoy. i was directed to recruit faith communities and communities of the affected and infected to support and assist in garnering national and international support for the who hiv/aids program of treatment expansion to meet the 2005 target. i joined the program in spring of 2004 and by january 2005 had built a small team to reach out to international partners: plhiv organizations, hiv/aids ngos, and faith communities, alike. however, there was a deep resistance on both sides of the equation, particularly about the role of faith communities, who were often cast as those who condemned people living with or affected by hiv/aids. since the 1980s, there had been no systematic data collected about faith communities and their religious health assets, particularly the scope of what they actually did. the relative failure of the world to reach “health for all” by 2000 created fallout and distrust, and as a result, there had been little substantive communication with the wcc or cmc for nearly a decade. there were also new players in the international health and development arena: islamic relief, adventist development and relief (adra), catholic relief services (crs), american jewish world service (ajws), caritas internationalis, world vision, aga khan foundation, a number of hindu-related health and hospital systems in india, brac in bangladesh, buddhist hospices in thailand, myanmar, and cambodia along with a number of us-based super churches, all claiming to be doing aids/hiv work. many of these organizations had developed relationships with the us government through domestic and international contracts and agreements. to address the evidence gap and go beyond mere anecdotes and stories, in july 2005, who commissioned the interfaith health program of emory university rollin’s school of public health in collaboration with the university of cape town to study the actual “on the ground” shape of religious health services within several districts of zambia and lesotho. along with this study, the european union funded several studies on the same districts around internationally funded hiv/aids programs to determine their efficacy and efficiency and to document their relationships with the local, regional, and national government. the global fund also funded who to monitor several studies to determine how international funding was flowing to faith-based organizations and identify the relative percentage support given to faith-based organization in comparison to other communitybased ngos. the project was known as the italian initiative. meanwhile, who assisted wcc in reconvening faith community health service providers to discuss and plan for more effective hiv/aids services and to study primary health care. who and unaids also funded several denominational and faith community studies to “get a handle” on who was doing what with whom. for four years, a flurry of studies yielded startling and yet consistent information about what was going on in the field by faith communities and their sponsored health services. 22 june 2014. christian journal for global health, 1(1):16-25. impact of religious health assets in late 2006, the arhap report, as it came to be called, appreciating assets: the contribution of religion to universal access in africa mapping, understanding, translating and engaging religious health assets in zambia and lesotho in support of universal access to hiv/aids treatment, care and prevention, was presented to who at an international press conference at washington national cathedral, washington, dc, in february 2007, with active participation by un agencies and faith communities with representatives from around the world. 4 the findings of the “arhap report” were both clear and tentative. it was evident that there was a long way to go to fully describe and understand what had been happening on the ground with the work of religious communities. that faith-based organizations were significant in health care delivery at the country level could no longer be questioned. who claimed that religious health assets (rhas), which were sponsored by faith communities, faith-based or faithinspired, organizations, could provide up to 40% of the health services in any given country. these rhas were primarily dedicated to health care and were less concerned about the faith or faith traditions of their founding, but that they were “unafraid” to claim faith was not a matter of controversy. more specifically, the arhap report also revealed a much more pragmatic response in a broader way to include traditional healers, sangomas, witch doctors, as part of the overall community health service system. it was a more nuanced, diverse, and wider-reaching landscape than who had expected. the arhap report had also demonstrated that there was also a problem with the actual tool used by who health mapping program. while the who reported a minimal number of health services in the researched area, arhap investigators found literally hundreds of providers. further investigation and conversations within the who leadership revealed that the services availability mapping and readiness assessment (sam) simply missed or overlooked longtime, well-established facilities operated by religious foundations or religious communities. the unique identifiers were skewed in such way as to overlook the “who or what” entity that provided the health service depending on the notion of whether or not they were a for-profit or nonprofit entity. in 2009, a consultation convened in partnership with the us-based center for interfaith action on global poverty (cifa), the world council of churches, and who; it was held to develop a consensus on how health mapping could be enhanced with the fine-tuning of the unique identifier. the who-cifa report contained in the archive of the anglican health network executive summary reported it this way: based on who's tool and methodology for assessing and mapping health services availability and readiness (sam), working groups discussed standard approaches to data collection, management, use, and dissemination for mapping data that represent the value added by fbos in health services delivery, especially those religious health assets deemed to be intangible or at least difficult to quantify. specific modifications to the services availability and readiness assessment (“sam”) core instrument were suggested, including the addition of a module to represent specific interests of fbos (e.g., provision of free or concessional care, capacity for spiritual care providers and volunteer staff, and provision of psychosocial services, including bereavement services). 5 back to primary healthcare in 2008, building from common foundations: the world health organization and faithbased organizations in primary healthcare was published jointly by the who and geneva global performance philanthropy, a us-based global philanthropy organization. the summary was produced for a first consultation with the faith community since alma ata (1978), marked the 20 th anniversary of the declaration, and noted the changes in faith-based interactions with 23 june 2014. christian journal for global health, 1(1):16-25. who and updating of primary healthcare. who had begun a primary healthcare initiative in late 2006. reinvigorating primary healthcare and strategic partnerships for health in light of the relative success of the “3 by 5” effort became a priority, and while the 2008 world health report on primary healthcare said virtually nothing about the role of faith-based organizations and the history of the primary healthcare initiative since 1968, it curiously validated the results sought by the wcc in 1978. the who report called for decentralization and communitydeveloped services and responses to health crises. three decades of government-managed phc had produced mixed results at best and only represented a portion of the primary healthcare revolution, which had continued unabated in the faith communities since the 1960s. the introduction to this who report contains these words: the report notes the revival of the primary healthcare and health systems debate with who. this report also emphasized that if who wants to encourage this framework as a more sustainable system of health servicing and delivery, including fbs, although not always easy, is necessary to achieving desired coverage. as the who documentation shows, fbos cover about 40 percent of the healthcare and services in africa alone. but they tend to operate outside governmental planning exercises and are, therefore, generally unrecognized. this has significant implications for how new initiatives are—such as the international health partnerships and others, as well as funding mechanism – design, plan and deliver national health programs. varied assets used by fbos – physical, human and community support – have great potential for increased value to the benefit of their communities and nations. the report details how engaging with fbos will bring challenges, but the authors conclude that all parties stand to gain by this approach. ultimately the communities that both who and fbos seek to serve will be better cared for, and the possibility of achieving the mdgs will be enhanced. 6 other studies commissioned in the same years also demonstrated the inherent inequities of financial support for faith-based, targeted ngo programming and services from multi-laterals such as unaids, global fund, european union, unaids and who. yet service provision by faith-based health services or religious health assets could be evaluated and accounted for if only these entities were asked for their data. data was kept, details were measured, and quality controls enumerated and accounted. in many ways, the rhas were competing with profit and non-profit organizations alike, through local chapters of transnational organizations like lutheran world service, tearfund, christian aid, catholic relief, caritas internationalis, anglican health network, adventists development and relief association (adra), office health ministries-seventh day adventist church, and specific consortia or associations, like christian health associations. all of this was happening at the country level. mdg’s and foundational partnerships with these results and the urgency of international health issues pressing on the leadership of the united nations and the drive to meet the millennium development goals (mdgs), many of the un agencies and specialized programs began reaching out to faith-based organizations and religious communities in an effort to enroll communities and nations in the mdg process. among the global leaders who reached out was dr. thoraya obaid, a muslim from saudi arabia, who was appointed director of unfpa. she announced in the first meeting with unfpa board that she would reach out to faith communities who both supported and challenged the aims of objectives of the population agency. she pointed to the board and to leaders in the un system that she needed all players at the table. in that spirit, they came. in 2008, unfpa 24 june 2014. christian journal for global health, 1(1):16-25. established the global interfaith network on population and development, representing an agreement of faith communities around the world on principles of working together and with unfpa to combat global challenges of maternal death, aids and poverty, violence against women, and issues related to youth and migration. again, with her leadership at the center, in 2009, dr. obaid invited all the un agencies to collaborate and promote discussion across the un agencies on the role of faith groups through a un inter-agency taskforce on engaging fbos in development that she established. more importantly, all the un programs and un specialized agencies and institutions sent representatives to the meeting, demonstrating again that there was global activity among and interest in such entities. through these activities, a variety of studies were launched and completed by 2010. each of them pointed to a paucity of measurable verifiable data and a dearth of anecdotal information. un administrators keep calling for scientific or empirical data to establish a solid and reliable foundation for government engagement with religious entities at country level. that said, the real evidence is that rhas are there and actively engaged already. while it is still painfully true that they do not appear on who health maps (previously discussed), the work continues, nonetheless, and agreements are being made in a non-systematic way. perhaps the more important information is what is going on since 2010, with whom, why, and how? summary thus, this “revolutionary” movement of service provision or resource sharing between governments, ngos, and, now, faith-based organizations is not new. while it is evident that there have been moments of great flourishing and expansion of international health work with faith-based organizations, there have also been times of neglect, disinterest, and even distrust. however, relationships between multilaterals and un agencies and programs have often been brokered by the world council of churches and the christian medical commission, since the late 1960s. the moment is right, though, for ongoing engagement and expansion of collaborative work with faith-based or faith-inspired organizations. it is already underway, built on a foundation of hundreds of years of christian mission work as well as a recent, careful, and more researched international readiness. with or without studies, it is still patently clear that religious health assets (rhas) are still providing healthcare services to communities and persons in need. the fact remains that in who-generated health service area maps, governments still tend to ignore most activities by faith-based organizations, with the notable exception of the christian health association of kenya (chak) that is identified as part of the nation health plan of kenya. this makes chak accountable for delivery of certain health services to meet certain national goals and objectives. the fact remains that the mission and purpose of government and of faith communities is still a variance and should be. nonetheless, there remains a common purpose caring for those in need. the original nine points identified in the mid-1960s are still a viable agenda for considering health services provision by faith communities. these include the following: comprehensive health care, community organization, cooperation with governments and other agencies, interchurch coordination and cooperation, planning mechanisms appropriately structured in regional and local organizations, re-orientation of personnel, need for administrative reorganization, data systems, and facing the problems of population dynamics. 1 finally, as a postscript, the notion of “prophetic” ministry (which holds in tension the demands for justice and enactment of mercy in our own time) and the larger concerns of justicemaking as part of the reason for providing health services and health care need to be debated, yet again, to ensure that the charism (calling) to health and healing are held in tandem. 25 june 2014. christian journal for global health, 1(1):16-25. references 1. grundmann ch. sent to heal! university press of america, inc. boulder: 2005. [p.1, 8] 2. smith d, editor. a christian medical commission [contact no.161/162] june. geneva: 1998. available from: https://www.oikoumene.org/en/what-wedo/health-and-healing/con161162_p218.pdf [last accessed on 8 april 2014] [p. 2,16, 8-10.] 3. world health organization. whoqol and spirituality, religiousness and personal belief (srpb), a report from who/msa/mhp/ 98.2.geneva: 1998 [p. 3,4,6] available from: http://www.scielosp.org/scielo.php?pid=s00349102003000400009&script=sci_arttext&tlng=en 4. african religious health assets program. appreciating assets: the contribution of religion to universal access in africa: mapping, understanding, translating and engaging religious health assets in zambia and lesotho in support of universal access to hiv/aids treatment, care and prevention. geneva: 2006. available from: http://www.arhap.uct.ac.za/pub_who2006.php [last accessed 9 april 2014]. 5. world health organization. executive summary: who-cifa consultation on ngo mapping standards describing religious health assets, march 2010, world health organization and center for interfaith action on global poverty. geneva: 2010. [p.3] available from: http://www.anglicanhealth.org/resourcespage.aspx [last accessed on 9 april 2014]. 6. karpf t, ross a, editors. introduction: building from a common foundation: the world health organization and faith–based organizations in primary health care. geneva: world health organization, december 2008. [p.4, 8] this article is peer reviewed competing interests: none declared. correspondence: the reverend canon ted karpf, post office box 6654 santa fe, nm 87502-6654, usa ted.karpf@gmail.com cite this article as: karpf t. faith and health: past and present of relations between faith communities and the world health organization. christian journal for global health (august 2014), 1(1): 16-25. © karpf, t this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.oikoumene.org/en/what-we-do/health-and-healing/con161162_p218.pdf https://www.oikoumene.org/en/what-we-do/health-and-healing/con161162_p218.pdf http://www.scielosp.org/scielo.php?pid=s0034-9102003000400009&script=sci_arttext&tlng=en http://www.scielosp.org/scielo.php?pid=s0034-9102003000400009&script=sci_arttext&tlng=en http://www.arhap.uct.ac.za/pub_who2006.php http://www.anglicanhealth.org/resourcespage.aspx mailto:ted.karpf@gmail.com http://creativecommons.org/licenses/by/4.0/ commentary may 2016. christian journal for global health, 3(1): 73-76. christian involvement in sustainable development goals raymond downing a a md, senior lecturer, department of family medicine, moi university school of medicine, kenya introduction the sustainable development goals (sdgs) describe the world we all want: no poverty, zero hunger, good health for all, reduced inequalities, sustained economic growth, peace and justice. 1 we, christians, want these as much as anyone. these goals, however, are for the post-apocalyptic world, the world after the return of christ. the distinction is important. the world we long for, where there is no mourning or crying or pain or death, will come, but only after the fall of babylon who bragged that she would never be in mourning. 2,3 it was a reasonable brag, in light of the considerable political and economic power of babylon — of all babylons. 4 the kings and merchants of today's babylons have enough excess wealth to be able to imagine a world with no poverty or hunger or inequality, to even set sustainable goals to achieve those ends. but the biblical narrative does not see babylon and its kings and merchants as achieving zero hunger and good health for all and an absence of the mourning that goes with death and disease. it sees rather the collapse of babylon. nevertheless, the bible is quite clear about hunger and poverty and peace and justice. from leaving the gleanings of the field for the poor and sojourner in leviticus 19, through the multiple injunctions in psalms and proverbs about concern for the poor and isaiah's blunt “seek justice, correct oppression, defend the fatherless, plead for the widow,” to jesus' spelling out what he had been doing, “the blind receive their sight, the lame walk, lepers are cleansed, and the deaf hear . . . ,” and james' exposure of the injustice of “the wages of the laborers who mowed your fields, which you have kept back by fraud,” the biblical ideal looks a lot like the world of the sustainable development goals. 5,6,7,8,9 consequently, the christian journal for global health has called for papers to explore christian involvement in sdgs. recognizing that in the new sdgs “there is very little specifically related to healthcare,” the journal notes that the sdgs “express a more sophisticated recognition of the complexities of determinants of human health” including social determinants of health. “the public sector is increasingly recognizing the key role of religious health assets in sustaining progress in development. . . . in order to retain credibility for this work and message, christians are called to use contextual language, to measure, evaluate, and report outcomes. . . . ” 10 this paper seeks to examine the involvement of christians with the sdgs. certainly, if someone's faith and institutional religious affiliation helps to improve the health of people, that it is, in fact, a social determinant of health, that is useful. but why are we as christians interested in the “the key role of religious health assets in sustaining progress in development,” which “the public sector is increasingly recognizing?” 10 “religious health assets” are clearly sociological qualities, part of the social determinants of health. any religion offers this; there is nothing distinctly christian about it. christians should be free to offer their religious health assets — recognizing that this is no more distinctively christian than, say, a christian surgeon performing technically good surgery. the key role of christianity cannot just be a piece of a development goal, a quality to make that goal more attainable, to make more people 74 downing may 2016. christian journal for global health, 3(1): 73-76. healthy. our faith is not subject to measurement; we were not left on earth as christians to help accomplish some global development goal. why should we want “to retain credibility for this work and message?” 10 are we trying to gain the praise and respect of the world or fit in with their agenda? our first task as christians should be to critique the development goals themselves and the means of arriving at them. what is this development that is now so assumed that we can remove the word “development” from sustainable development goals and simply call them “global goals?” 11 the appearance of this development coincided with the conclusion of wwii and the ending of the colonial period. 12 the “developed” world, the rich countries which had just nearly destroyed each other for the second time in one generation, decided that the rest of the world needed developing. for the next half a century they debated the nature of this development, a debate that took place in the context of the new cold war. the soviet union and its allies believed that development would come about through central government planning, employing socialist or communist principles. the west believed that the capitalist market alone was sufficient for development. yet, note that for both sides there was a fundamental agreement on two points: 1) the rest of the world, the “third world,” needed “development,” and 2) the key to development was economic: development meant economic development. all other aspects of national interest, culture, history, environment, and religion, were secondary. however, with the collapse of the soviet union, there is no longer a debate on how to arrive at this economic development. “development” now has only one meaning and one method: free markets. and in order for market economies to function, they must grow. yet by the 1970s, it was very clear that the earth and its people could not withstand unlimited industrial growth, which was tied to unlimited economic growth. books with titles like limits to growth and small is beautiful appeared; their titles speak for themselves. the development discussion was maturing, and christian thinkers were at the core of this discussion. in 1964, jacques ellul's the technological society appeared in english. 13 here he made clear that despite economic differences between east and west, both were committed to technology as the means of “progress.” unfortunately, there are no built-in negative feed-back mechanisms to the growth of technology. we have an imposed “technological imperative:” what can be done will be done, and we call that “progress.” building on the same christian understanding, ivan illich, in 1980, defined “development” as “the transformation of subsistence-oriented cultures and their integration into the economic system.” 14 he was clear about the implications of this definition: “this expansion proceeds at the cost of all other traditional forms of exchange.” 15 illich made clear what was by now becoming obvious, that third world development was only economic development, a development that progressively erased indigenous cultures. then, in 1989, when the communist vs capitalist debate began to evaporate with the fall of the berlin wall, the nature of the economic system into which all subsistence-oriented cultures were integrated was no longer debatable. the only system left was the market. the market, as we noted above, works by growing. today, everything is growing, straining the ability of the earth to sustain that growth, and that growth increasingly benefits the very few. five years ago, half of the world's wealth was controlled by 388 people. today the number that controls half the world's wealth has shrunk to only 62. 16 so, how is this related to christian participation in the sdgs? the cjgh rightly saw that the underlying purpose of the sdgs is “human flourishing,” a bleak prospect when wealth is being increasingly concentrated rather than distributed. but, perhaps it is not so important that we as christians embrace the sdgs. our ultimate task is love, which cannot usually be measured as statistical change. of 75 downing may 2016. christian journal for global health, 3(1): 73-76. course we can choose to work in projects that build systems and measure their output as data, if that is our occupation. but as christians that is not the same as our vocation, our calling. when we love, statistics may not improve. and if statistics do improve as a result of our work, we can rejoice but should not be complacent in thinking that that is the only improvement needed in the world. we still live in babylon. sdgs are short and medium term goals; they, and the measurement of them, are means to an end. jacques ellul frequently pointed out that in technological societies; all of our activities have become means. we are so focused on techniques that we neglect true ends; our technological means have become our ends. 17 there is nothing wrong with measurable goals — which may be means to some greater end (such as human flourishing or human redemption) — except when those means become the ends in themselves; and they can easily become ends because we can control means far better than ends. we can understand and engage with means, precisely because they are specific and measurable and achievable and all the rest. if we, as christians, fully embrace sdgs, we must never forget that sdgs are only means. if we forget, the sdgs will be just as cruel a joke as alma ata's “health for all by the year 2000.” references 1. united nations development programme. [internet]. a new sustainable development agenda [accessed 9 may, 2016]. available from: http://www.undp.org/content/undp/en/home/mdgov erview.html 2. revelation 21:1-4 3. revelation 18:7 4. revelation 18: 9, 11. 5. leviticus 19:10 6. for example, psalm 9:12, 41:1, 68:10, 72:2ff, 82:3-4, 112:9, 113:7. 132:15, proverbs 14:21,31, 19:17, 22:9, 28:29, 31:9. 7. isaiah 1:17 8. luke 7:22 9. james 5:4 10. christian journal for global health (internet). announcements [accessed 9 may, 2016]. available from http://journal.cjgh.org/index.php/cjgh/announceme nt 11. “the 2030 agenda comprises 17 new sustainable development goals (sdgs), or global goals, which will guide policy and funding for the next 15 years, beginning with a historic pledge to end poverty. everywhere. permanently.” united nations development programme [internet]. a new sustainable development agenda [cited 9 may, 2016]. available from: http://www.undp.org/content/undp/en/home/mdgov erview.html 12. this brief discussion is drawn from the arguments fully developed. in sachs w, editor. the development dictionary, 2 nd ed. london: zed books; 2009. available at https://www.google.com/search?client=ubuntu&ch annel=fs&q=sachs+the+development+dictionary &ie=utf-8&oe=utf-8 13. ellul, j, the technological society. new york: vintage books; 1964. 14. “the condition at the end of time which today takes its form in our thoughts, feelings, and perceptions can only be grasped by those who unequivocally believe in the reality of the gospel.” duden, b, quoting illich in “ivan illich. beyond medical nemesis (1976): the search for modernity’s disembodiment of “i” and “you””, available at www.pudel.unibremen.de/pdf/iv_tra_b.pdf . “i could not have analyzed medicine without bringing into this analysis my passionate attempt to understand a little bit of the gospels. . . ” illich, in cayley d, editor. the rivers north of the future. toronto: anansi press; 2005. p 121. 15. illich, i, in the mirror of the past. london: marion boyars publishers; 1992, p. 21-2. http://www.undp.org/content/undp/en/home/mdgoverview.html http://www.undp.org/content/undp/en/home/mdgoverview.html http://www.undp.org/content/undp/en/home/mdgoverview.html http://journal.cjgh.org/index.php/cjgh/announcement http://journal.cjgh.org/index.php/cjgh/announcement http://journal.cjgh.org/index.php/cjgh/announcement http://www.undp.org/content/undp/en/home/mdgoverview.html http://www.undp.org/content/undp/en/home/mdgoverview.html https://www.google.com/search?client=ubuntu&channel=fs&q=sachs+the+development+dictionary&ie=utf-8&oe=utf-8 https://www.google.com/search?client=ubuntu&channel=fs&q=sachs+the+development+dictionary&ie=utf-8&oe=utf-8 https://www.google.com/search?client=ubuntu&channel=fs&q=sachs+the+development+dictionary&ie=utf-8&oe=utf-8 http://www.pudel.uni-bremen.de/pdf/iv_tra_b.pdf http://www.pudel.uni-bremen.de/pdf/iv_tra_b.pdf 76 downing may 2016. christian journal for global health, 3(1): 73-76. 16. yahoo! news [internet]. keneally m. richest 62 people control same wealth as poorest half of world's population, report states [19 january, 2016]. available from http://news.yahoo.com/richest-62-people-controlsame-wealth-poorest-half-165238838--abc-newstopstories.html 17.jacques e. the presence of the kingdom. new york: seabury press; 1967. [chapter iii “the ends and the means”] peer reviewed. competing interests: none declared. correspondence: raymond downing, moi university school of medicine, kenya.armdown2001@yahoo.com cite this article as: downing r. christian involvement in sustainable development goals. christian journal for global health (may 2016), 3(1):73-76. ©downing r this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visithttp://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:armdown2001@yahoo.com http://creativecommons.org/licenses/by/3.0/ capacity building nov 2016. christian journal for global health, 3(2): 129-133. equipping healthcare professionals to care for the whole person sharon ann falkenheimer a a md, mph, ma, phd(c), academy of fellows, center for bioethics and human dignity, trinity international university, illinois, united states abstract western medical education has only recently sought to attend to the spiritual aspects of the patient. the overwhelming evidence of the role the spiritual plays in health and disease has led to movement to adopt a bio-psycho-social-spiritual model of care. however, these efforts often lack wholistic integration. the purpose of this article is to describe a program and international network helping to address the need for curricula and methods to educate healthcare professionals in whole person care wholistically and to make the availability of these resources more widely known to those likely to benefit from and use them. the uk christian charity prime: partnerships in international medical education provides a free curriculum and training opportunities for this purpose. prime’s approach and course have been widely sought and accepted by professionals from different cultures and faith groups and has developed into an international network. introduction christians recognize the importance of caring not only about the physical, mental, emotional, and social needs of patients, but of attending to their spiritual needs, as well. 1-2 however, for decades, western medicine has tended to employ a biopsycho-social model of care, ignoring the spiritual. 3,4 this is changing due to the overwhelming evidence that the spiritual plays an influential and most often positive role in health and healing. 5-7 as a result, since the 1990s, many north american and united kingdom medical schools have given increased attention to the spiritual aspects of care and worked to transition to a biopsycho-social-spiritual model. 5 however, with rare exceptions, the medical and spiritual aspects of care are often still taught separately, rather than wholistically. *8-11 healthcare professionals trained in this way may have never seen whole person care actually practiced or modelled and may struggle with or be at a loss how to care for their patients in this way. in addition, although many parts of the nonwestern world are much more wholistic in their approach to life than the west, their medical * the term “wholistic” is used here in place of “holistic” to indicate the focus is on care of the patient as a unified person. “holistic,” in contrast, can be used to discuss combining allopathic and alternative medicine approaches, which is not being discussed. 130 falkenheimer nov 2016. christian journal for global health, 3(2): 129-133. education systems tend to be based on western models. they also need to learn to incorporate the spiritual aspects of care into healthcare professional education and practice. many are low income countries (lic) with serious shortages of healthcare facilities and professionals, especially healthcare professional educators. these countries, christian hospitals, and healthcare professional training programs would greatly benefit from the availability of a free curriculum in whole person care and education in how to use and teach it. the purpose of this article is to describe a program and international network helping to address these needs and to make the availability of these resources more widely known to those likely to benefit from and use them. an internationally accepted curriculum and training in whole person care partnerships in international medical education (prime) [www.prime-international.org], a christian charity in the united kingdom, has developed a curriculum on whole person care, which is available for free and has been accepted and used in many countries and among many faith groups. 12 the curriculum is based on studies and evidence related to patient-centered medicine, the doctor-patient relationship, and communications skills and incorporates biblical and hippocratic values. the goals of prime’s whole person medicine (wpm) course are two-fold: to equip healthcare professionals to provide whole person care and to train them to teach others to care for the whole person. the prime wpm curriculum includes a manual consisting of three parts: 1) introduction and spiritual basis, 2) a course in whole person medicine, and (3) teaching methods † , and a cd † prime also publishes a manual, the good teacher: a values-based approach, which may be of interest to readers of this journal. 13 with teaching resources, including powerpoint presentations of each lesson. any healthcare professional who is in agreement with the prime principles and ethos may teach the course. when requested, prime tutors, i.e., teachers, assist in whole person training in other countries. however, the user determines the duration, format, and comprehensiveness of the training and whether it is given as stand-alone training or part of another course. the duration of training varies with the location and time available and typically ranges from three to 20 hours. the most comprehensive course, as given by prime at its annual international conference, lasts approximately three days. 14 part i discusses course aims and assumptions, the spiritual basis and history of wpm, and the sources of its core content. the second part of the manual begins with a discussion of course planning and management. it begins by outlining prime’s principles: 1) integration of the spiritual with “evidence-based medical practice from a christian perspective,” 2) the importance of learner-centered educational methods, 3) providing a safe atmosphere of mutual respect and kindness, 4) the importance of modeling “what we teach by the way we teach;” and 5) the importance of building healthy relationships in both teaching and medical practice. course content is broken down into six topics with lesson plans, power point presentations, and teaching notes. the first topic seeks to get students to think critically about their setting. the second focuses on helping participants identify with and reflect on illness from the point of view of the patient. the third lesson presents a model which helps bring together the bio-physical and psychospiritual aspects of healthcare by considering seven levels or aspects of an illness and how to best manage them from the physical, mental and spiritual perspectives. the fourth topic is “whole person medicine in action,” which uses faculty and student role play to model use of the wpm method with a simulated patient, identifies the physical and 131 falkenheimer nov 2016. christian journal for global health, 3(2): 129-133. non-physical (emotional, personal, spiritual) aspects of the illness, and discusses how the latter might be handled by healthcare professionals. a presentation is included on spiritual care, the difference between religion and spirituality, how to take a spiritual history, and appropriate spiritual care to support the patient’s coping style and spiritual practices. it emphasizes the health impact of unforgiveness and regrets and the importance of always giving the patient hope and assurance the professional will not abandon him or her. the fifth lesson helps participants apply what they’ve learned when they return home; each evaluates what he would like to change, identifies likely allies and opponents, and plans specific steps to take toward their goals. the final section brings closure; participants share what they have learned and hope to do, submit a course evaluation, and receive course certificates. the last part of the wpm course manual on teaching methods focuses mainly on adult learning methods such as role-play, brainstorming, pre-tasking, using visual materials, summarizing, and evaluation and assessment. research is in progress to describe how such plans for whole person medicine training have been implemented in a variety of nations and will be published separately. international support network for whole person care and education prime has an “international network of professional healthcare educators, committed to integrating rigorous science and compassionate care for the whole person body, mind and spirit.” 15 at present, prime’s international network exceeds 600 members from 65 nations (table 1). table 1. countries represented in the prime network 16 africa  egypt  ethiopia  ghana  kenya  madagascar  mali  nigeria  senegal  sierra leone  south africa  south sudan  swaziland  tanzania  togo  uganda  zambia asia  bangladesh  china  india  malaysia  myanmar  nepal  pakistan australia and the pacific  australia  indonesia  papua new guinea  philippines  new zealand caucasus and central asia  armenia  georgia  kyrgyzstan europe  albania  austria  “balkans”**  belgium  czech republic  estonia  france  germany  italy  lithuania  netherlands  norway  poland  portugal  romania  russia  slovenia  sweden  turkey  ukraine  united kingdom middle east  iraq  israel  palestine  qatar  saudi arabia  yemen north america  canada  mexico  united states of america ** prime network member identified location only as “balkans” and not by country 132 falkenheimer nov 2016. christian journal for global health, 3(2): 129-133. south america and the caribbean  brazil  haiti  peru  uruguay unspecified (1) although formal evaluation is limited to reports from prime tutors and partners and further research is needed, there are indications that prime’s model of “networking experienced medical teachers from developed countries with those in developing countries has proved successful in promoting sustained, positive changes in poorly resourced situations.” 17 participants have rated wpm training highly for its practical value and for how it changed their view of medical practice and made it more meaningful and enjoyable. 18 summary and conclusion western medical education has only recently sought to attend to the spiritual aspects of the patient. prime provides a free curriculum and training opportunities to provide whole person care according to the bio-psycho-social-spiritual model. prime’s approach and course have been widely sought and accepted by professionals from different cultures and nations and it has developed into an international network. prime’s work continues to expand and is making a significant contribution to the spread of wpm internationally. it is hoped these efforts will enable educators throughout the world to take advantage of prime’s resources to train colleagues and students in whole person care and improve healthcare professional and patient satisfaction wherever it is used. references 1. world council of churches. [internet]. preparatory paper n° 11: the healing mission of the church. world council of churches. 2005. available from: http://www.oikoumene.org/en/resources/document s/other-meetings/mission-andevangelism/preparatory-paper-11-the-healingmission-of-the-church 2. the lausanne movement. [internet]. cape town commitment: a confession of faith and a call to action. the lausanne movement. 2011. available from: https://www.lausanne.org/content/ctc/ctcommitme nt#p2-1 3. engel gl. need for a new medical model: a challenge for biomedicine. science. 1977; 196:129–36. http://dx.doi.org/10.1126/science.847460 4. frankel r, quill t, mcdaniel s, editors. biopsychosocial approach: past, present, future. 1st ed. rochester, ny: university of rochester press; 2003. 5. puchalski cm, blatt b, kogan m, butler a. spirituality and health: the development of a field. academic medicine. 2014; 89(1):10-6. [cited 2015 march 4] http://dx.doi.org/10.1097/acm.000000000000008 3 6. koenig h, king d, carson vb. handbook of religion and health. 2nd ed. new york: oxford university press; 2012. 7. koenig h. editor. handbook of religion and mental health. 1st ed. san diego: academic press; 1998. 8. mcnamara h, boudreau jd. teaching whole person care in medical school. in: hutchinson ta. whole person care: a new paradigm for the 21st century. new york: springer; 2011. 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[internet]. battle, sussex, uk: home – prime; 2016. available from: http://www.prime-international.org/home.htm 16. prime-international.org. [internet]. battle, sussex, uk: prime network audit data 2005-2015; 2015. available from: https://blu185.mail.live.com/?tid=cmy0ojlpe65rg qvmw75af6da2&fid= fllmpswto8ye6xl6agmkkhdw2&paid=cm1mf ybr655rgbnwaec8u88a2&pad=2016-0112t11%3a20%3a13.087z&pat=3&pidx=2. 17. prime-international.org. [internet]. battle, sussex, uk: foundation principles prime; 2016. available from http://www.primeinternational.org/foundationprinciples.htm. 18. prime-international.org. [internet]. battle, sussex, uk: feedback from prime courses; 2016. available from http://www.primeinternational.org/ feedbackfromprimecourses.htm. peer reviewed competing interests: none declared. correspondence: sharon ann falkenheimer, trinity international university, united states. flyramma@msn.com cite this article as: falkenheimer sa. equipping healthcare professionals to care for the whole person. christian journal for global health (nov 2016), 3(2):129-133. © falkenheimer sa this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.prime-international.org/home.htm https://blu185.mail.live.com/?tid=cmy0ojlpe65rgqvmw75af6da2&fid=%20fllmpswto8ye6xl6agmkkhdw2&paid=cm1mfybr655rgbnwaec8u88a2&pad=2016-01-12t11%3a20%3a13.087z&pat=3&pidx=2. https://blu185.mail.live.com/?tid=cmy0ojlpe65rgqvmw75af6da2&fid=%20fllmpswto8ye6xl6agmkkhdw2&paid=cm1mfybr655rgbnwaec8u88a2&pad=2016-01-12t11%3a20%3a13.087z&pat=3&pidx=2. https://blu185.mail.live.com/?tid=cmy0ojlpe65rgqvmw75af6da2&fid=%20fllmpswto8ye6xl6agmkkhdw2&paid=cm1mfybr655rgbnwaec8u88a2&pad=2016-01-12t11%3a20%3a13.087z&pat=3&pidx=2. https://blu185.mail.live.com/?tid=cmy0ojlpe65rgqvmw75af6da2&fid=%20fllmpswto8ye6xl6agmkkhdw2&paid=cm1mfybr655rgbnwaec8u88a2&pad=2016-01-12t11%3a20%3a13.087z&pat=3&pidx=2. https://blu185.mail.live.com/?tid=cmy0ojlpe65rgqvmw75af6da2&fid=%20fllmpswto8ye6xl6agmkkhdw2&paid=cm1mfybr655rgbnwaec8u88a2&pad=2016-01-12t11%3a20%3a13.087z&pat=3&pidx=2. https://blu185.mail.live.com/?tid=cmy0ojlpe65rgqvmw75af6da2&fid=%20fllmpswto8ye6xl6agmkkhdw2&paid=cm1mfybr655rgbnwaec8u88a2&pad=2016-01-12t11%3a20%3a13.087z&pat=3&pidx=2. http://www.prime-international.org/foundationprinciples.htm http://www.prime-international.org/foundationprinciples.htm http://www.prime-international.org/%20feedbackfromprimecourses.htm. http://www.prime-international.org/%20feedbackfromprimecourses.htm. mailto:flyramma@msn.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ book review june 2014. christian journal for global health, 1(1): 64-65. commitment, conscience or compromise: the changing financial basis and evolving role of christian health services in developing countries. peter rookes and jean rookes. saarbrücken, germany: lambert academic publishing; 2012 mathew santhosh thomas a a mbbs, md, executive director, emmanuel hospital association, india. the book commitment, conscience or compromise: the changing financial basis and evolving role of christian health services in developing countries is an excellent research document converted into a book by the researchers peter and jean rookes. the authors had years of experience, working in a developing world christian health care services context and prior to this in academics and health service management. this varied and long experience brings a wealth of perspectives and wisdom into this well researched document. being a ph.d. thesis, the book is in the form of a research report rather than a narrative style, but the report is interposed with various quotations and stories from the interviews. this brings life and emotion into what could otherwise have been a colourless academic paper. the research hypothesis, “the necessity of seeking alternative funding sources has resulted in changes in the types of provision of christian health services in contemporary developing countries, their users, and their relationship with governments” came out of the experience of the authors in the anglican health service and other programs in papua new guinea (png). though the broader areas of christian health care services have been researched by many, this research seems to be the first of its kind where the issue of relationship between changing financial contexts, government relationships, and services provided are being studied. in doing this, the authors have done excellent work in knitting together a study and a book on christian mission history, health service management, and non state providers and their roles in a comprehensive health care system. the initial chapters cover much history and back ground information on missions at large, medical missions, public health, primary health care, and christian developmental work, at the same time bringing researched information on varying perspectives, theological conflicts, complexities, and challenges christian missions have gone through in the past few decades. these sections are an excellent resource, to understand where we have come from and the challenges our predecessors have gone through. the challenges of the “post-colonial era,” finances in health care and missions, the global changes in health care directions, and polices affecting missions and health care have been very well researched and documented. limiting the study to uk-based mission organizations, and their counter parts in countries which were colonized by the uk and doing in depth study on two countries, namely, malawi and india, gives a focus for the research and book. the challenge of this is that in the broader contribution to medical missions, many non uk based organizations and institutions have played major roles, and these have not been captured. at the same time, the choice of 2 countries for in-depth study and comparison is good, since india is a large multicultural and complex nation with a small christian community, whereas malawi is small and less complex with a large christian presence. the challenge of india is that no statement on india can ever be generalized for the whole country, since it is large and varied in culture, language, and geography. the book has entered the market at a time of rapid changes in the health care field globally and, thus, is an excellent resource for christian health care associations, health care institutions, and professionals to reflect on how their own responses to changes can impact the country, their purpose 65 thomas june 2014. christian journal for global health, 1(1): 64-65. and mission, and their relationship with government and other stake holders. the challenge of any book on health care is that changes happen rapidly; many of the observations and findings of a study done in 2006 — 2007 may become irrelevant, a reason to read the book sooner rather than later. the conclusions of the authors are worth reflecting on as we go through a sea of change in missions and health care: how can finances and funding influence the core purpose for which christian health care institutions and services were established, and, in a globalized context and with changing world equations, the relationship between mission agencies and missions need to be constantly reviewed and repositioned. the differences that exist in missions and health care between various countries require context-specific solutions if we are to be true to our call and purpose. there is value added for christian health associations working with all resources and mobilizing churches to participate in health promotion through community health workers. there is potential for christian health care services to provide compassionate and quality care with an ethos preferred by many seeking care. at the same time, the values of justice and equity and cooperation valued by governments can be preserved. these institutions can be part of nationbuilding in addition to building the kingdom of god. broadened areas of involvement and working in partnership with each other can strengthen the purpose of caring for the poor. for all this, christian health care services need constant review and repositioning, while, at the same time, holding on to the primary purposes for which each health care institution was established, as well as understanding history and current trends when initiating new programs into the future. ______________________________________________________________________________ competing interests: none declared. dr. thomas is on the editorial board of cjgh author correspondence: m.s. thomas. eha 808/92, deepali buildings, nehru place, new delhi 110019 india santoshmathew@eha-health.org cite this article as: thomas, ms. book review: commitment, conscience or compromise: the changing financial basis and evolving role of christian health services in developing countries. christian journal for global health (2014), 1(1):64-65. © thomas, mt. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ ______________________________________________________________________________ www.cjgh.org mailto:santoshmathew@eha-health.org http://creativecommons.org/licenses/by/4.0/ conference report nov 2016. christian journal for global health, 3(2): 168-175. mobilizing and training academic faculty for medical mission: current status and future directions james d smith a , roger p holland b , j dwight phillips c , sharon a falkenheimer d a md, professor emeritus, oregon health and science university, portland, oregon, united states b md, dean, myungsung medical college, addis ababa, ethiopia c md, professor of pediatrics, department of pediatric and adolescent medicine, mayo clinic, minnesota, united states d md, mph, ma, academy of fellows, center for bioethics and human dignity, trinity international university, deerfield, illinois, united states introduction international professional education represents an expanding frontier for medical missions. in november 2015, 67 medical missionaries and academicians met in conjunction with the global missions health conference (gmhc) in louisville, kentucky. most of the participants involved in the discussion were of north american origin, some originated and resided on other continents, and most participants had spent years working professionally outside of north america. they reviewed the current situation of international medical education missions and discussed future directions. a subgroup of 14 educators held specific discussions about mobilizing medical educators from high income countries (hics) and then reviewed their findings with the entire group. additional discussions have been held since the november 2015 meeting. arising from those discussions, this paper represents a consensus about the current status of mobilization of academic medical faculty in missions and about future directions recommended by the group. the workgroup divided up its discussion between short(less than 2 years) and long-term (more than two years) missions and then focused the discussion on the following topics: 1) current status, 2) identifying and mobilizing faculty, 3) medical school needs in lowand middle-income countries (lmics), 4) motivation for participation, 5) barriers to participation in medical education missions, 6) issues in medical education missions, 7) recommendations for future efforts, and 8) best practices. current status in the last several years, there has been an increasing recognition that treating individual patients in hospitals by expatriate health care professionals is neither sustainable nor capable of building long-term capacity. the result is an increasing interest in education by starting medical and dental schools, nursing schools, post graduate (resident) training, and training in the paramedical professions. 1 it is also recognized that sending nationals from lmic to hic countries for training will result in a high percentage staying in the hic where they train, supplementing the health care force in that country, but doing nothing of lasting importance for their country of origin. when a country is dependent upon the presence or absence of expatriate professionals, it creates inherent instability in the medical care capacity, constant turnover, and an inability of the countries’ health professions to mature and reproduce themselves and their programs. 2 in this time of transition from expatriate to national medical educators, it is imperative that the goal be not just to produce new 169 smith, holland, phillips & falkenheimer nov 2016. christian journal for global health, 3(2): 168-175. health care professionals, but that a cadre of educators be developed to take on the roles of modeling, encouraging, and training the teachers how to teach, especially with the types of interactive teaching methods recommended by medical education leaders 3,4 rather than pure lecture/memorization. identifying and mobilizing faculty traditionally medical missions have been considered the purview of doctors and nurses, giving direct medical care and not been seen as an area for basic science teachers, academics, researchers or subspecialists. many of these nonphysician/nurse teachers feel marginalized when it comes to contributing tangibly to missions, and they feel the only way to participate is to be involved with secular organizations and international meetings which are normally held in hic. as christian organizations see the need for medical and nursing schools, residency training and other health training programs, they realize that they need to mobilize an entirely new group of missionaries. to build the necessary foundation for this new educational endeavor, expatriate educators can, at least initially, build capacity by participating with health care educational professionals in lmic, especially in the basic sciences, along with individuals who have experience in adult medical education methods. those from lmic with these qualifications are often already working in national universities or frequently already have emigrated to hic. this is especially acute where groups have started new medical schools, specifically christian medical schools and have not been able to find basic science faculty. in some countries, it has been possible to hire faculty from secular schools to teach courses, but this usually means to come for short-term periods and give a modular series of lectures. even this option may not work in schools without a modular curriculum. the ability both to model christian principles and to develop teaching skills is a long-term process that depends upon building trusting relationships with local faculty. some present short-term visits tend to result in minimal interaction between the students and faculty and provide mainly rote memory learning. 5 this is not just a problem for christian schools, but also occurs in new secular government schools as witnessed by some of the participants in indonesia and elsewhere. to improve this situation will require the goal of training teachers at all levels. since this is a growing area of educational need, we must look at how we can mobilize an entirely new group of educators to consider medical education missions in their career plans. when one considers working with students as a mission field to represent christ, there are great possibilities for multiplicative impact when compared to treating individual patients. not only does one have the possibility of training the next generation of health care providers, thus changing medical care in the country, but one is also modeling a christ-like approach to caring for patients. as trainees learn to be christ’s witnesses, they are well-suited to reach their own people as they know the culture and the language better than any expatriate. in this way, equipping local health care providers as educators can become a sustainable program. does this mean there will be no role for missionaries sometime in the future? no, but the roles will change. the new missionaries will be colleagues who provide resources for partnering with local health care providers in maintaining skills, and acting as mentors and role models. this is truly an exciting multiplicative opportunity for missionary health care providers-educators. medical school needs in lmics traditionally medical mission agencies sent expatriate doctors and nurses to staff smaller rural mission hospitals, and nurses to staff rural clinics. while christian missionaries have already been leaders in primary and secondary education, in many lic, there have been relatively few efforts in post-secondary school education, especially in 170 smith, holland, phillips & falkenheimer nov 2016. christian journal for global health, 3(2): 168-175. medical education. many mission hospitals, out of need, have started nurses training programs, but mainly serve local needs. two exceptional christian medical schools are the excellent medical school in vellore, india, which is internationally recognized for its excellent training, and a more recent program in africa at the kilimanjaro medical center in arusha, tanzania. both have maintained their christian heritage, but not necessarily uniform christian commitment among their staff. in the last ten years, there has been an increasing interest in starting new medical schools, usually associated with christian universities or stand-alone programs, especially in africa. several examples include schools in ethiopia, nigeria, burundi, kenya, and swaziland, and there are plans for more in zambia, malawi, and uganda. along with these schools are new government-sponsored and private for-profit schools. 6 it is recognized that there is a huge need to increase the health care workforce in lmic, but there are two problems: (a) where to find basic science teaching faculty and (b) where to find clinical facilities with faculty willing to teach the “hands-on” clinical side of medical education. if the faculty and facilities are not adequate, teaching ends up focusing on lectures and rote memory with little or no direct patient care experience. another concern for the future is whether there will be post-graduate training and employment opportunities, especially for physicians since some lmic, for financial reasons, train far more medical students than they can employ. the excess trained health care providers have to emigrate to other countries. this defeats one of the original purposes of starting new schools, filling manpower needs in the country. these new medical schools, especially the christian schools, have a huge need for teachers, especially those in the basic sciences, such as anatomy, histology, physiology, microbiology/ parasitology, pathology, and biochemistry. there will also be a need for teachers in the clinical years. since many of the new schools plan to use mission hospitals for their students’ clinical experience, there is a need for faculty-development training that focuses on newer teaching methods for doctors already working in these settings as most do not come from an academic background and may feel inadequate to teach medical students. finally, there will be a need for physician-scientists who can teach research methodology and mentor young physician scientists to seek out and conduct research projects; these projects should, ideally, be generated from within the lmic and of direct relevance in the lmic. newly minted physicianscientists in lmic need to be taught and mentored, otherwise research in lmic will continue to be directed by overseas universities with budgets that are unrealistic for the lmic to sustain on their own and that typically end when overseas researchers return home. one problem is that adding this load to an already overburdened mission hospital staff will be difficult. because of the need, these schools may need to supplement their teaching by recruiting expatriate faculty willing to teach courses or modules online or by telemedicine. these activities could be supplemented by on-site instructors. another area to which some have been called is working in government/secular medical schools. there are many examples of christians taking fulltime faculty positions to teach medical students in medical skill laboratories and clinical departments. many times, where one is not allowed to practice medicine by the ministries of health (mohs) licensing requirements, a limited license to teach medical students in a clinical setting may be granted. this may be a way to serve in creative access nations. also, where there is an interest in starting family medicine training programs by the moh, but where the specialty has not been recognized, there will be a need for expatriates to help start and advise such programs. the need for teaching faculty may be divided into short-term (less than 2 years) and long-term (more than 2 years). the most pressing need is for long-term committed individuals to provide continuity for the 171 smith, holland, phillips & falkenheimer nov 2016. christian journal for global health, 3(2): 168-175. medical students, but more importantly to equip nationals to take over and maintain the school. this does not negate the value of short-term faculty for these new schools, at least in the near future. motivation to serve in medical education missions the working group noted several motivational factors among those who the lord has called to serve this way in medical education missions. while these factors vary in importance, the most vital is that there be spiritual motivation and direction to maximize the “christian” value of international medical education. common and relevant motivational factors include:  first, a call from the lord to serve in this setting, followed by a response to the command (while going) to follow christ’s example to “teach and heal,”  a recognition of humanitarian needs and a desire to serve those with relatively fewer educational resources,  a desire for relationship with people from other cultures and to contribute positively to other groups,  a response to “peer pressure” related to a broad interest in north america on “paying back” and global health,  a recognition of the benefits and potential long term impact of multiplication and capacity building through health care provider education compared to providing direct patient care,  personal invitation to go with someone or visit a facility,  academic benefits to participants’ curriculum vitae, participation in research, and international networking,  desire for family to experience “missions” and other cultures, and,  personal enjoyment of adventure or travel. barriers to participation in medical education missions as there are motivational factors for being involved with missions through teaching, the working group also identified several barriers to serving. these may include the following: short term missions  busy professional and family schedules,  institutional constraints (call schedules and vacation planning often done far in advance) restricting ability to leave on short notice. there are also economic factors when departments require faculty to do clinical work for income to the department or medical school, which may limit the time someone can be away.  limitations due to school schedules for those in academics or their children,  priority given to direct patient care missions versus educational missions by either the individual or institutions,  cost, especially for those with lower salaries such as paramedical professionals, medical laboratory technicians, basic science teachers, researchers and retired individuals,  perceived and real risks, and dangers to the individual and/or family members,  unfamiliarity with or fear of local disease, especially in tropical countries,  lack of familiarity with intercultural expectations or barriers, and  the need to teach through translators. long term missions  family needs or concerns,  children’s education,  obligation to repay school-related debt,  requirement for language study,  obtaining a license in host country,  stepping off an academic career ladder,  local standards of teaching and assessments, 172 smith, holland, phillips & falkenheimer nov 2016. christian journal for global health, 3(2): 168-175.  unfamiliarity with diseases and conditions in tropical countries,  limited availability of facilities and infrastructure,  working with limited technology and equipment, especially in the surgical fields, and  problems with re-entry into home countries when leaving the field. academic experience and qualifications another area of consideration is whether people who have a call from the lord need academic experience and credentials. this depends on the teaching situation, but it should usually be required that a health care educator going overseas have both appropriate cultural humility and adequate training in education. however, with newer education methods such as organ-based (e.g., modular) teaching, there is integration of purely basic science faculty with clinicians, both working together to teach the basic sciences. this gives medical students earlier clinical knowledge and experience than the traditional two years of basic sciences followed by two years of clinical experience. in these limited settings, clinical health care provider educators may not require academic experience, as long as they are current in their knowledge and practice. the key requirement is that the person should have an interest in teaching and be willing to help teach the clinical correlation of basic science topics. however, new long-term health care provider-educator missionaries will need training in faculty development topics and experience in teaching to equip local health care providers as educators. short-term educators with academic experience can also contribute to the effort to train trainers. eventually, faculty development for basic and clinical science teachers in the lmic will be needed as well. this will require not only training in the usual areas for new missionaries such as cultural awareness, language training, and biblical training, but also now topics such as lecture preparation, adult learning theory, small group teaching, and assessment methods. all of this may seem daunting and discourage some, but there are many resources already available to those pursuing health care education missions. most medical schools have modules for faculty development topics, which may be open to nonfaculty members. there are online resources and even online medical education masters degrees and online certificates. 7, 8 pre-field training for medical education missionaries one problem for medical education training is that missionaries are sent out by a number of different mission/church organizations, but they are trained in the same topics as all the missionaries going to the field, such as church planting and seminary training and not in medical education topics. 9 various sending organizations could combine to provide specific pre-field training for medical educators. one effort to bring new medical missionaries together for this type of training is the christian medical and dental associations’ center for medical missions pre-field training course which is offered two to three times each year. 10 however, there are currently no sessions specific to equipping in medical education methods and practices. additional sessions for those involved with health care education could be added to this and other missionary meetings such as the global missions health conference (gmhc) 11 and the cmda-affiliated annual overseas conference for missionaries. stand-alone courses could also be offered, perhaps by cmda’s medical education international ministry. an internationally available equipping effort is also conducted by the uk christian charity, prime: partnerships in international medical education. 12 prime has excellent, free curricula and courses in whole person care and interactive teaching methods; these have been implemented in many nations and cultures. 173 smith, holland, phillips & falkenheimer nov 2016. christian journal for global health, 3(2): 168-175. recommendations for future efforts since international medical education is a new area of recruitment it will require new initiatives. there could potentially be a central clearinghouse available to individuals or mission organizations interested in health care education. the www.medicalmissions.com/network/ education website has started pulling some information together. at present, samaritan’s purse/world medical missions provides a database of needs for medical missionaries requested by mission hospitals. they send out bimonthly updated information, recognizing those who have served and needs requested by mission hospitals. they also help provide travel arrangements for those wishing to serve. something similar is needed for those interested in health care education. samaritan’s purse already helps the pan african academy of christian surgeons (paacs) recruit and send short term surgical educators. they also provide a two-year fellowship for finishing residents who want to do missions but have large debt loads. they help them find opportunities to serve, but thus far, that service is focused on clinical care rather than medical education. expenses are covered during that period, but for the recipients to continue on the field, they need to return to their home country to find a sending organization and raise support. these two things, plus many times burnout by the individual and/or family, have resulted in a relatively low retention rate. another organization that helps potential health care professionals stay on the field is project medsend. 13 most individuals graduating from a health care field have a large debt load. medsend and some us governmental organizations help by covering the cost of education debt payments while health care workers are on the field. recruiting new missionaries for areas of medical education will need a multi-pronged approach. recruitment has traditionally been by personal involvement of missionaries speaking and presenting a compelling story of how the lord uses missions to reach unreached people groups and especially stories of how mission hospitals can heal people physically and spiritually. the venue is usually in churches or mission conferences such as urbana or gmhc. since there are very few missionaries engaged in health care education, potential missionaries and mission organization have not been exposed to the value of such efforts. it will take time, but everyone interested in this area needs to look for speaking opportunities to disseminate the message. there are many opportunities that have not been tapped, such as speaking at local cmda chapters. the key is networking to receive invitations to speak. one group that is difficult to reach are those in basic sciences since they do not usually consider missions as an area where they may serve! the key to reaching this group is going to be clinical colleagues who are made aware of opportunities and who can then reach out to this group. an opportunity to reach a large number of young people interested in missions is the annual gmhc meeting. workshops and exhibits are opportunities to meet and encourage young people to consider medical education missions as a way to serve the lord. groups such as paacs and medical education international (mei) find this meeting one of the best areas to recruit and network. another recruitment tool would be short term “vision trips” that could be sponsored by individuals, mission groups, or educational institutions. the idea would be that someone who visits and gets involved will see the potential opportunities and have a desire to participate longer term or on repeated trips. probably the most fruitful recruitment is by personal invitation from those interested in health care education. it is imperative that those of us who have an interest in this field seek out opportunities to deliver this message. http://www.medicalmissions.com/network/%20education 174 smith, holland, phillips & falkenheimer nov 2016. christian journal for global health, 3(2): 168-175. best practices there is a need to continue to develop and disseminate best practices in medical education missions. most international medical schools will have a curriculum designed by the local government to approve the school and its graduates. it will be necessary to work within these guidelines, but people who are called to serve can still use the latest teaching and adult education methods. other curricular topics that need to be introduced relate to medical ethics and the concepts of ambulatory and preventive medical care. of course, these methods will need to be made culturally relevant to the country where the teaching takes place. for both shortand long-term participants, having training sources in the form of online courses or educational conferences would be useful. it would be best if these could be coordinated by a central organization. having a toolkit of lectures, powerpoint presentations, videos, webinars, and educational resources available for people to use would be useful. again, this would require a central clearing agency. the provision of information would need to be supplemented by personal relational connections to maximize the value of the education. some groups that could be resources for information are the society of teachers of family medicine, medsend, and leaders in north america with connections to global health training programs. one encouraging development is the desire for indigenous health care workers and medical missions to cooperate and work together rather than working in separate “silos.” 14 this will continue to require mutual respect and a willingness to work together as partners. conclusion as mission groups become involved with health care education in lmic, it will be necessary to recruit a new cadre of missionaries that are interested and knowledgeable about current educational methods. there is a special need for educators in the area of basic sciences as well as those willing to be teachers in the clinical hands-on areas. there are several motivational factors for individuals to serve in these opportunities, but foremost there must be a call from the lord. there are also many barriers to participation, especially for those in academic careers. to find and equip these new missionaries will require the cooperation of mission groups and organizations involved in starting new education endeavors. these groups need to develop “best practices” based on international educational standards, but also making them relevant to the local culture. references 1. magadza m. swaziland: first school of medicine to be built [internet]. u world news. 2011 july 03;80(5). 2. firsing s. how severe is africa’s brain drain? quartz africa. 2016 jan 21. 3. cooke m, irby dm, o’brien bc; carnegie foundation for the advancement of teaching. educating physicians: a call for reform of medical school and residency. san francisco: jossey-bass; 2010. 4. frenk j, chen l, bhutta za, cohen j, crisp n, evans t, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet (north american edition). 2010;376(9756):1923–58. http://dx.doi.org/10.1016/s0140-6736(10)61854-5 5. custers ejfm, boshuizen ha. the psychology of learning. in norman gr, ven der vleuten cpm, newble di, editors. international handbook of research in medical education, part i. kluwer academic 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[internet] [cited 2016 october 8] available from: http://www.une.edu/com/mmel 9. strand ma, chen ai, pinkston lm. developing cross-cultural healthcare workers: content, process and mentoring, christ j glob health. may 2016;3(1):57-72. http://dx.doi.org/10.15566/cjgh.v3i1.102 10. cmda.org [internet]. bristol, tn: christian medical and dental associations. [cited 2016 august 30]; center for medical missions. available from: https://cmda.org/missions/detail/cmm 11. cmda.org [internet]. bristol, tn: christian medical and dental associations. [cited 2016 august 30]; global missions health conference. available from: https://cmda.org/missions/detail/cmm 12. prime: partnerships in international medical education [internet] [cited 2016 aug 30]. available from: http://www.prime-international.org/home.htm 13. medsend [internet] [cited 2016 aug 30]. available from: https://medsend.org/ 14. oman k, khwa-otsyula b, majoor g, einterz r, wasteson a. working collaboratively to support medical education in developing countries: the case of the friends of moi university faculty of health sciences. educ health. 2007;20:1-9. available from: www.educationforhealth.net/ competing interests: none declared. correspondence: james d smith, oregon health and science university, oregon, united states. jamesd.smith@yahoo.com roger p holland , myungsung medical college, addis ababa, ethiopia. hollandinethiopia@gmail.com j dwight phillips, department of pediatric and adolescent medicine, mayo clinic, minnesota, united states. jdwightphillips@gmail.com sharon a falkenheimer, academy of fellows, center for bioethics and human dignity, trinity international university, illinois, united states. shari.falkenheimer@cmda.org cite this article as: smith jd, holland rp, phillips jd, falkenheimer sa. mobilizing and training academic faculty for medical mission: current status and future directions. christian journal for global health (nov 2016), 3(2):168-175. © smith jd, holland rp, phillips jd, falkenheimer sa. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.une.edu/com/mmel http://dx.doi.org/10.15566/cjgh.v3i1.102 https://cmda.org/missions/detail/cmm https://cmda.org/missions/detail/cmm http://www.prime-international.org/home.htm https://medsend.org/ http://www.educationforhealth.net/ mailto:jamesd.smith@yahoo.com mailto:hollandinethiopia@gmail.com mailto:jdwightphillips@gmail.com mailto:shari.falkenheimer@cmda.org http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ increasing the church’s relevance and impact in poor-resource areas by adding sexual reproductive health to missional activities www.cjgh.org july 2017 | 95 field report christian journal for global health | increasing the church’s relevance and impact in poor-resource areas by adding sexual reproductive health to missional activities margaret lynne dockinga a director, wise choices for life reproductive health training workshops, uganda to be relevant in the world today, the church must prioritise sexual reproductive health and family planning. the church’s silence about god’s creation of our sexuality needs to be broken; it is an essential part of our calling. for most of my life, maternal mortality was a statistic not a reality. as a midwife for 30 years in australia, arriving in uganda nearly ruined me as i faced the high incidence of teenage maternal deaths. the turning point came six months into my two-year internship with african enterprise uganda. i had become a registered midwife with the ugandan nurse’s board and was volunteering on a weekly basis teaching students at the government regional referral hospital in jinja. there was no privacy, linen, or supportive fathers. the ugandan women were stoic, and without much fuss the babies arrived. however, the day that three women required an emergency caesarean, one of them a very young girl, changed my direction in life. the midwife on duty continued without stress, in spite of complicated cases arriving endlessly. the doctor arrived, confirmed obstructed labour in all three and said he would operate when they had money to pay for sterile gloves, sutures, and iv fluids. tears and sickness welled up in me and all my work seemed a waste of time. not one of these women was prepared with the resources to pay for their lifesaving operation. according to the ugandan demographic health survey (2011), one in four girls between the ages of 15 and 19 have had a baby or is currently pregnant. the average fertility rate in rural uganda is seven children per mother, which often results in haemorrhages, a major cause of maternal death.1 the three women that day were facing tragic results: death, stillbirth, or life with a vesico–vaginal or recto-vaginal fistula. fistulas occur where the foetal head creates pressure on the urethra and/or the bowel leading to necrosis, and leakage of urine and faeces through the vagina. these are common in very young girls whose pelves are not yet capable of birth, leading to incontinence, shame, and isolation. because of their immature physiological development, adolescents are more likely to experience complications during delivery than older women.2 in many societies, the mistaken assumption is made that the onset of menses signals reproductive maturity. that day i knew i was being called from the birthing unit to move into the community setting, to warn future mothers and fathers about the causes of maternal deaths. i believed if i could involve male religious leaders, who held more influence in the community than midwives, to understand prevention strategies, we could prevent more maternal deaths. fortunately, i did not have to wait long for my first opportunity. bringing midwifery out of the clinic and into the community northern uganda is perhaps mostly known for its conflicts and the terror organisation lord’s resistance army (lra) led by joseph kony. the missionary living there invited me to share god’s design for sexuality with 60 women from the border of uganda and south sudan. these women were from various faiths, and i immediately recognised it http://www.cjgh.org 96 | christian journal for global health 4(2) www.cjgh.org as an opportunity to put my growing conviction into practice. can we find ways to mix faith, science, and traditional practices in a way that leads to reduced maternal deaths? i started with god’s amazing story of creative love with the meeting of the sperm and ovum, pregnancy, birth, menstrual cycle and fertile days, and finally family planning methods. after two days, the women were angry. they asked me why they had not been told this good news about their bodies before. one of them said, “we now know why you white women don’t have so many babies. we want this also.” they continued on, “where have you been?!” and “when are you coming to all our villages to tell everyone?” the missionary admitted afterwards that she had never been taught this subject in bible school. the women were rightfully angry. in faith matters international family planning from a christian perspective, we can read the following: there are an estimated 222 million women in less-developed countries who experience this unmet need (of family planning). if these women have access to family planning methods and unmet need is addressed, it would prevent 26 million abortions, 79,000 maternal deaths, and 1.1. million infant deaths.3 the role of the church in family planning back at jinja, i stayed at a christian vocational institute where male and female students were segregated by locking the dormitories at 7:30 in the evening, to prevent unwanted pregnancies. i was asked to do random pregnancy checks on the girls, and if positive they were told to leave. the nurse admitted that no one could talk to the girls or boys, as staff were ignorant and reluctant to talk about sexuality. this helped me see that we, the church, also battle ignorance and reluctance about sexual reproductive health. many of the talks to youths are focused on fear and immoral behaviours. with teenagers dying from abortions, perforated uteruses, or haemorrhages, we must dare to admit that fear tactics and silence do not work. we have missed the opportunity to talk with truth and courage about god’s wonderful creation of true love, faithfulness, sexuality, and pregnancy, which must now include how to control our fertility using the latest research. we have not been holistic in addressing the challenges of the real world. to reduce poverty, the church globally needs to be equipped to effectively communicate god’s creation of our sexuality and add that into their current ministry. the local church is one of the best places to deliver lifesaving messages about spirituality and sexuality. which bible colleges train pastors and youth workers in the wonderful story of the menstrual cycle, puberty, and how babies are made? involving men and community leaders in most developing countries, it is the male political or religious leaders that have the greatest power and influence. we want to see a shift toward equal value for women but we cannot afford to wait for that change. to the international community, this is old news. in the un report from the 1994 internadocking christian journal for global health | figure 1. a pastor in mch sensitization training http://www.cjgh.org www.cjgh.org july 2017 | 97 tional population and development conference, we can read the following: special efforts should be made to emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behaviour, including family planning; prenatal, maternal and child health; prevention of sexually transmitted diseases, including hiv; prevention of unwanted and high-risk pregnancies; shared control and contribution to family income, children’s education, health, and nutrition; and recognition and promotion of the equal value of children of both sexes.4 we must face the facts and make sexual reproductive health our new frontier in mission. the church needs training in how to talk to men about sex, pregnancy, childbirth, and family planning, and not leave this to overworked midwives in hospital settings. a change of approach: wise choices for life driven by my experiences and encouraged by dr. david cummings, past president of wycliffe bible translators international and now senior trainer at leadership matters, i designed a creative, interactive curriculum, and it was endorsed by the ugandan ministry of health in 2015. use of the manual life skills by the u.s. peace corps (publication moo63, 2001, used with permission) was a helpful start. the final curriculum integrates: • principles of the christian faith to provide and care for all children. (i tim 3:12 and 5:8), • the ugandan culture, and • god’s creation for us to be sexual beings. it has a positive focus on god’s design for true love, commitment, and faithfulness. the training is implemented by the ugandan people under the capable leadership of mrs. joyce kidulu, our regional coordinator based in eastern uganda. ultimately, the goals of this training are to contribute to: • better health outcomes for women, • fewer unplanned pregnancies, orphans, and abandoned babies, • manageable family sizes, and • increased respectful relationships and parenting skills. the “train the trainer model” includes practical skills in communication, drama, and leading debates. it aims to create safe spaces for respectful discussions around culture, faith, traditions, and discerning myths and truths about our bodies. the lessons include: • our value and worth as children of god, • puberty, • the miracle of birth, • maternal mortality, docking christian journal for global health | figure 2. a man in mch sensitization training http://www.cjgh.org 98 | christian journal for global health 4(2) www.cjgh.org • advantages of abstinence, • parenting, family planning, and rights of children, • hiv, • population growth and the environment, and • gender-based violence and rape. this curriculum, called wise choices for life (wcfl), is now used in uganda in a variety of settings – uganda christian university, youth groups, prisons, and schools. wcfl has also been endorsed by the uganda christian university, the ministry of health, and the archbishop of uganda, stanley ntagali. he writes, “the church of uganda recognises this manual and the wise choices for life program as a unique opportunity to equip youth all over the world with knowledge on sexual reproductive health, family planning, maternal child health, and hiv/aids within the context of their families and environment.”5 the demand for training grows in uganda, and is an opportunity for churches to disciple youths holistically. as a church, we should be a voice for the vulnerable but not at the expense of their decision-making power. withholding lifesaving scientific knowledge perpetuates the poverty trap and makes us moral policemen, not disciples of men. if we deem family planning good enough for ourselves, why neglect to empower others with the same options? to be truly christ-like in a broken world, we need to add reproductive health into missional training schools. youths who are ignorant of the science of human reproduction become vulnerable to sexual exploitation. the church and mission-training institutions need to change their approach and equip youths with knowledge and life skills to make wise decisions in life. life skills include choosing safe relationships, ensuring effective communication, and practising critical thinking combined with discussions around faith and traditional customs. this is creating a shift in thinking regarding the traditional need to have many children, starting very young, and continuing till menopause. the success in uganda has led to requests from ethiopia, tanzania, and kenya. the board of wcfl in australia has been encouraged by the growth and we have begun the registration process as a non-government organisation in uganda. this is a step toward real ownership of the training and will over time lead to less dependency on australia. it is an exciting time as we see transformation and a shift in thinking around such traditions as child marriage and producing large families that has led to many obstetric fistula-led maternal deaths and poverty. breaking the silence around god’s creation of our sexuality is part of our calling. we need a global united voice that empowers whole communities. it is time for us to change. i now know that the tragic experiences in the hospital labour wards were not in vain. the result of the initial 2-day training with the 60 women in northern uganda started me on a new curriculum development path that now reaches the male leaders in local churches, and supports and cares for women’s wellbeing and saves their lives. to save the mothers we need to reach the men with the amazing story of god’s creation so evident in childbirth. our next international training conference is at kampala in november. www.wisechoicesforlife. org/kampala-conference docking christian journal for global health | http://www.cjgh.org http://www.wisechoicesforlife.org/kampala-conference http://www.wisechoicesforlife.org/kampala-conference www.cjgh.org july 2017 | 99 references 1 uganda bureau of statistics, measure dhs, icf international. uganda demographic and health survey, 2011. 2012. august: 67 & 58. available from: https://dhsprogram.com/pubs/pdf/fr264/fr264.pdf 2 zabin ls, kiragu k. the health consequences of adolescent sexual and fertility behaviour in sub-saharan africa. studies in family planning. june 1998. 29(2):210-32. https://doi.org/10.2307/172160 3 huber d, wilson a, pirzadeh p, funna s, bormet m, orange, m, et. al. faith matters international family planning from a christian perspective. christian connections for international health. 2015: 6. available from: http:// www.ccih.org/faith-matters-fp-christian-perspective.pdf 4 united nations. programme of action adopted at the international conference on population and development, cairo, 20th anniversary edition. new york: united nations population fund (unfpa). 2014: 37. 5 statement from the archbishop of the church of uganda. june 2015. peer reviewed competing interests: none declared. correspondence: margaret lynne docking, marg@wisechoicesforlife.org cite this article as: docking ml. increasing the church’s relevance and impact in poor-resource areas by adding sexual reproductive health to missional activities. christian journal for global health. july 2017; 4(2):95-99; https://doi.org/10.15566/cjgh.v4i2.173. © docking ml. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ docking christian journal for global health | http://www.cjgh.org https://dhsprogram.com/pubs/pdf/fr264/fr264.pdf https://dhsprogram.com/pubs/pdf/fr264/fr264.pdf http://dx.doi.org/10.2307/172160 http://www.ccih.org/faith-matters-fp-christian-perspective.pdf http://www.ccih.org/faith-matters-fp-christian-perspective.pdf mailto:marg@wisechoicesforlife.org https://doi.org/10.15566/cjgh.v4i2.173 http://creativecommons.org/licenses/by/4.0/ commentary nov 2017. christian journal for global health 4(3):12-20 reflections on the challenges and opportunities for palliative care in nepal daniel munday a , ruth powys b a phd frcp mrcgp ffarcsi dippallmed pgcertmeded drcog mbbs, consultant advisor in palliative care and health services research, international nepal fellowship, nepal b mbbs mpc fachpm, consultant advisor in palliative care, international nepal fellowship, nepal abstract palliative care in nepal has been developing over the last 20 years, led by pioneering doctors and nurses who have gained experience in the specialty, often while working overseas, or who have had the opportunity to do clinical attachments abroad. recently, in collaboration with international palliative care specialists, a national strategy has been developed and adopted to guide future development so that palliative care for all who need it can be provided. this article explores the faith-based context for palliative care and describes the particular issues nepal faces, the work of christian mission organizations in supporting palliative care development, and the need for religious and cultural sensitivity. faith and the development of hospice and palliative care care of the dying is a recognized part of nearly all ancient religious philosophies and ways of life. nepal is a majority hindu country with a sizeable buddhist population, each with its own beliefs and practices around the end of life and after death. in hindu philosophy, death is not seen as being the opposite of life, but the opposite of birth. 1 death is a process whereby the soul migrates to the next life or to heaven. the soul is enabled to transmigrate by various rituals being observed, such as cremation taking place in sacred places near to water. the famous pashupathinath aryan ghat on the banks of the bagmati river, a tributary of the sacred ganges, is traditionally where cremations take place in kathmandu. faithful hindus may prepare for death by travelling there, as some indians travel to the holy city of banares in preparation for death. 2 an ashram has been provided on the pashupatinath site, where the old, infirm, and those who are dying are often brought and cared for. in recent years, this service has incorporated some of the practices and principles of modern palliative care. 3 (see figure 1). 13 munday & powys nov 2017. christian journal for global health 4(3):12-20 figure 1 – the ‘hospice’ ashram at pashupatinath temple (note the body prepared for cremation in the foreground). while buddhists also believe in the transmigration of the soul, pre-death rituals and the site of death are not so important. in buddhist philosophy, one should always be ready for death and banish all fear of it. 4 buddhists prepare for death by caring for the dying person, particularly for their psychological and spiritual state, keeping them calm and focused, enabling them to progress smoothly to the next life. 5 caring for those who are dying is an important service to perform and karuna-shechen, a buddhist charity, set up a hospice in 2000 as part of a medical service in the grounds of the shechen monastery in bouddha, an area of kathmandu with a large tibetan buddhist population. for christians, palliative care with its holistic, patient-centered approach resonates with the principles jesus summarizes in the great commandments — love god, and love your neighbor as yourself. ferngren suggests, “it was the christian belief in personal and corporate philanthropy as an outworking of christian concepts of agape and the inherent worth of individuals who bore god’s image that introduced into the classical world the concept of social responsibility in treating epidemic disease.” 6 christians, caring for people suffering with plague, were potentially a significant contributor to the rapid church growth of the second and third centuries. 7 early christianity adapted jewish service ideals of generosity and hospitality, linking these to faith and salvation, especially by serving the poor and afflicted. as christianity spread and developed, institutions to care for the sick and destitute were established frequently linked to places of worship and monasteries. 6 hospices, as places to care for the sick and dying traveler, were set up by the 14 munday & powys nov 2017. christian journal for global health 4(3):12-20 knights hospitaller in the 14 th century during the time of the crusades. 8 increasing formalization of services with development of institutions later led to depersonalization, segregation, and commercialization of health services. 8 catholic and protestant missionary revivals of the 19 th century led to the establishment of hospices to care for the dying such as the hospice of the association des dames de calvaire in lyon and that of the sisters of charity in dublin. towards the turn of the 20 th century in london, amongst other christian institutions founded to care for the dying, was the hospital of st john and st elizabeth and st lukes’ and st joseph’s hospices, 9 where dame cicely saunders, founder of the modern hospice movement was later to work. 10 up until the development of the modern hospice movement in the uk, most hospices were christian charities. 7 palliative care in low and middleincome countries palliative care services are developing in lowand middle-income countries, with christian organizations often at the forefront. palliative care embraces a holistic approach with patient-centered care spanning physical, psychological, social, and spiritual domains. however, for care to be effective, models, in addition, need to be socially, economically, and culturally appropriate. with reduced health resources and individual poverty, normally treatable conditions may well be palliative at an earlier stage in low-income settings. this can include acute surgical conditions such as major burns or acute abdomens occurring in remote or inaccessible areas that lack services and clinicians able to provide necessary curative care, medical conditions requiring intensive care, or where resistance to treatment has emerged (e.g., hiv/aids or multidrug-resistant tb). 11 as hospice and palliative care services developed in industrialized settings, their main focus was on advanced cancer. 12 in africa, particularly, palliative care developed to care for huge numbers suffering from hiv/aids. 13 palliative care has also responded to local and more esoteric needs, for instance, with an innovative approach to end-of-life care for patients suffering from rabies in an infectious diseases hospital in manilla and a service focusing on the palliative needs of the transgender population in delhi. 14,15 currently, the demographics of nearly every country is changing with ageing population trends, but in lowand middleincome countries, this demographic change is particularly significant with a rapid increase in non-communicable disease (ncd) in areas where death was previously commonly due to infections and maternal and child health conditions. 16 nepal, compared to other lowincome countries, is ahead of the curve, with already 60% of deaths occurring from ncds according to who modelling. 17 palliative care development in nepal nepal is a low-income country reported as being 145 out of 187 countries globally in terms of its un human development index. 18 the geography of nepal is hugely varied and challenging, with the high himalayan range in the north, hills in the central zone, and plains (terai) on the southern border with india. in nepal, eighty-three per cent of the population lives in rural areas that can be very remote. it can take up to 4 days to reach the nearest district level health facilities. 19 nepal’s health care system is based on local health posts, referring up to district, zonal, regional, and tertiary hospitals. health, in general, in nepal has improved with life expectancy, increasing from 45 to 69 years between the mid 1980s and 15 munday & powys nov 2017. christian journal for global health 4(3):12-20 today; 20 however, much of the focus of healthcare provision has until recently concentrated on achieving the millennium development goals. this has led to some marked successes; for instance, maternal mortality rates have reduced from 870 per 100,000 live births in 1990 to 380 per 100,000 by 2008. 21 despite these achievements, universal health coverage remains a somewhat distant aspiration. palliative care in nepal started to emerge in the late 1990s with cancer specialist doctors, nurses, and others becoming aware of the specialty through working in other countries or having had the opportunity to study abroad. the first modern hospice was established in 2000 in the capital, kathmandu, followed by others, either stand alone hospices or palliative care units, part of cancer hospitals mostly in kathmandu or other major cities. 22 also, there has been interest and support from abroad, particularly through the international network for cancer treatment and research (inctr). 22 the nepalese association of palliative care (napcare) was established in 2009, bringing together those interested in palliative care and providing a vehicle for training and advocacy. in 2013, the ministry of health established a two-week introductory course, facilitated by napcare. through the efforts of the napcare community, supported by the pain and palliative care policy unit in wisconsin, morphine has been made available in palliative care formulations manufactured in nepal by a nepalese pharmaceutical company. 23 palliative care is still a relatively new specialty for nepal, and there is only one nepali trained medical palliative care specialist, a limited number of experienced nepali palliative care nurses, and almost no trained palliative care allied health professionals. early palliative care in nepal was mainly cancerfocused. cancer is a significant palliative care issue since although only around 8% of deaths are due to cancer, up to 75% of people are in an advanced stage at the time of diagnosis. 24 hiv/aids is an issue mainly within specific subgroups of migrants and sex workers across the open border with india, but the epidemic remains numerically small overall. 25 our own survey of an inpatient unit in a mission hospital in western nepal revealed that chronic respiratory illness was by far the most common illness requiring palliative care. 26 a recent survey in one rural area has indicated that chronic disease management (cdm) is a significant challenge, and most people with a chronic illness do not receive any effective management (paper in preparation), so any palliative care intervention in rural areas will need to be embedded within the context of the spectrum of cdm. in nepal, like other lowand middleincome countries with little subsidized health care or health insurance, catastrophic household debt can easily be precipitated by health expenditure, particularly from accessing the private sector. 27 this health expenditure can often be futile in people with advanced noncurable illnesses. palliative care training can empower health workers in remote, rural areas to care for people with good symptom management, rather than sending patients & families away for clearly inappropriate and expensive treatment. so palliative care can have a significant role in the reduction of poverty for surviving family members. 28 challenges for nepal the number of frail elderly is increasing in nepal, as people live longer, with a 2011 survey reporting that over 65s made up 6% of the population, increasing from 4% over seven years. 29 as a result, there is a rapidly increasing incidence of multi-morbidity and complex medical issues associated with increasing ncds in an aging population. 30 in industrialized 16 munday & powys nov 2017. christian journal for global health 4(3):12-20 countries, geriatrics and palliative care have developed as separate specialties. however, for lowand middle-income countries, this may not be a replicable model due to limitations in health resources. new ways of developing care of the elderly including palliative care need to be explored. 31 nepal is experiencing another significant demographic shift as many of the younger generation move from their rural homes to other parts of nepal for work, or, increasingly, leaving nepal as migrant workers or for opportunities to study abroad. the nepal household survey 2012 revealed 27% households have at least one family member working overseas and 28% of households have female heads. 29 in addition, many mothers with school age children will migrate from rural areas to the city for education. this means that the traditional extended family structure that has supported the elderly and infirm is now breaking down, and an increasing number of older people are living alone. 32 palliative care development in nepal needs to be considered in its particular geographical, demographic, and economic context. its low-income status is reflected in its rudimentary healthcare provision, particularly in rural areas. however, with its burgeoning incidence of ncds, palliative care is an important facet of universal health coverage if the people are to have access to the type of healthcare they need. over the last two years, napcare along with partners from the government of nepal, who, and some international partners has been involved in developing a national strategy. this takes a public health approach 33 with the aim of integrating palliative care into the health system of nepal so it is available to all who need it. the ministry of health in nepal has now adopted the strategy as government policy. 34 serving the poor and marginalized in nepal, two christian ingos, united mission to nepal (umn), and international nepal fellowship (inf) have been seeking to serve the poor and marginalized for over 6 decades. 35 this has been done through health and community development, education, and various innovative models of economic and industrial development. umn and inf have both established mission hospitals that seek to model holistic care. 35 36 under inf’s umbrella, this concern for the poor and marginalized has led to health work with people affected by leprosy, tb, spinal cord injuries, and those needing rehabilitation. over the past 4 years, this has expanded to the inclusion of palliative care development at both the local hospital level and in partnership with napcare on a national level. through supporting nepali colleagues, the inf program has included needs assessment research (funded by the health development charity emms international), education, and advising on the development of the national strategy. the church in nepal has been in existence for 60 years and now has a greater vision for social outreach to care for the vulnerable in surrounding communities. 35 following the 2015 earthquake, churches and christian organizations, along with many others, reached out to those in need. churches are recognizing the increasing numbers of frail aged members and others in their communities who have significant care needs. up to the present, there have been almost no old-age homes in nepal, but there is a need emerging as the extended family support system is breaking down. a few churches are already responding to this need in appropriate ways. churches are also requesting and receiving training for volunteer members to learn about caring for the frail elderly and those with palliative care needs. 37 there is great potential to expand this type of community 17 munday & powys nov 2017. christian journal for global health 4(3):12-20 training with community groups including churches and others, although whether community palliative care services similar to those in kerala 38 can be established remains to be seen. cultural and religious considerations in nepal, as in india, most people believe in god and are religious. 39 religious practices are very evident and commonly observed in temples, roadside shrines, and around peoples’ shops and houses as an aspect of everyday life. on the day of writing, people in nepal are honoring the “eternal spirit” in dogs, placing garlands around their necks and tikkas on their foreheads. for those from other cultures, some practices can seem strange. one of the authors was struck whilst visiting the ashram at pashupatinath (see figure 1) by the thick smoke from a funeral pyre seeping into the room where a person was dying. when he inquired how dying people reacted to this, the response was that they found it comforting, as the smoke and aroma reminded them that they were “passing on” in a holy place. hospices, even those that are not religious, will often have prominent pictures of hindu deities that patients frequently find comforting and give them a focus for spiritual care. 41 water containing tulsi (holy basil) leaves are given to a dying person to aid passage of their soul to the next life. hospices (and many houses) have tulsi plants growing in their gardens. another ritual of enabling the dying person to hold onto the tail of a cow is similarly said to enable the soul’s passage, 42 and we have also observed this practice in a hospice garden. it is important, when working with those from other faiths and cultures, to seek to understand the customs and rituals and so be able to practice in a way that is respectful and enabling to patients and their families. for the christian, practicing palliative care is often seen as part of the calling to serve the poor, marginalized, and those who suffer. unlike nepal, in india, christians were at the forefront of palliative care provision in the early days of its development. this was not without some concern that christians caring for those of other faiths could lead to difficulties, including conflict in families if the dying person wanted to convert. 42 it is vital that christians caring for those of other faiths and cultures understand and respect their beliefs and practices, particularly at a time of great vulnerability, such as for the patient receiving palliative care. in our travelling in india and nepal, we have also observed that christian hospitals have often developed a culture of patient centered medicine upon which palliative care services can be built. of course, such an approach is not exclusive to christian hospitals, but such patient centered institutions can provide excellent sites for palliative care model development and training, as we are currently piloting in one large mission hospital in west nepal. so, we believe that christian health care institutions can play an important role in the development of palliative care in nepal as they have been doing in india, for instance, in the emmanuel hospital association palliative care programme. 43 conclusion palliative care in the majority hindu country of nepal has been developing over the last 20 years. recently, nepal has established a palliative care strategy to guide development of appropriate palliative care over the next 10 years. this has been led by the napcare, supported by expatriate specialist physicians from inf. they have been undertaking needs assessment research to promote an evidencebased approach to palliative care development in nepal. the next step for the nepali palliative 18 munday & powys nov 2017. christian journal for global health 4(3):12-20 care community and its supporters is working toward implementation of the national strategy. palliative care development in nepal aims to identify and respond to the local needs and contexts in an appropriate way, which is respectful to local customs and religious practices. appropriate palliative care will necessitate incorporating end-stage care into emerging chronic disease management models, establishing frail elderly care, and defining appropriate models for rural and remote areas. there continues to be a need for overseas trained palliative care clinicians to be involved in supporting palliative care development, particularly, in the coming few years while more national staff can be trained and gain experience. christian health care workers have an opportunity to be a part of this. local churches can take a lead in developing social care in their communities and can respond to the need for elderly and palliative care by setting up volunteer services and collaborating to serve their communities. in this way, they will carry on the christian tradition of caring for the sick and dying established nearly two millennia ago. references 1. inbadas h. indian philosophical foundations of spirituality at the end of life. mortality 2017:114. https://doi.org/10.1080/13576275.2017.1351936 2. justice c. dying the good death: the pilgrimage to die in india's holy city. new york: state university of new york; 1997. 3. shrestha s. challenges and solutions for developing palliative care in nepal [last cited 2015 dec 19]. palliative care in oncology symposium 2015 [internet] 2015 sept 10. available from: http://pallonc.org/challenges%c2%ad-and%c2%adsolutions%c2%addeveloping%c2%adpalliative-%c2%adcare %c2%adnepal 4. masel ek, schur s, watzke hh. life is uncertain. death is certain. buddhism and palliative care. j pain symptom manag. 2012;44(2):307-12. https://doi.org/10.1016/j.jpainsymman.2012.02.0 18 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2017; coimbatore, tamil nadu: ind j palliative care; 2017. p. 12179. 16. who. global action plan for the prevention and control of noncommunicable diseases 20132020. geneva: world health organisation; 2013. 17. who. ncd country profiles: nepal. secondary ncd country profiles [last accessed 2017 october 19]: nepal: world health organisation; 2014. available from: http://www.who.int/nmh/countries/npl_en.pdf?u a=1 18. malik k. human development report 2014: sustaining human progress: reducing vulnerabilities and building resilience. united nations development programme; 2014. 19. central bureau of statistics. national population and housing census 2011. national report. kathmandu, nepal: nepal; 2012. 20. world bank. life expectancy in nepal [last cited 2017 october 19]. available from: https://data.worldbank.org/country/nepal 21. malla ds, giri k, karki c, chaudhary p. achieving millennium development goals 4 and 5 in nepal. bjog. 2011;118(s2):60-8. https://doi.org/10.1111/j.14710528.2011.03113.x 22. brown s, black f, vaidya p, shrestha s, ennals d, lebaron vt.. palliative care development: the nepal model. j pain symptom manag. 2007;33(5):573-7. https://doi.org/10.1016/j.jpainsymman.2007.02.0 09 23. paudel bd, ryan km, brown ms, krakauer el, rajagopal mr, maurer ma, et al. opioid availability and palliative care in nepal: influence of an international pain policy fellowship. j pain symptom manag. 2015;49(1):110-6.: https://doi.org/10.1016/j.jpainsymman.2014.02.0 11 24. piya mk, acharya sc. oncology in nepal. s asian j cancer. 2012;1(1):5 https://doi.org/10.4103/2278-330x.96490 25. nepal b. population mobility and spread of hiv across the indo-nepal border. j health popul nutr. 2007;25(3):267-77. 26. bk m, munday d, powys r. non-communicable diseases and palliative care needs: a survey of a rural hospital in nepal. 24th international congress of the indian association of palliative care; 2017; coimbatore, tamil nadu: ind j palliative care; 2017:121-79. 27. saito e, gilmour s, rahman mm, gautam gs, shrestha pk, shibuya k. catastrophic household expenditure on health in nepal: a cross-sectional survey. bulletin of the world health organization. 2014;92:760-67. https://doi.org/10.2471/blt.13.126615 28. ratcliff c, thyle a, duomai s, manak m. poverty reduction in india through palliative care: a pilot project. ind j palliative care. 2017;23(1):41-45. https://doi.org/10.4103/09731075.197943 29. ministry of health and population. nepal demographic and health survey 2011. kathmandu, nepal: nepal; 2012. 30. mishra sr, neupane d, bhandari pm, khanal v, kallestrup p. burgeoning burden of non communicable diseases in nepal: a scoping review. globalization health. 2015; 11 (1 ). https://doi.org/10.1186/s12992-015-0119-7 31. humphreys g. the health-care challenges posed by population ageing. bulletin of the world health organization. 2012;90:82-3. https://doi.org/10.2471/blt.12.020212 32. gartaula hn. international migration and local development in nepal. contrib nepalese studies. 2009;36(1):37-65. 33. stjernswärd j, foley km, ferris fd. the public health strategy for palliative care. j pain symptom manag. 2007;33(5):486-93. https://doi.org/10.1016/j.jpainsymman.2007.02.0 16 34. munday d. national strategy for palliative care handed over to the government of nepal [last accessed 2017 sep 14]. ehospice 2017; 25 april 2017. available from: http://www.ehospice.com/articleview/tabid/106 86/articleid/21936/view.aspx 35. hale t. light dawns in nepal: a story about ordinary people used by god to do the impossible: the story of the international nepal http://www.who.int/nmh/countries/npl_en.pdf?ua=1 http://www.who.int/nmh/countries/npl_en.pdf?ua=1 https://data.worldbank.org/country/nepal https://doi.org/10.1111/j.1471-0528.2011.03113.x https://doi.org/10.1111/j.1471-0528.2011.03113.x https://doi.org/10.1016/j.jpainsymman.2007.02.009 https://doi.org/10.1016/j.jpainsymman.2007.02.009 https://doi.org/10.1016/j.jpainsymman.2014.02.011 https://doi.org/10.1016/j.jpainsymman.2014.02.011 https://doi.org/10.4103/2278-330x.96490 https://doi.org/10.2471/blt.13.126615 https://doi.org/10.4103/0973-1075.197943 https://doi.org/10.4103/0973-1075.197943 https://doi.org/10.1186/s12992-015-0119-7 https://doi.org/10.2471/blt.12.020212 https://doi.org/10.1016/j.jpainsymman.2007.02.016 https://doi.org/10.1016/j.jpainsymman.2007.02.016 http://www.ehospice.com/articleview/tabid/10686/articleid/21936/view.aspx http://www.ehospice.com/articleview/tabid/10686/articleid/21936/view.aspx 20 munday & powys nov 2017. christian journal for global health 4(3):12-20 fellowship. kathmandu: international nepal fellowship; 2012. 36. harper i. mediating therapeutic uncertainty: a mission hospital in nepal. in: harrison m, jones m, sweet h, eds. from western medicine to global medicine: the hospital beyond the west. delhi: orient longman; 2008. 37. russell r. mobilising the community for the provision of palliative care in nepal. ehospice 2016; 17 june 2016. available from: https://www.ehospice.com/default.aspx?tabid=1 0686&articleid=19728 38. sallnow l, kumar s, numpeli m. home-based palliative care in kerala, india: the neighbourhood network in palliative care. progress in palliative care. 2010;18(1):14-7. https://doi.org/10.1179/096992610x126242902 76142 39. mishra s, bhatnagar s, philip fa, et al. psychosocial concerns in patients with advanced cancer: an observational study at regional cancer centre, india. am j hosp palliat me. 2010;27(5):316-9. https://doi.org/10.1177/1049909109358309 40. simha s, noble s, chaturvedi sk. spiritual concerns in hindu cancer patients undergoing palliative care: a qualitative study. ind j palliative care. 2013;19(2):99. https://doi.org/10.4103/0973-1075.116716 41. dam a. wading through quicksand: palliative care, spirituality and sanatan dharma. chennai: notion press; 2015. 42. chaturvedi sk. spiritual issues at end of life. indian j palliative care. 2007;13(2):48. https://doi.org/10.4103/0973-1075.38899 43. munday d, haraldsdottir e, manak m, thyle a, ratcliff c. rural palliative care in north india: rapid evaluation of a programme using a realist mixed method approach. ind j pall care (in press). peer reviewed competing interests: none declared. correspondence: daniel munday, international nepal fellowship, nepal. daniel.munday@inf.org cite this article as: munday d, powys r. reflections on the challenges and opportunities for palliative care in nepal. christian journal for global health. nov 2017; 4(3):12-20. https://doi.org/10.15566/cjgh.v4i3.194 © munday d, powys r. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.ehospice.com/default.aspx?tabid=10686&articleid=19728 https://www.ehospice.com/default.aspx?tabid=10686&articleid=19728 https://doi.org/10.1179/096992610x12624290276142 https://doi.org/10.1179/096992610x12624290276142 https://doi.org/10.1177/1049909109358309 https://doi.org/10.4103/0973-1075.116716 https://doi.org/10.4103/0973-1075.38899 mailto:daniel.munday@inf.org https://doi.org/10.15566/cjgh.v4i3.194 http://creativecommons.org/licenses/by/4.0/ commentary the annunciation of the gospel: a humble goal for medical missions raymond downinga a md, senior lecturer, department of family medicine, moi university school of medicine, kenya at the beginning of his many dramatic proposals for living humanly in the modern world, ivan illich first addressed the church. better known for his counter-intuitive views on transportation, education, and medicine, illich began his career as a priesteducator in the catholic church, spending over a decade educating would-be missionaries to latin america. in 1967, addressing an anglican consultation for social issues, he declared that the time had come for the church to withdraw from its current role in third-world development and focus on what he called “the annunciation of the gospel.”1 mission had, of course, always been about the gospel, but the role of “development” followed closely. how could you preach to people who were hungry or sick? and how could they read the bible if they were illiterate? there were very good reasons why the church broadened its mission. medical missions were one of the early forms of development, and medical missionaries in the 19th and 20th centuries recorded their justifications for their expanded roles. though we no longer discuss, or are even aware of, these archaic rationales, they remain disturbingly consonant with our contemporary foundations for mission institutions. a century of early apologetics for development in 1842, daniel macgowan, a young doctor headed to china as a medical missionary, gave an address in new york entitled “claims of the missionary enterprise on the medical profession.”2 he was speaking as a doctor, though from the perspective of missionaries, asserting their need to embrace medicine. and he was clear about the link: speaking of the physician, he said, “it is his province to assuage human suffering, in all its varieties and aggravations, and, in imitation of the saviour, ‘to heal all manner of diseases.’” then he suggested the source of some of those diseases: ... many regions of the pagan world are at this time enduring fearful miseries, which they trace directly and undeniably to their intercourse with our commerce and our civilization... here is a vast amount of wretchedness produced by civilized man. 2 — a frank confession. therefore, ... as civilized men, we, by our skill and experience, should strive to alleviate, nor is it too much to say, that we have it in our power in a measure to save some of these races from entire annihilation. 2 — a solution even more grandiose than his mea culpa. even before scientific medicine had much to offer, this young doctor saw the potential; he unwittingly predicted the yet undeveloped power of the medical profession. illich, 125 years later, suggested that, in the name of announcing the gospel, we relinquish this kind of power. then, in 1886, in medical missions, their place and power, john lowe presented a view of western civilization much less critical than macgowan's.3 among “the heathen,” lowe writes, “the arts and usages of civilization are unknown” and, therefore: ... no humanizing influences are at work... the sick are uncared for, or treated with barbarous cruelty... the aged and infirm are counted a burden, and either perish from neglect or linger on in misery.3 yet ironically, his conclusion mirrors illich's: under circumstances such as these, what can the missionary do? 'preach the gospel,' we say, for the 'glorious gospel of our blessed god' is the one only panacea for all the world's miseries. 3 he should have stopped there. but he continued: yes, the gospel is the 'power of god' — the power which has made britain a land of 17 downing greatness, intelligence, and influence beyond any other nation on the face of the globe. it is the power which, again and again, has broken the arm of oppression and tyranny, and, dispelling from the minds of millions the dark clouds of ignorance and superstition, has raised the beggar from the dung-hill and set him among princes. 3 the colonial project which britain was just then beginning in africa would show lowe to be a false prophet. in 1912, a victorian lady named elma k. paget published the claim of suffering: a plea for medical missions.4 it exemplifies a subtle shift from the saviour of souls to the succorer of bodies. citing the example of “the great physician,” and noting 250 doctors who had signed an appeal on behalf of medical missions, she explained her title: “medical missions relieve an unspeakable amount of human suffering due to the ignorance and quackery of native doctors.” she then continued the argument lowe had drawn. a cloud of despair seems to hang over the non-christian races and to render them helpless if they are overtaken by misfortune or calamity... to the christian, pain may become a factor in man's moral, intellectual, and spiritual life; we do not deny its existence nor underrate its sting, but we seek with confidence to use it and in due time to conquer it. so we believe ourselves to be by god's will masters of our destiny, and acting on this assurance we have seen disease retreat from territories where hitherto it has held supreme. 4 she grants the role of suffering as a potentially positive “factor” in a christian's life. but paget does not mention sharing in the sufferings of christ or following christ's example of suffering. her view is far more triumphalist, with us ultimately becoming “masters of our destiny,” an idea that comes more from the poem invictus by william ernest henley than from the bible. the claim of suffering on us, she says, is not to share it but to eliminate it. now we may take issue with some of the victorian analysis above. was there really such lack of care and concern for the ill, such wretchedness in the so-called heathen lands? how many of those approaches were simply culturally different from the europeans’? how much was simply sensible use of the resources they had? or again, to what extent was our western civilization really built on our christian faith? macgowan at least admitted his view that some “wretchedness” was due to our civilization more than that of the “heathen.” and as for the claim of suffering on us, as noted above, paget and others could see only that it needed to be eliminated, even though the biblical account was far more nuanced. nevertheless, there is much above to which we still hold: that biblical ministry is both physical and spiritual, that we are called to care for the suffering, and that — extrapolating from the above — poverty underlies much of the third world's miseries. in addition, implied for addressing all of these tasks is the setting up of powerful institutions — churches, schools, hospitals, and clinics. the development discussion of the 1970s it was these institutions of development that illich was addressing, saying it was time for the church to withdraw from this sort of development so it could rediscover its “specific function,” he said, which was “the annunciation of the gospel.” this would be the church's “contribution to development which could not be made by any other institution.” in 1967, he was saying that other organizations could carry out these tasks.1 this call went unheeded. instead, the christian medical commission (cmc), founded in europe in 1968, provided a christian rationale for development in the form of primary health care; it was one of the main organizations influencing the articulation of primary health care as presented at alma ata in 1978.5 several recent reviews have reaffirmed the role of the cmc in developing primary health care, along with the influence of illich and others.6-9 however, these reviews do not reference illich's call for the church to withdraw from development as noted above. rather, they refer to his best-selling medical nemesis and his tools for conviviality, both of which challenged the assumption that more medical technology led to better health. there certainly was synergy between illich's views of medicine and the primary health care redirection advocated by the cmc. but illich, even before medical nemesis, had made clear what this redirection would mean for the church: letting go of power, which, he said would be painful because “the church still has so much power — which has so often 18 downing been used for evil.” he titled his presentation “the powerless church.”1 “it is my thesis,” he wrote, ... that only the church can ‘reveal’ to us the full meaning of development. to live up to this task the church must recognize that she is growing powerless to orient or produce development. the less efficient she is as a power the more effective she can be as a celebrant of the mystery. 1 illich's thesis requires some unpacking. what seems particularly strange is his call to renounce power. many would argue today that power is needed, both to announce the gospel and to carry out development. further, it seems anti-climactic as well as counter-intuitive, that illich's radical proposal was what the church had claimed its mission to be all along the annunciation of the gospel. what, then, is the nature of this gospel, this mystery? what made illich state the obvious as a radical proposal? and when he said “annunciation,” did he simply mean the tasks of preaching and teaching? what is the gospel? most of us have a concept of what the gospel is and can capsulize it: good news; or john 3:16; or salvation from sin by christ's sacrifice; or the incarnation and atonement; or justification, sanctification, and glorification. our review of medical missions, however, reveals that over the last two centuries, apologists have included a great deal which may not be gospel. in this context, we will begin considering what the gospel is primarily by suggesting what it is not. what the gospel is not • the gospel does not free us to gain secular power, but rather to relinquish and avoid it; consider jesus’ arrest in gethsemane. we may now recognize the power of our medical science, for example, and we can even advocate its judicious use. however, we cannot claim that the gospel is the power behind it, the way that lowe claimed it was the power which made britain the greatest nation in the world. either claim would be blasphemy. today we are cannier. we don't attribute the benefits of our medical science or western civilization directly to the gospel. however, we see little conflict in employing them alongside the gospel as a means of demonstrating our compassion. despite its value, we must remember that employing medical science requires complex institutions and power. think of any hospital. should the church be managing these complex and powerful institutions? • the gospel does not admonish us to eliminate suffering, but rather to endure it and to suffer compassionately with those who are suffering. in identifying the christian roots of contemporary humanitarianism, dider fassin writes, [t]he valorization of suffering as the basic human experience is closely linked to the passion of christ redeeming the original sin... the singular feature of christianity in this respect is that it turns suffering into redemption.10 mcneill and his colleagues explain: the mystery of god's love is not that he takes our pains away, but that he first wants to share them with us . . . the great mystery is not the cures, but the infinite compassion which is their source.11 biblically we are enjoined to suffer with those who suffer (rom 12:15), and to share in the sufferings of christ (i pet 4:13). we also, of course, follow christ when we seek to comfort those who are suffering — but this is most authentic when rooted in our own experience of suffering, as it was with christ. to seek only to eliminate suffering is to blunt the biblical understanding of it. but, some might ask, how should the church as an institution relate to human suffering? this question exposes the fundamental issue underneath illich's critique of development. development needs an institution to carry it out. the gospel is not an institution. when we put it into a sociological or political structure or reduce it to an ideology or an “ism,” we have subverted it. jacques ellul was disturbed enough about this subversion that he wrote a whole book about it and, to reduce confusion, called the real christianity “x.”12 illich took the discussion one step further: “the subversions of what ellul calls “x”... i would openly name, divine grace.”13 please note that illich and ellul are not calling for a new ecclesiology. the call is to announce and live the gospel despite the institutions of church and mission and development which are inevitable. they do not call us to destroy institutions. we may claim institutions facilitate living out the gospel. 19 downing illich seems to suggest they more likely get in the way. i suspect illich would have denied an institutional church could respond to the suffering of peoples. i suspect he would have said only people can respond to the suffering of people. • several of the sources above made the claim that as christian doctors we are imitating jesus’ healing ministry. we are not. jesus healed by miracle; we treat by adjusting biological mechanisms. jesus eliminated disability; we only manage it. adjusting a disordered biological mechanism is good, but it is not a miracle. there is nothing in biomedical treatments that is distinctive to the gospel. there is also nothing wrong with adjusting mechanism, but that is not what jesus did. we do not heal. we treat and, in the process, require large and powerful institutions. should the church be burdened with all this that biomedicine requires? • finally, living out the gospel does not involve recruiting members, as for a club, but loving all people unconditionally (mat 11:28). medical mission should be the same. determining who is in and who is out is god's business, not ours. however, for the efficient running of institutions such as churches or hospitals, membership becomes important. who can work here? sometimes that decision for mission hospitals is based on religious membership as much as on work ethic and skills. yet, religion as a club distorts the gospel. the best way for the church to relieve the distortion is to withdraw from the work of managing these institutions. the gospel does not require us to follow an agenda of wholistic development which may have been derived from thoroughly christian principles. in fact, the gospel — that is, the mystery referred to repeatedly by st paul and named here by illich — may be impeded by people trying to carry out complex programs spawned by that same gospel. the power of the gospel, after all, is not the efficiency or success of the development program, but “christ in you, the hope of glory” (colossians 1:27). let development continue, and let us who are technicians — doctors, teachers, agriculturalists — join those complex development structures wherever they are and seek as much as possible to redeem them. but, let the gospel be the gospel, the news which is good. what the gospel is listen to some of these hints from illich about what the gospel is: • the function of the church “is to recognize the presence of christ among us through liturgical celebration and to charge human beings, through these celebrations, with the proper emotions toward social action... the less efficient the church is as a power, the more effective it is as a celebrant of the mystery.”14 the mystery of the gospel, we saw, was the presence of christ in us — and (according to the jerusalem bible translation) “among” us. institutional power, even unwittingly, can mask this presence of christ. • “what the church contributes through evangelization is like the laughter in a joke. two hear the same story — but one gets the joke.”1 in the same way that embracing the gospel gives us ears to hear — in this case, ears to hear the meaning of the story and to respond by laughing — so the gospel can provide us with ears and eyes to hear the meaning of suffering and, correspondingly, the meaning of healing. an efficient powerful institution can never do this; only the gospel can. • “the christian wants to remain free to find through the gospel a dimension of effective surprise beyond and above the humanistic reason which motivated social action.”1 humanistic reason can motivate social action in the same way scientific medicine can enable excellent medical care or management principles can build an efficient and powerful institution, even an institutional church. this is not the good news of the gospel, but the laughter, the surprise: these may be the holy spirit breaking through. • the rejection of power, in greek the anarchy, of jesus troubles the world of power, because he totally submits to it without ever being part of it. even his submission is one of love. this is a new kind of relationship, which paul has well explained in romans chapter 12.15 romans 12:2 admonishes us not conform to the pattern of the world (niv translation), and not to model ourselves on the behavior on the world around us (jerusalem bible). in other words, not to be part of the world of power. earlier in the same article, illich refers to: ... the analogy between the answer to the devil who tempted him with power and to the herodians who tempt him with money. his response is clear: abandon all that which 20 downing has been branded by caesar; but then, enjoy the knowledge that everything, everything else is god's, and therefore is to be used by you... 15 illich calls jesus a “dropout from power and money,” and explains: the established order of power is evil not because it is bad, but because it is a spiritual, demonic establishment in this world. the kingdom of god is its opposite.15 illich's critique was of institutions, not of living out the gospel. his simple plea 50 years ago was that we disengage from development institutions so that we could more fully live the gospel. it’s time to begin. references 1. illich i. celebration of awareness: a call for institutional revolution. garden city, new york: doubleday & company; 1970. [chapter 7, “the powerless church”]. 2. macgowan dj. claims of the missionary enterprise on the medical profession. new york: william osborn; 1842. available from: https://archive.org/details/62740930r.nlm.nih.gov 3. lowe j. medical missions: their place and power. new york: fleming h. revell; 1886. available from: https://archive.org/details/medicalmissionst00lowe 4. paget, ek. the claim of suffering: a plea for medical missions. westminster: society for the propagation of the gospel in foreign parts; 1913. [first short quote p 113; second longer quote p. 32]. available from: https://archive.org/details/cu31924024018628 5. flessa s. christian milestones in global health: the declarations of tübingen. christ j global heal, 2016 may;3(1):11-24. https://doi.org/10.15566/cjgh.v3i1.96 6. cueto m. the origins of primary health care and selective primary health care. amer j public heal, 2004 november;94(11):1864-74. https://doi.org/10.2105/ajph.94.11.1864 7. cueto m, palmer s. medicine and public health in latin america. cambridge: cambridge university press; 2014. [p. 206] 8. litsios, s. on the origin of primary health care. in: medcalf a, bhattacharya s, momen h, et al., editors. health for all: the journey of universal health coverage. hyderabad (in): orient blackswan; 2015. [chapter 1] 9. hanrieder t. international organization in time: fragmentation and reform: oxford university press; 2015. [p. 76] 10. fassin d. humanitarian reason: a moral history of the present. berkeley: university of california press; 2012. [both quotes from the conclusion] 11. mcneill dp, morrison da, nouwen hjm. compassion: a reflection on the christian life. garden city, new york: doubleday & company; 1982. [p 18] 12. ellul, j. the subversion of christianity. grand rapids, michigan: eerdmans publishing company; 1986. [p. 11] 13. illich, i. to honor jacques ellul. 1993, no 13. bordeaux, france. [based on an address given at bordeaux, november 13, 1993]. available from: http://www.davidtinapple.com/illich/ 14. du plessix gray, f. the rules of the game. new yorker. 1970, april 25. [ p. 78-9] 15. illich, i. the educational enterprise in the light of the gospel. chicago. [lecture manuscript, printout nov.15th, 1988. currently being edited by dr. lee hoinacki]. available from: http://www.davidtinapple.com/illich/1988_educational .html peer reviewed: submitted 3 nov 2017, accepted 9 jan 2018, published 12 july 2018. competing interests: none declared. correspondence: raymond downing, moi university school of medicine, kenya. armdown2001@yahoo.com cite this article as: downing r. the annunciation of the gospel: a humble goal for medical missions. christian journal for global health. july 2018; 5(2):16-20. https://doi.org/10.15566/cjgh.v5i1.202 © downing r. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://archive.org/details/62740930r.nlm.nih.gov https://archive.org/details/medicalmissionst00lowe https://archive.org/details/cu31924024018628 https://doi.org/10.15566/cjgh.v3i1.96 https://doi.org/10.2105/ajph.94.11.1864 http://www.davidtinapple.com/illich/ http://www.davidtinapple.com/illich/1988_educational.html http://www.davidtinapple.com/illich/1988_educational.html mailto:armdown2001@yahoo.com https://doi.org/10.15566/cjgh.v5i1.202 http://creativecommons.org/licenses/by/4.0/ short communication june 2014. christian journal for global health 2014, 1(1): 53-56. the intersection of home care and hiv with health and faith ian d campbell a a mb,bs; mrcp(uk); drcog; mftm (rcps-glasgow), coordinator, affirm facilitation associates abstract this paper describes significant events in the 1980s in zambia which involved communities and health institutions in change that is still felt today. the churches health association of zambia leadership wanted this history to be retold by a leader from the past, and remembered as a vision and values framework that is still relevant. it is experienced as indigenous, describing strengths that are not brought from outside with funding of any kind. the story still influences an awakening of strength in places far removed from africa. a recent example is shared from china, where community health and church workers have an intense interest in the development of local initiative in response to hiv. introduction the emergence of hiv and aids in zambia from 1983 illuminated the presence of god as a foundation for healing and expression of care that would generate sustained local community movements for prevention. this paper describes significant events in the 1980s in zambia that involved communities and health institutions in change still felt today. in zambia, and other sub-saharan african countries, the role of expatriate health workers has changed dramatically in the past thirty years, from heads of institutions in the 1970s through 1990s to occasional consultants and friends. young zambians move into senior positions early because of the societal changes brought by decades of hiv impact, and history can be forgotten. the churches health association of zambia (chaz) leadership wanted this history to be retold by a leader from the past and remembered as a vision and values framework that is still relevant. it is experienced as indigenous, describing strengths that are not brought from outside with funding of any kind. the story still influences an awakening of strength in places far removed from africa. a recent example is shared from china, where community health and church workers have an intense interest in the development of local initiatives in response to hiv. the salvation army chikankata hospital, with neighboring communities in the southern province, became a demonstration of response from 1986 with which i was privileged to participate over a seven year period, from 1983 to 1990. the experience has informed global health practice, for me and many others. 54 campbell june 2014. christian journal for global health 2014, 1(1): 53-56. leprosy and family response in zambia chikankata had a leprosy compound in the hospital grounds for more than 40 years. the 450 people who lived there lived a segregated life, rarely visited except by the physiotherapy team and some valiant nurses. when curative treatment became available in the early 1980s, a team began to facilitate their return to home. facilitation had to be face-to-face and sustained over several months, in multiple visits, with each family and community, to ensure inclusion in family, engagement in local neighbourhoods, de-stigmatisation, and disability prevention. the results were astounding, with nearly everyone choosing to be repatriated to their villages of origin. hiv--is there another way? then, along came hiv, or as it was called: htlv1, 2, then 3. at chikankata, we saw people with aids from 1984; it was clinically recognized from 1986. a donor wanted us to fill the vacant leprosy buildings, but why would we reintroduce segregation? we needed to respond naturally and in tune with family anxiety, so that the enormity of intergenerational prevention response needed could be fostered right away. we formed an interdisciplinary team and followed people with an hiv diagnosis home, by their invitation. this approach was new and exploratory. the word of god in the home i joined a home visit, where we found a woman lying on the ground outside her house. she was weak, tired, lethargic, thin, and listless, soaking up the sun. the team attended her. she had recently been in the hospital for some weeks as a tb inpatient. when i asked her why she would not return to hospital, she said, “the team comes to me!” i asked, “what difference does that make?” she responded, “they take care while i need to be at home. they bring the word of god.” there were no bibles, nothing obvious, but to her it was clear. god was present, comforting, assuring, and healing. faith and health work together. the crossroad of home, hiv, faith, and health aids was a big crossroad that would lead us into new ways of working as health professionals. gradually, care with the person in their home became linked with potential for change in the family and the surrounding community. if unattended, anxiety would produce stigma, but if community concern about hiv was acknowledged, attitudes would rapidly shift toward personal action and an inclusive hope for the future. people in the local community could and would change behavior by their choice, because they cared for their family and their future. “care to change” was defined as a way of working for the team. syanyoolo responds toward the end of 1987, a call was received from a headman in the valley from syanyoolo. his son was dead, having burned himself alive in his hut as he lay there, unwell from aids. the father wanted all the headmen to meet and discuss the prevention of anything like this from happening again. i watched for three hours as the hospital team carefully conversed, listened, reflected, gave back questions, explored meanings, and asked the group for their next steps. the community decision was to act in their families, to move together. stigma finished in that area for that period that day. i realized that i had experienced a special form of counseling. this was “community counseling.” 1 health teams respond by early 1988, we saw that we could clearly articulate behavior change as community determined. belief that communities can, and do, initiate 55 campbell june 2014. christian journal for global health 2014, 1(1): 53-56. change stretched the local decision makers, the facilitators, certainly the donors, church leaders, academics, and government. chaz responds the churches medical association of zambia (cmaz), as it was then called, took a stand in 1988 by asserting that church involvement in health was about healing relationships as well as body, mind, and spirit. a national home care and community prevention response to hiv was channeled through cmaz health facilities. in late 1989, a historic partnership with the zambian ministry of health, the norwegian agency for development (norad), and cmaz led to official government policy by 1990 declaring that home care was necessary for long-term effectiveness, impact, and going to scale with local and national responses to hiv. at the core, it was a choice made by the country to be true to itself. the courage of zambians, back in 1988 and since, is still an influence on others to find the way to be true to themselves. an example of transfer concepts can transfer; programs of action may not. part of the global hiv experience is that vision, arising from honest acknowledgement of concern, ignites a fire of agency, responsibility, and ownership that is essentially relational, about ourselves together with those we know and love. 2 china 1997-2013 elvis simamvwa, from chikankata, and part of chaz, visited yunnan province, china in 1997. he met dr. wang, then the provincial leader of the hiv response in longchuan county. hiv-related home visits were part of the learning experience to encourage local inclusion. it was a radical step at that time in china. seventeen years later, in march 2013, i met dr. wang in baoshan county as part of an evaluation team. he is a prevention researcher now, and he was excited, because he was seeing change in neighbourhoods, particularly in relation to the link of drug use as well as sexual risk with hiv transmission, both well recognized in that county. we had recently learned that in the nearby county of longchuan, where we had met originally, 5 of 8 towns in one administrative area had become drug free over an eight-year period, by intensive local community conversation combined with good county level health systems support. 3 local responses and inter-country transfer influence sustained care and change over decades. health and faith intersect with home and hiv, in china as well as in zambia. syanyoolo revisited during 2012, a small group returned to syanyoolo as a component of an affirm initiative called glocon (“global and local community conversation”). 4 we found a group of headmen and community members having a planning meeting. when we asked whether anyone was present at the meeting, 25 years ago, called by the headman, five people raised their hands. i was sitting next to the brother of the original headman who had died just one month previously. the group was electrified with our recognition of their past. the young men asked where the young man who had died so long ago had been buried, and an older lady said she knew the place. the youths said they needed to create a memorial to the young man to remind them that their community decision to take a journey forward had influenced so many other communities and countries. patterns of response patterns of local response can be discerned globally over years. in 2012, 38 communities in 19 countries were visited and thanked for their resilience, courage, and faith in sustaining responses over decades (see the global and local community conversation [glocon] at www.affirmfacilitators.org). 4 these communities responded on similar principles 56 campbell june 2014. christian journal for global health 2014, 1(1): 53-56. and continue as cost-effective movements for health and faith. where are we? where is a national association such as chaz, or a specific mission health entity, in this journey? most are burdened by task, by scope, and by responsibility. how can christians in health care remain true to themselves? we each, and all, want continuing intersections of health and faith. in local community we find who we are, and we meet god, if we wish, because he is the facilitator of reconciling relationships. with faith, we can imagine anything, and we can speak truth, share burdens, and understand health better, because we know health is indivisible from relationship. we practice more strategically, we mission more effectively, and we manage financially. can we let this depth be the essence of our future mission journey through home and neighbourhood encounters supported by health systems? the “home” and “neighbourhood” is where faith, health, and healing can flourish and expand. those of us who are part of health systems need to find our way into that intersection. references 1. campbell id, rader ad. hiv counselling in developing countries the link from individual to community counselling for support and change. brit j guid couns. 2002;23(1): n.p. pubmed pmid: 12290300 http://dx.doi.org/10.1128/jv1.01333-09 2. campbell id, rader ad. aids as a development issue. aids care.1991;3(4):395-8. http://dx.doi.org/10.1080/09540129108251597 3. campbell id, rader a. what can tearfund learn from an evaluation experience in china? reflections with tearfund (uk) staff, may 2nd 2013 on the cedar fund -church mobilisation for hiv prevention project evaluation: 1-12 march 2013: n.p. (contact facilitators for more information: iancampbell11@aol.com; alisonrcam@gmail.com) 4. affirm [internet]. london. glocon: the global and local community conversation; february 2012-september 2013 [cited march 2014] available from http://www.affirmfacilitators.org this article was peer reviewed. based on a keynote address given at the churches health association of zambia (chaz) annual council 19 june 2013 acknowledgments: dr. karen sichinga, chaz; mr. elvis simamvwa, ministry of health, zambia; and alison rader campbell (uk) for collaboration. competing interests: none declared. correspondence: ian cambell. c/o interhealth worldwide, 111 westminster bridge road, london se1 7hr, uk. iancampbell11@aol.com +447713149203 www.affirmfacilitators.org cite this article as: campbell, ian, the intersection of home care and hiv with health and faith. christian journal for global health 2014, 1(1): 53-56. © campbell, i. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1128/jv1.01333-09 http://dx.doi.org/10.1080/09540129108251597 mailto:iancampbell11@aol.com mailto:alisonrcam@gmail.com http://www.affirmfacilitators.org/ mailto:iancampbell11@aol.com http://www.affirmfacilitators.org/ http://creativecommons.org/licenses/by/4.0/ commentary sept 2018. christian journal for global health, 5(2):21-28. responding to refugees in australia: what is the christian response? tim costelloa & nils von kalmb a dr(sac theo), chief advocate, world vision, australia b grad dep theol, blitt soc, church and community engagement, anglican overseas aid abstract what role should christians play in dealing with the march of displaced people across the globe? what moral and spiritual obligations do we owe the distant stranger — the refugee? we can learn from the experience of the hebrew refugees leaving egypt and the inclusive nature of the early christian church. in the australian context, this article explores the historical and current attitudes towards asylum seekers and calls for a faith-led movement to stand shoulder to shoulder with those who are demonised and dehumanised. current state of the world’s refugees according to the un refugee agency, there are currently 68.5 million people around the world who have been forcibly displaced. more than 25 million of these people have fled to other countries as refugees. from gaza to northern uganda, to the rohingya people, to yemen, refugees are struggling just to survive. the majority of the world’s refugees are also hosted by lowand middle-income countries. these people are often helped by ngos like world vision through the provision of aid, including food, special nutrition treatment for malnourished children and breastfeeding mothers, livelihood training, seeds and farming supplies, household items like bed nets and blankets, and water and sanitation services. the 1951 un convention on refugees defines a refugee as any person who, . . . owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.1 the convention also outlines the rights of the displaced, as well as the legal obligations of states to protect them. an asylum seeker is an individual seeking international protection. not every asylum seeker will ultimately be recognised as a refugee, but every refugee is initially an asylum seeker. what is the role of the christian toward the stranger in this current global crisis of displacement? the moral question for christians the plight of refugees raises a moral question for christians. it is one of the great moral questions 22 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. of our time. it is the question of my duty towards the refugee. in christian thought, we start from the biblical teaching in the first chapter of genesis that everyone, rich and poor, national or refugee alike, is made in the image of god. all deserve respect and protection. this is seen in the experience of the people of israel leaving egypt as strangers, becoming refugees and being forced to travel through a harsh wilderness. the bible describes the lessons gained from their suffering in the desert. god commanded israel: “do not oppress a foreigner; you yourselves know how it feels to be foreigners, because you were foreigners in egypt” (ex 23:9). later, god told israel: “when a foreigner resides among you in your land, do not mistreat them. the foreigner residing among you must be treated as your native-born. love them as yourself, for you were foreigners in egypt” (lev 19:33-34). the book of ruth tells the story of a foreigner who came to israel, and worked as a labourer in the fields, hoping for a better life. it is this refugee who is the ancestor of king david and joseph, the earthly father of jesus. the obligation to the distant stranger was even stronger in the gospels. it started with the identification of jesus himself as a refugee, when his parents were forced to flee with the young jesus to egypt to escape the murderous intent of herod (mt 2:13-23). in jesus’ own ministry, our duty to care for the refugee is seen in the overarching question in jesus’ teaching: “who is my neighbour?” (lk 10:29). the famous parable of the good samaritan directs the christian to care for the stranger regardless of their background. similarly, in the parable of the sheep and the goats in matthew 25:31-46, jesus spoke of how the righteous should welcome the stranger. “i was hungry and you gave me food, i was thirsty and you gave me drink, i was a stranger and you welcomed me.” jesus’ intimate identification with the refugee is seen in his follow-up statement that when we do it to them, we are doing it to jesus himself. we have been created by god to love our neighbour; it is part of the greatest commandment that jesus gave (mt 22:39). in reference to refugees, this means not turning away from the needs of the world’s refugees. we are commanded to be intentional about love. when we turn away from refugees, we turn away from god. christianity is about learning to love like jesus loved. and jesus loved the poor and jesus loved the broken. he called us to practice that radical love. we also read in acts 2 and 4 that the members of the early church sold their property and possessions and shared the money with those in need. christians extended love way beyond the boundaries of family and congregation to their pagan neighbours. this was counter-intuitive because at the time justice demanded that everyone got what they deserved. mercy, grace, and love shown by the christians were uncharacteristic in the ancient world. it was distinct in a “user pays” society. the apostles turned the world upside down with "good news of great joy for all the people" (luke 2:10). they healed the sick, cast out devils, and performed signs and wonders on a consistent basis. genuine christianity is daring to step outside the status quo to follow the beat of a different drummer. it calls followers of jesus to fight for the rights of invisible people everywhere. they are neither rich nor powerful. jesus turned away from respectable society and made the marginalised his friends. he addressed crowds of people, many of whom were desperately poor, often without work or money. jesus was saying, to everyone who would listen, that relationships with the marginalised provided the key to life. he said that the remedy to the invisibility of “the other” was simple acceptance. we had to stand shoulder to shoulder with those in society who were demonised and dehumanised. the early christian movement continued the example of jesus in this care for their neighbours. the sociologist, rodney stark, points out that the early church grew very rapidly during the first centuries after the resurrection because the love 23 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. shown by christians to all was genuinely persuasive.2 during famine and plague, christians, at immense cost and risk, cared for the weak and sick who had been abandoned, not just their fellow christians.3 a hallmark of true christian faith is that it welcomes refugees with open hearts and arms, and advocates on their behalf. they are our brothers and sisters in the family of humanity. however, we live in an age of social and economic insecurity and a sense of cultural and spiritual drift colours our attitudes towards issues of cultural identity and social cohesion. in europe fear of terror is real, and consequently, so is a fear of outsiders and newcomers. it can be argued that this fear is reflected in the brexit vote and the ascendancy of right-wing populist parties with an anti-immigration platform. in our country, australia, fear of “the other” has led to a toxic debate on refugees and asylum seekers that has damaged our collective soul. the complex australian experience australia has a complex and ambivalent attitude to migration in general and refugees in particular. many thousands of australians share a sense of shame about australia’s current border policing policies. the white australia policy of yesteryear is now a ghost that haunts current policies. the echo of that policy is reflected in contemporary parliamentary debate.4 the populist ideology is that national rights have greater importance than human rights. australia’s current refugee policy – which places those trying to escape persecution by boat into inhuman offshore detention camps – is designed to appeal to our insecurities by linking immigrants, terrorism, and competition for jobs. it panders to our common fear of the foreign, of the “other.” contemporary australia is a product of its own history. being an island nation, a “western nation” dislocated from europe, has coloured our thinking in the past 200 years or so. the attitude prevails that we can quarantine ourselves from disruptive global forces. this idea of isolating ourselves ranges from dealing with refugees, asylum seekers and migrants, to terrorism and the uncomfortable ideas and ideologies that feed it, to the cost and inconvenience of shifting to a low carbon economy if we are to avoid catastrophic climate change. this thinking comes in several manifestations, from mild to manic – at times including, among others, economic protectionism, the white australia policy, a rigorous system of quarantine, obsessive border protection, cultural xenophobia, and a radical scepticism about international institutions. the very first act passed in the new parliament of australia in 1901 the immigration restriction act gave effect to a white australia policy.5 the act excluded non-white potential immigrants (and anyone else thought undesirable) primarily by introducing a dictation test where potential immigrants were required to undergo dictation in any european language. it gave official blessing to australia’s isolationist stance. the philosophy was that we were safer if we were a fortress cut off from the rest of the world. the concept of “fortress australia” still has its supporters. it ignores the reality that australians – via trade, migration, exchange of technology, tourism, and our personal friendships with those in other nations and support of international charities – constantly engage with the world. australia has always been dependent on external exchanges. aside from our indigenous people, we are all immigrants or descendants of immigrantsa nation largely comprised of “boat people.” much of australia's greatness comes from that fact. about a quarter of australians were born overseas, and almost half the population has at least one parent who was born overseas.6 more than a third of chief executives of asx100 companies are foreignborn.7 in 1959, while marking world refugee year, then prime minister robert menzies said: it is a good thing that australia should have earned a reputation for a sensitive understanding of the problems of people in other lands; that we should not come to be regarded as people who are 24 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. detached from the miseries of the world. i know that we will not come to be so regarded, for i believe that there are no people anywhere with warmer hearts and more generous impulses.8 in the current century, our attitude towards refugees has changed. it is now more in line with former prime minister john howard's 2001 statement: “we will decide who comes to this country and the circumstances under which they come.”9 the stopping of asylum seeker boats and the detention of their occupants in off-shore detention centres has become bipartisan policy among australia’s two main political groupings – the labor and the liberal-national coalition. this policy has been condemned by the australian human rights commission,10 amnesty international,11 and the united nations human rights council.12 characterisation of “good” and “bad” refugees a succession of australian political leaders, anxious to sway public opinion on refugees, have divided asylum seekers into two disparate groups those who are considered “genuine” and those who are considered undeserving and illegal (especially those arriving by boats). the liberal/national coalition’s operation sovereign borders policy of 2013 made the clear distinction. it stated, more than 14,500 desperate people have been denied a place under our offshore humanitarian programme because those places have been taken by people who have arrived illegally by boat. these people are genuine refugees, already processed by united nations agencies, but they are denied a chance at resettlement by people who have money in their pocket to buy a place via people smugglers.13 in 2012, then opposition leader and soonto-be prime minister tony abbott described boat people as “unchristian” by "coming through the back door" and should not be encouraged to "jump the queue"14 with people-smugglers (who are defined by the united nations as people who gain financially or through some other material benefit from the procurement of the illegal entry of a person into a state party of which the person is not a national or a permanent resident). the australian public though has generally expressed more openness. a 2016 poll showed that a majority of australians 63% opposed the bipartisan policy that refugees who arrive in australia by boat should never be allowed to settle in the country, instead saying those found to have a valid claim for protection should be allowed to stay in australia.15 that same year, in the run-up to the 2016 federal election, the then immigration minister peter dutton linked asylum seekers with terrorism.16 in the australian church the response was mixed. a national church life survey in 2011 polled a sample of catholic, anglican, and protestant church attenders and found that those who believed the refugee intake should be at a lower level made up 32% of responses. the proportion of attenders who believed the intake should be at the existing level (26%) was the same as that who thought it should be at a greater level (26%). a minority of 16% were unsure.17 the opposition to refugee settlement in australia has a link to anti-islamic feeling in some sectors of the community. according to a university of melbourne study, many people concerned about the "islamisation" of australia were "unshakably convinced" that muslims were universally overpowering christian traditions such as christmas cards and the singing of carols in schools, despite having no such direct or secondhand experiences.18 a 2015 poll showed australians, on average, estimate muslims make up 12% of the australian population.19 but according to the 2016 census, the proportion of the population identifying as muslim was 2.6%.20 25 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. scott higgins’ book, boundless plains to share? australia, jesus and refugees, points out that australia is a swirling mass of contradiction, fear, and hope when it comes to refugees.21 our status as an island nation far removed from the world's conflict hotspots means that we have very few refugees showing up on our borders seeking protection, yet we have imagined a crisis into being and enacted harsh measures to assert control over our fictional predicament. higgins says our public discourse is characterised by half-truths, misconceptions. and outright falsehoods. we have learned to fear asylum seekers and refugees. he says the public discourse around refugees would be different if we began by listening to their stories. stories bring us down out of the clouds of abstraction, ideology, mythology, and politicking to the realities of life. they also humanise people, making it more difficult for us to fear them and easier to love them. faith can fuel change a collective sense of peace and justice for all has clearly not yet been achieved. christians, however, should aim to counter the dominant narrative of isolationism and fear and are called to unveil a pragmatic and inspiring view of a better world. during the past year, one of the authors has travelled to several refugee camps. one horrifying scene was the vast congested refugee camp of cox’s bazar, bangladesh overwhelmed by more than 600,000 people who identify as rohingya muslims fleeing their burning villages in myanmar. the following month involved a visit to manus island as part of a fact-finding mission under the auspices of the australian council for international development to witness the conditions of refugees and asylum seekers stalled there for more than four years under australia’s border protection policies. in both cox’s bazar and manus, the overwhelming impression was of an absence of hope, the most shocking of all deprivations. a subsequent visit to uganda then provided a sharp contrast. this relatively poor nation has welcomed hundreds of thousands of south sudanese fleeing famine and war. the fact that one million south sudanese have fled for their lives across uganda’s border seeking safety since the start of the war in 2013 shows the extent of uganda’s generosity. the plight of refugees and asylum seekers strikes at the heart of our faith. for those who claim the label “christian” the choice is clear. a key nonnegotiable component of jesus’ gospel is to reach out to the excluded, the poor and those in despair, as well as to protest injustice. it should concern every christian that there are children in detention centres who are living lives behind bars, lives that were already blighted in some way by the circumstances that pushed their families from their homes, lives that are suspended. historically, many great social movements have their roots from within faith communities from the slavery abolitionist movement to civil rights, anti-apartheid roles in south africa, and more recently, climate change debates. faith has been the fuel that has fed a passionate quest for justice and inspired many movements for social reform. fifty-one years ago, martin luther king, jr. sat in a jail cell in birmingham, alabama and wrote a letter to clergymen in white mainline churches. in it he expressed his disappointment in the church’s inability to be a people formed more by a vision of jesus than by fear of cultural rejection. dr king wrote: "if today’s church does not recapture the sacrificial spirit of the early church, it will lose its authenticity, forfeit the loyalty of millions, and be dismissed as an irrelevant social club with no meaning."22 elsewhere he said: “an individual has not begun to live until he can rise above the narrow horizons of his particular individualistic concerns to the broader concerns of all humanity."23 recommendations for action there is an urgent need for ordinary christians to continue to engage on the issue of refugees and inform the debates about offshore detention systems that imprison vulnerable people. movements like love makes a way are gaining 26 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. momentum amongst many christians.24 this particular movement is well-planned and intelligent in its ideology and methods, particularly in the way it mobilises christians to sit and pray in the offices of members of parliament across australia. more generally, we endorse the following recommendations of the australian human rights commission as an effective and compassionate advocacy in the treatment of refugees and asylum seekers in the australian context25: 1. the australian government should end the system of mandatory and indefinite immigration detention. 2. the need to detain should be assessed on a case-by-case basis taking into consideration individual circumstances. 3. australian government policy should be reformed so that individuals in immigration detention who have received an adverse security assessment can be considered for release from detention or for placement in a less restrictive form of detention. 4. the australian government should comply with its international human rights obligations by providing for a decision to detain a person or to continue a person’s detention to be subject to prompt review by a court. 5. the australian government should work towards a uniform model of community assessment and placement for asylum seekers, irrespective of their place or mode of arrival in australia. 6. the australian government should introduce reforms so that refugees who have received adverse security assessments from the australian security intelligence organisation are provided with appropriate information and access to effective mechanisms to review their assessments. 7. the australian government should develop a formal statelessness determination mechanism that recognises both de jure and de facto statelessness and establish administrative pathways for the grant of substantive visas to stateless persons who have been found not to be refugees or otherwise owed protection. 8. a uniform national policy on the use of restrictive places of detention should be developed and cover all places of detention that may be used for observation and segregation. conclusions with millions of people displaced worldwide, more than half of them children, displacement is the biggest humanitarian challenge of our times. whilst difficult, we must find ways to give dignity and freedom – not cruelty and despair. purpose unites us and focuses our dreams for a fairer world. it defines and shapes us. it enables us to do great things. we have an abiding belief that all of us have to be a part of the solution. we all have gifts, privileges, and talents to make a difference. references 1. united nations high commission for refugees. convention and protocol relating to the status of refugees. december 2010. available from: http://www.unhcr.org/en-au/3b66c2aa10. 2. stark r. the rise of christianity. san francisco, ca: harper; 1997. pp. 74-75. 3. ferngren gf. a new era in roman healthcare: how the early church transformed the roman empire’s treatment of its sick. healthcare and hospitals in the mission of the church. christian history 101. 2011. pp. 6-12. available from: https://christianhistoryinstitute.org/magazine/issue/ healthcare-and-hospitals-in-the-mission-of-thechurch 4. anning f. first speech. australian senate. parliament of australia. 14 aug 2018. available from: https://www.aph.gov.au/parliamentary_business/h ansard/hansard_display?bid=chamber/hansards/3c ee6e8f-15b4-468c-91dd-05ded6631e43/&sid=0136 5. national archives of australia. immigration restriction act 1901 (commonly known as the white australia policy). available from: http://www.naa.gov.au/collection/a-z/immigrationrestriction-act.aspx\ 6. australian bureau of statistics. census of population and housing: australia revealed, 2016. 27 june 2017. available from: http://www.unhcr.org/en-au/3b66c2aa10 https://christianhistoryinstitute.org/magazine/issue/healthcare-and-hospitals-in-the-mission-of-the-church https://christianhistoryinstitute.org/magazine/issue/healthcare-and-hospitals-in-the-mission-of-the-church https://christianhistoryinstitute.org/magazine/issue/healthcare-and-hospitals-in-the-mission-of-the-church https://www.aph.gov.au/parliamentary_business/hansard/hansard_display?bid=chamber/hansards/3cee6e8f-15b4-468c-91dd-05ded6631e43/&sid=0136 https://www.aph.gov.au/parliamentary_business/hansard/hansard_display?bid=chamber/hansards/3cee6e8f-15b4-468c-91dd-05ded6631e43/&sid=0136 https://www.aph.gov.au/parliamentary_business/hansard/hansard_display?bid=chamber/hansards/3cee6e8f-15b4-468c-91dd-05ded6631e43/&sid=0136 http://www.naa.gov.au/collection/a-z/immigration-restriction-act.aspx/ http://www.naa.gov.au/collection/a-z/immigration-restriction-act.aspx/ 27 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. http://www.abs.gov.au/ausstats/abs@.nsf/latestpro ducts/2024.0main%20features22016 7. durkin p, bailey m. more than a third of asx100 ceos are foreign. financial review. 23 april 2017. available from: http://www.afr.com/leadership/more-than-a-thirdof-asx100-ceos-are-foreign-20170420-gvoiny 8. menzies r. broadcast by the prime minister (mr. menzies) for the opening of the world refugee year in australia. 27 sept 1959. available from: http://pmtranscripts.pmc.gov.au/release/transcript108 9. howard j. australian federal election speeches. 28 oct 2001. available from: https://electionspeeches.moadoph.gov.au/speeches/ 2001-john-howard 10. australian human rights commission. pathways to protection: a human rights-based response to the flight of asylum seekers by sea. report 2016. available from: https://www.humanrights.gov.au/sites/default/files/ 20160913_pathways_to_protection.pdf 11. mccarthy-naidoo k. closing the offshore detention centres. 22 june 2017. amnesty international. available from: https://www.amnesty.org.au/close-the-offshoredetention-centres/ 12. doherty b. scathing un migration report mars australia's first week on human rights council. the guardian. 1 mar 2018. available from: https://www.theguardian.com/australianews/2018/mar/02/scathing-un-migration-reportnot-ideal-start-to-australias-human-rights-counciltenure 13. the coalition’s operation sovereign borders policy. july 2013; pg. 3. available from: http://past.electionwatch.edu.au/sites/default/files/d ocs/operation%20sovereign%20borders_1.pdf 14. burnside, j. boat people un-christian? wrong, mr abbott. abc. 11 july 2012. available from: http://www.abc.net.au/news/2012-07-11/burnsidean-unchristian-view-of-asylum-seekers/4123872 15. the australia institute. asylum seeker policy – polling brief. june 2016. available from: http://www.tai.org.au/sites/defualt/files/polling%2 0brief%20-%20may%202016%20%20asylum%20seeker%20policy.pdf 16. the sydney morning herald. federal election 2016: immigration minister peter dutton links asylum seekers with terrorism. 1 july 2016. available from: https://www.smh.com.au/politics/federal/federalelection-2016-immigration-minister-peter-duttonlinks-asylum-seekers-with-terrorism-20160701gpvykq.html 17. powell r, pepper m, bevis s. refugee intake – church attenders’ views, ncls research fact sheet 14017. adelaide: mirrabooka press. 2014. available from: http://www.ncls.org.au/download/doc5566/2011% 20ncls%20research%20collection%20%20march%202016.pdf 18. hasham n. some voters believe asylum seekers get $10,000 and nike shoes. the age. 10 march 2016. available from: https://www.theage.com.au/politics/federal/somevoters-believe-asylum-seekers-get-10000-andnike-shoes-20160310-gnfbdo.html 19. ipsos game changers. perils of perception – perceptions are not reality: what the world gets wrong. 14 dec 2016. available from: https://www.ipsos.com/en-au/perils-perceptionperceptions-are-not-reality-what-world-gets-wrong 20. australia bureau of statistics. 2016 census data reveals “no religion” is rising fast. 27 june 2017. available from: http://www.abs.gov.au/ausstats/abs@.nsf/med iareleasesbyreleasedate/7e65a144540551d7ca2 58148000e2b85?opendocument 21. higgins sj. boundless plains to share? australia, jesus and refugees. a just cause. 2014. 22. king ml. letter from a birmingham jail. 16 april 1963. african studies center, university of pennsylvania. available from: http://www.africa.upenn.edu/articles_gen/letter_ birmingham.html 23. king ml. conquering self-centeredness: sermon delivered at dexter avenue baptist church. montgomery, alabama, usa. 11 aug 1957. available from: https://kinginstitute.stanford.edu/kingpapers/documents/conquering-self-centerednesssermon-delivered-dexter-avenue-baptist-church 24. love makes a way. [internet] available from: http://lovemakesaway.org.au/ 25. australian human rights commission. community arrangements for asylum seekers, refugees, and stateless persons recommendations. available from: https://www.humanrights.gov.au/publications/com munity-arrangements-asylum-seekers-refugeesand-stateless-persons-recommendations peer reviewed: submitted 9 june 2018, accepted 7 sept 2018, published 22 sept 2018. competing interests: none declared. http://www.abs.gov.au/ausstats/abs@.nsf/latestproducts/2024.0main%20features22016 http://www.abs.gov.au/ausstats/abs@.nsf/latestproducts/2024.0main%20features22016 http://www.afr.com/leadership/more-than-a-third-of-asx100-ceos-are-foreign-20170420-gvoiny http://www.afr.com/leadership/more-than-a-third-of-asx100-ceos-are-foreign-20170420-gvoiny http://pmtranscripts.pmc.gov.au/release/transcript-108 http://pmtranscripts.pmc.gov.au/release/transcript-108 https://electionspeeches.moadoph.gov.au/speeches/2001-john-howard https://electionspeeches.moadoph.gov.au/speeches/2001-john-howard https://www.humanrights.gov.au/sites/default/files/20160913_pathways_to_protection.pdf https://www.humanrights.gov.au/sites/default/files/20160913_pathways_to_protection.pdf https://www.amnesty.org.au/close-the-offshore-detention-centres/ https://www.amnesty.org.au/close-the-offshore-detention-centres/ https://www.theguardian.com/australia-news/2018/mar/02/scathing-un-migration-report-not-ideal-start-to-australias-human-rights-council-tenure https://www.theguardian.com/australia-news/2018/mar/02/scathing-un-migration-report-not-ideal-start-to-australias-human-rights-council-tenure https://www.theguardian.com/australia-news/2018/mar/02/scathing-un-migration-report-not-ideal-start-to-australias-human-rights-council-tenure https://www.theguardian.com/australia-news/2018/mar/02/scathing-un-migration-report-not-ideal-start-to-australias-human-rights-council-tenure http://past.electionwatch.edu.au/sites/default/files/docs/operation%20sovereign%20borders_1.pdf http://past.electionwatch.edu.au/sites/default/files/docs/operation%20sovereign%20borders_1.pdf http://www.abc.net.au/news/2012-07-11/burnside-an-unchristian-view-of-asylum-seekers/4123872 http://www.abc.net.au/news/2012-07-11/burnside-an-unchristian-view-of-asylum-seekers/4123872 http://www.tai.org.au/sites/defualt/files/polling%20brief%20-%20may%202016%20-%20asylum%20seeker%20policy.pdf http://www.tai.org.au/sites/defualt/files/polling%20brief%20-%20may%202016%20-%20asylum%20seeker%20policy.pdf http://www.tai.org.au/sites/defualt/files/polling%20brief%20-%20may%202016%20-%20asylum%20seeker%20policy.pdf https://www.smh.com.au/politics/federal/federal-election-2016-immigration-minister-peter-dutton-links-asylum-seekers-with-terrorism-20160701-gpvykq.html https://www.smh.com.au/politics/federal/federal-election-2016-immigration-minister-peter-dutton-links-asylum-seekers-with-terrorism-20160701-gpvykq.html https://www.smh.com.au/politics/federal/federal-election-2016-immigration-minister-peter-dutton-links-asylum-seekers-with-terrorism-20160701-gpvykq.html https://www.smh.com.au/politics/federal/federal-election-2016-immigration-minister-peter-dutton-links-asylum-seekers-with-terrorism-20160701-gpvykq.html http://www.ncls.org.au/download/doc5566/2011%20ncls%20research%20collection%20-%20march%202016.pdf http://www.ncls.org.au/download/doc5566/2011%20ncls%20research%20collection%20-%20march%202016.pdf http://www.ncls.org.au/download/doc5566/2011%20ncls%20research%20collection%20-%20march%202016.pdf https://www.theage.com.au/politics/federal/some-voters-believe-asylum-seekers-get-10000-and-nike-shoes-20160310-gnfbdo.html https://www.theage.com.au/politics/federal/some-voters-believe-asylum-seekers-get-10000-and-nike-shoes-20160310-gnfbdo.html https://www.theage.com.au/politics/federal/some-voters-believe-asylum-seekers-get-10000-and-nike-shoes-20160310-gnfbdo.html https://www.ipsos.com/en-au/perils-perception-perceptions-are-not-reality-what-world-gets-wrong https://www.ipsos.com/en-au/perils-perception-perceptions-are-not-reality-what-world-gets-wrong http://www.abs.gov.au/ausstats/abs@.nsf/mediareleasesbyreleasedate/7e65a144540551d7ca258148000e2b85?opendocument http://www.abs.gov.au/ausstats/abs@.nsf/mediareleasesbyreleasedate/7e65a144540551d7ca258148000e2b85?opendocument http://www.abs.gov.au/ausstats/abs@.nsf/mediareleasesbyreleasedate/7e65a144540551d7ca258148000e2b85?opendocument http://www.africa.upenn.edu/articles_gen/letter_birmingham.html http://www.africa.upenn.edu/articles_gen/letter_birmingham.html https://kinginstitute.stanford.edu/king-papers/documents/conquering-self-centeredness-sermon-delivered-dexter-avenue-baptist-church https://kinginstitute.stanford.edu/king-papers/documents/conquering-self-centeredness-sermon-delivered-dexter-avenue-baptist-church https://kinginstitute.stanford.edu/king-papers/documents/conquering-self-centeredness-sermon-delivered-dexter-avenue-baptist-church http://lovemakesaway.org.au/ https://www.humanrights.gov.au/publications/community-arrangements-asylum-seekers-refugees-and-stateless-persons-recommendations https://www.humanrights.gov.au/publications/community-arrangements-asylum-seekers-refugees-and-stateless-persons-recommendations https://www.humanrights.gov.au/publications/community-arrangements-asylum-seekers-refugees-and-stateless-persons-recommendations 28 costello & von kalm sept 2018. christian journal for global health, 5(2):21-28. correspondence: rev tim costello, world vision, australia tim.costello@worldvision.com.au cite this article as: costello t, von kalm n. responding to refugees in australia: what is the christian response? christian journal for global health. sept 2018; 5(2):21-28. © authors this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:tim.costello@worldvision.com.au http://creativecommons.org/licenses/by/4.0/ historical review june 2014. christian journal for global health, 1(1):6-15. sent to heal! about the biblical roots, the history, and the legacy of medical missions christoffer h. grundmann a a m.th., d.th., the john r. eckrich university professor in religion and the healing arts at valparaiso university, valparaiso, in, usa abstract the article situates medical missions within the broader context of the healing ministry of the christian church. in its first part it sketches the biblical tradition of this healing ministry and its meaning in the life of jesus and his disciples. the second section provides a survey of christian healing initiatives and care for the sick from the early church until the emergence of medical missions in the nineteenth century. the third part focuses on the development of the concept medical missions and its changes up to the present, while the final part briefly reflects on the lasting legacy of medical missions which is seen in that, if christians ignore and neglect corporeality, they disgrace god the creator and god's incarnation in jesus christ. the article therefore concludes that medical missions remind the church that at the root of too spiritual a concept of mission and too materialistic a concept of health lies a misconceived, non-biblical anthropology which profoundly distorts the christian witness to god incarnate in christ. introduction christian medical missions are a particular expression of the healing ministry of the church. rooted in biblical tradition, especially in the ministry of jesus and his charge to the disciples to cast out demons and to heal, medical missions emerged as a unique phenomenon in the nineteenth century within the context of the global expansion of christianity and alongside developments marked by spectacular discoveries in medicine. medical missions represent a special calling for people working in the healthcare professions to share their knowledge and skill with the deserving wherever their plight is heard as an expression of and witness to god’s unconditional love to all people and all of creation. to arrive at a meaningful understanding of this most interesting topic, i will discuss the biblical tradition of the concern for healing and its meaning and sketch in a history of christian concern for the care of the sick and history of medical missions. reflections on the vital and important legacy of medical missions for the christian witness, in general, conclude my contribution. biblical tradition of the healing ministry and its meaning healing has been present among the people of god from its earliest times (ex. 15:26: “i am the god who heals you”). 1 health and the power to heal were linked to faith in the god of israel and 6 grundmann june 2014. christian journal for global health, 1(1):6-15. to obedient living according to god’s commandments (num. 12:10-16; 21:4-9; isa. 38:1-6; sir. 38:9-15). it is particularly in the new testament that, unlike in any other religious tradition, healing is accorded a pointed significance. healing, actually, became part and parcel of the proclamation of the gospel, notably so in the ministry of jesus himself. 2 the gospel accounts contain more than forty different healing miracles of jesus and several brief summaries that impressively show that “jesus went about all the cities and villages, teaching in their synagogues, and proclaiming the good news of the kingdom … curing every disease and every sickness” (matt. 9:35; emphasis mine). the simple fact that jesus healed clearly indicates that to him salvation had an unquestionable bodily dimension. in his ministry, healing became a legitimate corporeal aspect of salvation, albeit he never equated healing with salvation (see mark 2:1-12). we also notice that numerous people were healed by jesus or drawn to jesus on account of his healings without becoming his disciples (matt. 4:23-25; mark 3:7; luke 6:18-19; see also acts 9:42). impressive as they were, jesus’ healings evoked appreciation and fear, sometimes leading to awe, sometimes to rejection (matt. 8:34; mark 5:17). however, in jesus’ ministry, salvation was always accompanied by healing. no one who was sick or diseased was sent away without being restored to health fully. jesus, thereby, showed that healing is characteristic of the reign of god (see rev. 21:4; 22:2). yet, it was jesus' healing on a sabbath that led to the accusation of his committing blasphemy entailing the decision by the authorities to destroy him (mark 3:1-6; matt. 12:9-14). this is a powerful, but oftentimes overlooked, indication of the core of the gospel, namely to bring about healing by restoring the god-likeness of every human in an all-encompassing way. and indeed, the first christians perceived jesus' passion in just this way when they related it to isaiah’s prophecy, acknowledging, “he took our infirmities and bore our diseases” (matt. 8:17; see also 1 pet. 2:24). looking up to jesus on the cross makes all healing ministry stay focused on its genuine task, namely to restore god-likeness to all people. however, jesus did not keep the healing ministry all to himself. he also charged his disciples to do likewise. he sent “them out to proclaim the kingdom of god and to heal” giving “them power and authority over all demons” (luke 9:1-2; also see 10:9; emphasis mine), a mandate that the risen christ reconfirmed, “and he [the risen lord] said to them [the disciples], ‘go into all the world and proclaim the good news to the whole creation … by using my name … cast out demons; … lay … hands on the sick, and they will recover’ ” (mark 16:15-18). we know that the apostles heeded this command and that their ministry was blessed accordingly as is told in the acts of the apostles. peter healed a crippled beggar at the entrance gate to the temple (3:1-8), the paralytic aeneas at lydda (9:32-35), and he raised the dead tabitha at joppa (9:36-41). ananias healed paul from his blindness at damascus (9:17-19). paul healed a crippled man at lystra (14:8-11), the diseased father of publius on the island of malta (28:8), and paul raised a dead person, too, viz., the young eutychus at troas (20:9-12). these are only the more outstanding examples of healings performed by apostles. 3 besides healing in the name of jesus and the anointing of the sick “with oil in the name of the lord,” (jas. 5:14) healings were also perceived during the apostolic age without any reference to jesus or his name, namely, as the work of the holy spirit; paul, for instance, counted healing among the many spiritual gifts present in the christian congregation (1 cor. 12:4-10). in further careful study of these texts, we notice certain differences between the various accounts within scripture. while the synoptics, that is the first three gospels matthew, mark, and luke, view jesus’ healings as efficacious signs of the presence of god the redeemer and as manifestations of “the kingdom of god at hand” (matt. 12:22-32; luke 10:9; 11:17-23), john regards healings as revelatory “signs” of jesus’ messiahship (john 3:2; 5:36; 9:3; 20:31). while 7 grundmann june 2014. christian journal for global health, 1(1):6-15. jesus healed by the authority of god incarnate, his disciples did so in his name (mark 16:17; acts 3:6). this does not mean that they used jesus’ name as a magic formula; however, it does mean that the very ministry of the apostles was vested with an authority not their own. furthermore, the disciples had been mandated to bear witness to a power which was not at their disposal, something they painfully experienced when their well-intended attempts at healing failed (matt. 17:14-20; mark 9:14-29; luke 9:3743). they, thereby, came to realize the qualitative difference existing between their efforts and the powerful ministry of their lord and master, a difference which christian theology would later describe as “eschatological.” in sum, there is no one single biblical concept of healing to be found in scripture. the biblical tradition, rather, bears witness to a diverse perception of healing from the times of the old testament to jesus and his ministry and the apostolic era. yet, despite this diversity, healing is understood across the board as a result of god’s workings, a sign of the kingdom of god at hand, and as a foretaste of what is to be enjoyed by all at the end of times when god “will wipe away every tear,” because “death … mourning and crying and pain will be no more …” (rev. 21:4). christian healing ministry prior to medical missions the writings of the church fathers, christian authors from the second to the sixth century ad, refer frequently to the ministry of healing. this, evidently, reflects their argument with the then very popular greek healing-cult of asclepius. asclepius was revered as “the savior” in the hellenistic world over against which the early church had to articulate the specifics of christ. this confrontation made them to confess christ as being “the savior of the world” in order to indicate that christ actually did overcome death itself, which asclepius was unable to accomplish. another argument for the care of bodily needs was advanced by the north african church father, tertullian (c. 160-230), in the 3rd century ad. arguing against the radical dualistic separation of body and soul by the gnostics, tertullian reminded his contemporaries that “the body is the pivot of salvation” (caro cardo salutis), because christians not only confess that the corporeal world is god’s creation and believe in the resurrection of the body, but since god truly became incarnate--that is: enfleshed in jesus christ--the body is made the pivot of salvation. 4 adolf v. harnack, the eminent nineteenth century church historian of the early church, concluded his seminal study on the topic with the remark: christian religion and the care of the sick have traveled a long way together in the course of history; as a result, they now are inseparable. ... the influence and future of the church depend on her caring for those who suffer spiritually and physically. ... this is definitely the meaning of the gospel of the savior and of salvation. the early church understood this comprehensively. and the only way that the old church remains young and the young church remains the old is that it keeps and preserves this understanding of the gospel in its fullness. 5 however, despite the clear biblical mandate and the importance of healing in spreading the good news of salvation for all in the first centuries of the christian church, 6 active engagement in healing was hampered somewhat by the instruction that disciples should not make their living by healing. the disciples were not only charged to “cure the sick;” they also were reminded that they received their special gifts “without payment” and, therefore, had to share these “without payment” (matt. 10:8). to understand this directive, one has to know that the then very popular healing cults of asclepius and serapis were noted for their greediness. it was a common practice — not unlike today’s healthcare system — to demand more and more donations for whatever benefit or blessing for which the petitioners asked, making healing 8 grundmann june 2014. christian journal for global health, 1(1):6-15. extremely expensive and, thus, unaffordable for the most desperate. to pursue the art of healing in this environment as a way of earning a living, therefore, would have compromised the proclamation of salvation for all in no small degree. what could be done without compromising the faith instead was caring for the sick, including those beyond one’s own kin, which was not a popular thing to do. solidarity with members in need of one’s own family was common practice, of course, but to care for those outside, the strangers and those in desperate situations shunned by society at large, was not regarded as an obligation. in opposition to this attitude, christians were called to be concerned with those in need beyond their own families by feeding the hungry, giving drink to the thirsty, welcoming strangers, clothing the naked, caring for the sick, and visiting the incarcerated (matt. 25, 31-46), witnessing to god’s unconditional love for all humankind. they, thereby, also fundamentally changed the overall societal attitude towards the sick, something impressively epitomized in the parable of the good samaritan (luke 10:25-37). thus, caring for the sick and destitute as a charitable work of compassion eventually became the hallmark of christianity, while active involvement in the art of healing was not on the agenda, at least not until the nineteenth century. 7 the latin speaking church of the west, rather, developed an increasing dislike for the practice of medicine, especially surgery in later centuries. in 1215, the fourth lateran council, then the supreme authority of western christianity, ruled that no cleric should practice surgery, because a priest should never shed blood and for fear of committing unintentional homicide. 8 this was a wise decision considering the actual danger any surgical procedure posed in a time without anesthesia and antiseptic, and without sterile operating theaters so that postoperative death due to infection occurred frequently. things changed, somewhat, with the discovery of the “new world” and the spanish and portuguese divisions of newly discovered territories by the treaty of tordesillas of 1494 when the care for the sick became an official duty for missions and missionaries. the spanish “council for the indies” (consejo de las indias) ruled that hospitals were to be built at every new settlement under their rule, while in the territories under portuguese patronage charitable organizations, called misericórdia-societies, were established, whose members vowed to care for the needy in their community as had become a pious practice back home at lisbon since 1498. physicians were hired on the basis of need to work in the hospitals while christian brothers and sisters or members of the local christian community cared for the daily needs of patients. during the sixteenth and seventeenth centuries, franciscan and jesuit missionaries faced with unspeakable suffering could not avoid getting involved in the healing ministry despite the official prohibition, whereas the early protestant missions of the eighteenth century such as the danish-halle mission and the herrnhut brethren had no issue with sending out professionally trained physicians into the missions. these physicians, however, were not regarded as missionaries proper but as hired professionals to attend first of all to the health-care needs of the missionaries suffering from tropical diseases, especially malaria, and also, if time, funds, and skill permitted, to treat indigenous people in case of illness. yet, the impact of these initiatives was severely impeded by the kind of medical help which the physicians of that age could actually render, because such help was hardly any different from or superior to established indigenous systems of healing in place in the respective cultures. 9 medical missions past and present it was as late as the nineteenth century when medicine morphed from an old fashioned, authority-bound scientia into a modern science uncompromisingly studying human physiology and diseases. although this approach had begun long before, 10 it gained significant momentum in the second part of the nineteenth century, thanks, first, to the discovery of anesthesia (1846) and 9 grundmann june 2014. christian journal for global health, 1(1):6-15. anti-sepsis (1847/1867), leading to the previously unimaginable rise of successful surgeries; second, the detection of the importance of public hygiene and sanitation — providing safe drinking water and proper disposal of sewage — for the prevention of epidemics (1854/1859/1888); and, thirdly, thanks to laboratory based cellular pathology bringing about the age of bacteriology (rudolf virchow, 1821-1902; robert koch, 1843-1910; ronald ross, 1857-1932) and with it the discovery of the disease causing pathogens of epidemics at the level of their causation. this, consequently, led in rapid succession to the development of appropriate measures of disease prevention and effective treatment. 11 physicians were then truly enabled to heal diseases previously considered fatal. the new medical breakthroughs enabled christian physicians to reconsider once again the scriptural charge to be “sent to heal” by their lord and master. as much as medical missions is thus “an epiphenomenon of the development of medicine,” 12 it is also an epiphenomenon of the great missionary movement of the nineteenth century ignited by the great evangelical revival, thanks to which many pious individuals dedicated their gifts and life to missionary service; medical missionaries, in particular, perceived their work as bearing witness to disinterested benevolence. 13 formally organized medical missions first took shape with the foundation of the medical missionary society in china at canton (guangzhou) on february 21, 1838, of which the american rev. peter parker, m.d. (1804-1888) was its most renowned representative. 14 this society was a joint venture by missionaries, physicians, and philanthropic businessmen who were of different nationalities (british, american, chinese, indian), belonged to different denominations (presbyterian, congregationalist, episcopal), and different religions (christians, parsi, chinese). they all joined hands in this venture to guarantee institutional backing of hospital based medical services provided gratuitously to the destitute by missionary physicians trained in rational-scientific medicine. the program of the society was stated, as follows: we have … the pleasure of explaining our object, and of inviting the coöperation of all those who wish to mitigate the sufferings of their fellow-men. ... to restore health, to ease pain, or in any way to diminish the sum of human misery, forms an object worthy of the philanthropist. but in the prosecution of our views we look forward to far higher results than the mere relief of human suffering. we hope that our endeavors will tend to break down the walls of prejudice and long cherished nationality of feeling, and to teach the chinese, that those whom they affect to despise are both able and willing to become their benefactors. ... it has been sometimes objected, that to attend to the diseases of men is not the proper business of a missionary. this objection may be shortly answered by a reference to the conduct of the savior and his apostles, who, while they taught mankind things that concerned their eternal interests, were not indifferent to their bodily sufferings. ... to the various missionary boards whose coöperation is sought, we would respectfully say, imitate him whose gospel you desire to publish to every land. like him, regard not as beneath your notice the opening the eyes of the blind and the ears of the deaf, and the healing of all manner of diseases. until permitted to publish openly and without restraint the truths of the gospel, neglect not the opportunity afforded of freely practicing its spirit. scatter to the utmost its fruits, until welcomed to plant the tree that produces them the “tree of life.” 15 the interdenominational, even interreligious, approach coupled with pragmatic concerns for temporal wellbeing, however, rendered medical missions suspicious in the eyes of those who were solely interested in the pursuit of straight-forwardly spiritual goals. 16 as medicine was becoming more and more powerful and, as in the wake of the evangelical 10 grundmann june 2014. christian journal for global health, 1(1):6-15. revival inspired by dwight l. moody (18371899), an ever increasing number of pious physicians decided to serve as missionaries yearning for “the evangelization of the world in this generation,” medical missions became “the heavy artillery of the missionary army,” as herbert lankester, then secretary of the medical committee of the church missionary society (cms), london, characterized it. 17 by the turn of the twentieth century, medical missions were deemed so essential that it was declared in 1900 that no mission could “be considered fully equipped that has not its medical branch.” 18 while statements like these suggest that medical missions were being universally recognized, reality looked different. only a fraction of protestant missionary societies (26%) were engaged in medical missions, and their medical staff, both male and female, foreign and indigenous, represented just five percent of missionary personnel overall. 19 these figures have continued to dwindle since they reached their zenith in 1923, with (about) 1157 medical missionaries out of a total of 20,569 missionaries. 20 yet, medical missions had become a topic of real concern for protestant missions by that time, indeed, albeit a controversial one, while roman catholicism, bound by canon law, was remarkably hesitant to embrace the concept at all. with the exception of one remarkable initiative on the island of malta during 1881-1896 — the training institute for african medical catechists—by cardinal lavigerie (1825-1892), 21 medical missions simply were non-existent among catholics. this, however, changed dramatically once the society of catholic medical missionaries (medical mission sisters, scmm) was founded by austrian anna dengel, m.d. (1892-1980) in washington d.c., in 1925, and once the vatican revoked the former ruling on the study and practice of medicine by religious in 1936. 22 after the disruption caused by world war ii (1939-1945) and many violent struggles for national independence from colonial powers in african, asian, and latin american countries since the mid-1950s, medical missions were seriously questioned. this had to do with the formation and development of national healthcare administrations and departments as well as with the founding of the world health organization, who, in 1948, as a global agency for general health-care issues and politics across the globe. christian medical mission hospitals found themselves in an emergent competition with kindred government and private enterprises while rapid advancements in medical technology constantly demanded expensive upgrades of existing facilities, quickly depleting the limited funds of mission societies and churches “old” and “young.” priorities had to be set regarding the task and ministry of healing and how it would be best to invest the scarce resources at hand, priorities which were to be critically informed by the gospel, of course. to do this, an international conference of people engaged in medical missions was convened at tübingen, germany in 1964 by the world council of churches (wcc) and the lutheran world federation (lwf). the conference addressed the basic questions, “is the commission to heal an integral part of the ministry of the church?” and “what kind of service is the church called to give in the performance of its mission?” 23 struggling with these questions for about a week, the participants finally arrived at the unanimous opinion “that the church does have a specific task in the field of healing which arises from its place in the whole christian belief about god’s plan of salvation for mankind.” 24 the momentum of that conference and the widely read final report, the healing church, in 1968, led to the creation of the christian medical commission (cmc) by the world council of churches, charged “with responsibility to promote the national co-ordination of church-related medical programmes and to engage in study and research into the most appropriate ways by which the churches might express their concern for … health care.” 25 at the present time, the task of medical missions is seen in a much broader context than before. this reflects the post-colonial situation of 11 grundmann june 2014. christian journal for global health, 1(1):6-15. a truly globalized, ecumenical christianity demanding cooperation across national and denominational fault lines as well as across various disciplines. christian medical work cannot any longer stay content with only focusing on suffering individuals and providing hospital care amidst a situation which deprives the most deserving from having access to it. those who can afford health care will always have options to have their needs met, whereas the impoverished have none. this is not just fate; it, rather, is the product of existing injustice. oftentimes, the poor lack sufficient nourishment and live in unhygienic conditions which expose them to preventable diseases in the first place. this means, practically, that contemporary christian medical missions have not only to be concerned about the immediate signs of ill health in individual patients. modern christian medical missions concerned about bringing health and healing to the marginalized and deprived have to be concerned about sanitation and safe drinking water, too, about providing proper care for pregnant women and training traditional midwives in safe methods of delivery, and the adequate supply of basic generic drugs for the most common diseases; modern medical missions done by christians have also to be concerned about securing sufficient, nutritious foods and, last not least, about health education with a focus on enabling the health care potential of families and local communities to flourish, which has also proven to be most effective in successfully coping with the hiv/aids pandemic. 26 in prioritizing primary health care (phc), as this concept is called, and pragmatically accepting the cooperation with indigenous people across various denominations, disciplines, and with governments, christian or not, medical missions turned away from hospital-centered medical work fashioned according to the financial affluence of a technocratic, secular culture dominant in the western hemisphere and developed a health-care program so effective, that, finally, the world health organization (who), too, adopted it in 1978 at alma ata, kazakh (declaration of alma ata) with the motto “health for all by the year 2000.” 27 since then, individual nation-states have changed their healthcare focus in order to show quick results for the sake of securing world bank funding, etc. christian medical missionaries, however, continue to pursue the course and vision of the phc approach. their skillful use of medicine for the sake of bringing about life in abundance (john 10:10) and preventing untimely death (particularly among those most neglected, the poor, including, today especially, the victims of the hiv/aids pandemic) at once witnesses to the corporeality of salvation and to the proper use of medical knowledge, nursing skills, and operative funds for the benefit of all, thereby, profoundly critiquing other ways of doing medicine. a new phenomenon, availing of today’s fast and frequent air-travel and the wellfunctioning global communication networks and impacting medical missions, appeared in the 1980s, namely, short-term medical missions by physicians, nurses, and untrained helpers to medically underserved areas of the world and for instant disaster relief. these trips may last from a couple of weeks to several months and are carried out by highly motivated individuals who give of their time, their skill, and their funds. 28 however, as laudable as such initiatives appear to be at first sight, they do not solve prevailing issues due to lack of proper record-keeping, of qualified follow-up, of oftentimes deficient coordination with other agencies, and by a common dearth of intercultural competence. 29 to do medical mission work, good intentions simply are not good enough. untamed good intentions actually cloud the sober minded perception of what truly gets achieved 30 and, thus, become counterproductive to the proclamation of the gospel. the legacy of medical missions it has been argued above that the goal of the ministry of jesus was to reinstate the god likeness of all human beings bereft of it, which later became the well-known leitmotif for christian caritas. surveying the history of the 12 grundmann june 2014. christian journal for global health, 1(1):6-15. church, one cannot but give due honor and credit to the many works of charity which people felt called to do with the intention to better the fate of their fellow human beings and alleviate suffering “in the name of jesus christ.” despite all justified criticism of the church’s involvement in worldly strife, the history of christianity with its establishment of charitable institutions like hospitals, hospices, orphanages, and the many programs devoted to caritas is also one of genuine compassion and care. the healing ministry, as it has found expression in medical missions, however, while pursuing the same objective, acts differently in a very distinctive way unlike any other, namely, by drawing attention to the bodily and corporeal dimension of salvation. as every physician attempts to restore patients to the state of health they were in before they suffered from an injury or disease, an attempt which is called restitutio ad integrum (restitution to the former state), so, too, does any proclamation of the gospel attempt to bring people back into the presence of the living god as it once was in the very beginning. the good news of the gospel is that their original integrity is restored to humans by the reconciliation brought about in jesus christ (ro. 6:1-11; heb.7:27). this restitutio ad integritatem (restitution to original integrity) is commonly termed “salvation,” but it has also occasionally been described as a “healing.” 31 christians called to proclaim this restoration to original integrity cannot do so without reference to the passion, cross, and resurrection of jesus christ. that is, christians cannot but be mindful of corporeality. if they ignore and neglect corporeality by only being concerned spiritually, their proclamation disgraces god the creator and mocks god’s incarnation in jesus christ. it is precisely in this way that medical missions challenge the common conviction that the soul is more precious than the body. while most of the revivalists of the 19th century viewed it to be the case, one among them, who was deeply immersed in the revival himself, but a physician, too, chastised this conviction sternly by stating, “to merely talk piously and tell suffering people of a future state, while neglecting to relieve their present needs, when in our power to do so, must be nauseating both to god and man, and certainly is a libel upon the christianity christ both taught and practiced, in which he combined care for the whole being of man, body and soul.” 32 at the root of too spiritual a concept of mission and too materialistic a concept of health lies a misconceived, nonbiblical anthropology which profoundly distorts the witness to god incarnate in christ; caro cardo salutis, the body is indeed the pivot of salvation. endnotes and references 1. scripture passages are quoted from the new revised standard version (nrsv), 1989. 2. for a solid exegetical study of the topic see van der loos h. the miracles of jesus. preston ts, translator. leiden, boston: brill; 1962. see also seybold k, mueller, ub. sickness and healing. stott dw, translator. nashville: abingdon; 1981. 3. there are several additional summary accounts of like activities in acts. see 5:15-16; 8:6-7; 19:11-12; 28:9. other references to “wonders and signs” of the apostles may be found in acts 2:43; 5:12; 6:8; 14:3. 4. tertullian. de resurrectione carnis liber [treatise on the resurrection]. evans e, editor [introduction, translation, and commentary by evans e]. london: s.p.c.k.; 1960. p.26. 13 grundmann june 2014. christian journal for global health, 1(1):6-15. 5. harnack av. medicinisches aus der ältesten kirchengeschichte. in: texte und untersuchungen zur geschichte der altchristichen literatur. leipzig: akademie-verlag; 1982. 8(4): 37-147 [quote, p. 147; original emphasis] see also: harnack av. the mission and expansion of christianity in the first three centuries. new york: harper & brothers; 1961. [esp. p.101-46]. 6. amundsen dw, ferngren gb. the early christian tradition. in: caring and curing — health and medicine in the western religious traditions. amundson dw, numbers rl, editors. new york, london: macmillan publishing; 1986. p. 40-64. 7. sigerist he. civilization and disease. college park, md: mcgrath; 1970. p.69-70. 8. namely in constitution 18 (clerics to dissociate from shedding blood); see tanner np, editor. decrees of the ecumenical councils: from nicea i to vatican ii. washington dc, md: georgetown university press; 1990. [vol. 3] p.244. 9. see grundmann ch, sent to heal! — emergence and development of medical missions. lanham, md: university press of america; 2005. p.22-37. 10. see the anatomical drawings of leonardo da vinci [1452-1519] in o’malley cde, saunders jb de cm, editors. leonardo on the human body — the anatomical, physiological, and embryological drawings of leonardo da vinci [with translations, emendations, and a biographical introduction]. new york: gramercy books; 2003. vesalius a [1514-1564]. de humani corporis fabrica libri septem [seven books on the structure of the human body]. garrison dh, hast mh, editors. evanston, il: northwestern university; 2003. harvey w. [1578-1657]. the works of william harvey. willis r, translator. london: sydenham society; 1847. 11. ackerknecht eh. a short history of medicine. baltimore, md: the johns hopkins university press, 2nd ed.; 1982. p.145-74. 12. walls af. “the heavy artillery of the missionary army”: the domestic importance of the nineteenth century medical missionary. in: the church and healing. sheils wj, editor. oxford: basil blackwell; 1982. p.287. 13. “disinterested benevolence” was regarded as the hallmark of redeemed christians. its prototype was found in god offering his own son — and as such, offering himself — on the cross for the redemption of all. see hopkins s. an inquiry into the nature of true holiness. in: the works of samuel hopkins. 1773 [reprint, 1987]. [volume 3] p. 5-66. 14. see anderson gh. peter parker and the introduction of western medicine in china. in: mission studies. 2006: 23(2); p. 203-238. for a more general overview see: balme h. china and modern medicine — a study in medical missionary development. london: united council for missionary education; 1921. 15. this selection of quotes is based on the medical missionary society in china — address with minutes of proceedings; canton 1838; p.11-5,18-21. original emphasis. 16. grundmann c. sent to heal! — emergence and development of medical missions; p. 65-71, 92-5. 17. walls af. “the heavy artillery of the missionary army”: the domestic importance of the nineteenth century medical missionary. p.290. see also: browne sg, editor. heralds of health — the saga of christian medical initiatives. london: christian medical fellowship; 1985. 18. american tract society. report of the ecumenical missionary conference on foreign missions, held in carnegie hall and neighboring churches [vols. 1 and 2], 1900 apr 21-may 1; new york; 1900. [vol 2] p.199. 19. dennis js. centennial survey of foreign missions — a statistical supplement to “christian missions and social progress,” being a conspectus of the achievements and results of evangelical missions in all lands at the close of 14 grundmann june 2014. christian journal for global health, 1(1):6-15. the nineteenth century. new york, chicago, toronto: fleming h. revell company; 1902. and see: grundmann c, sent to heal! . p.150,159. 20. beach hp, fahs ch, editors. world missionary atlas — containing a directory of missionary societies, classified summaries of statistics, maps showing the location of mission stations throughout the world, a descriptive account of the principal mission lands, and comprehensive indices. edinburgh: edinburgh house press; 1925. 21. grundmann c, sent to heal! p.121-124. 22. dengel a. mission for samaritans. milwaukee: the bruce publishing company; 1945. p. 8-29. 23. mcgilvray jc. the quest for health and wholeness. tübingen: german institute for medical missions; 1981. p.9. [original emphasis] 24. mcgilvray jc. the quest for health and wholeness. p.13. 25. mcgilvray jc. the quest for health and wholeness. p.41. see also: ewert dm. a new agenda for medical missions. brunswick, ga: map international; 1990. 26. see martin j. primary health care and aids control programs. in: the handbook for aids prevention in africa. lamptey p, piot p, gringle r, editors. durham, nc: family health international; 1990. p. 211-9. see also: bruyn dm, hoeven fvd. primary health care and aids: african experience. aids bulletin.1994 apr; 3(1):6-7. see also: pfeiffer j, montoya p, baptista a, karagianis m, morais pugas md, micek m, johnson w, sherr k, gimbel s, baird s, lambdin b, gloyd s. intergration of hiv/aids services into african primary health care: lessons learned for health system strengthening in mozambique — a case study. j int aids soc. 2010 jan; 13(3): http://dx.doi.org/10.1186/1758-2652-13-3. see also: joulaei h, motazedian n. primary health care strategic key to control hiv/aids in iran. iran j public health. 2013; 42(5):540-1. 27. mcgilvray jc. the quest for health and wholeness. p.70-80. 28. see for instance, kuhn w, kuhn s, gross h., benesh s, editors. global medical missions: preparation, procedure, practice. enumclaw, wa: winepress publishing; 2007. 29. montgomery lm. short-term medical missions: enhancing or eroding health?. missiology. 1993 july;21(3): 333-41. and priest rj, dischinger t, rasmussen s, brown cm. researching the short-term mission movement. missiology. 2006 oct;34(4):431-50. http://dx.doi.org/10.1177/009182969302100305 30. for a pointed argument against good-will actions see illich i. to hell with good intentions. [internet] [cited 2014 march 3] available from http://www.swaraj.org/illich_hell.htm 31. the formula of concord, one of the lutheran confessional texts, describes the ministry of jesus, the restitution ad integritatem as “healing’ the ‘rift’ between god and humanity.” [see: solida declartio i= de peccato originis/original sin], tappert tg, pelikan j, fischer rh, piepkorn ac, editors. the book of concord: the confessions of the evangelical lutheran church. philadelphia: fortress; 1959; p.511 — for the medical maxim of “restitutio ad integrum” and its relation to the “restitutio ad integritatem” see schipperges h. motivation und legitimation des ärztlichen handelns. in: krankheit, heilkunst, heilung. schipperges h, seidler, unschuld p, editors. freiburg/münchen: alber; 1978; p. 447-89. 32. dowkontt gd. murdered millions. new york city: the medical missionary record. 5th ed; 1897; p.24. http://dx.doi.org/10.1186/1758-2652-13-3 http://dx.doi.org/10.1177/009182969302100305 http://www.swaraj.org/illich_hell.htm 15 grundmann june 2014. christian journal for global health, 1(1):6-15. before joining valparaiso university in 2001 prof grundmann, an ordained lutheran minister, worked in caracas, venezuela, served as a missionary and theological teacher in south india (tts arasaradi, madurai) and has been the theological consultant to the german institute of medical missions at tübingen, germany. from 1992 – 1999 he taught at the university of hamburg, germany, where he earned a couple of doctorates in the history of missions and missiology with a special focus on medical missions and healing. http://faculty.valpo.edu/cgrundma. peer reviewed competing interests: none declared. correspondence: prof. christoffer grundmann, valparaiso university, valparaiso, in 46383-6493 usa christoffer.grundmann@valpo.edu cite this article as: grundmann, c.h. sent to heal! about the biblical roots, the history, and the legacy of medical missions. christian journal for global health (august 2014), 1(1):6-15. © gundmann, ch. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://faculty.valpo.edu/cgrundma mailto:christoffer.grundmann@valpo.edu http://creativecommons.org/licenses/by/4.0/ conference report sep 2018. christian journal for global health 5(1):52-56 the lancet global health academic writing workshop: navigating and getting noticed in the scholarly publishing world daniel w. o'neilla a md, ma(th), assistant clinical professor, family medicine, university of connecticut school of medicine, usa zöe mullan, editor-in-chief, lancet global health, and audrey ceschia, editor, lancet public health, presented a half-day preconference session on thursday, march 15th 2018 prior to the 9th annual consortium for universities of global health conference in new york city. there was also a follow-up webinar on the topic on thursday, april 26th. the publishing environment has significantly changed from that of only a few decades ago. getting your research published, and published where it matters to you, your peers, and your university, requires skills and knowledge the academics of the last century could never have foreseen. the content of these seminars and some other sources will guide you through the challenges with insider tips and strategies from some experts in the field of publishing and journalism. the process getting your work published is a discipline that sharpens your work, builds collective knowledge for the common good, and inspires and fosters innovation. the peer review process can be intimidating but very rewarding. it starts with developing a research question or discovering a topic of interest to analyze from your field of work. looking at problems in light of previous work and existing knowledge helps you design a relevant research endeavor. there is a spectrum of academic rigor, cost, and profile among traditional and openaccess journals from which to pursue publication. what do editors look for in a paper? editors of top journals are looking for “an answer to a relevant question in an important population in the appropriate way at an opportune time.” the following set of criteria is used when accepting papers for publication: • relevance: it must be within the scope of the journal and relevant to the audience of the journal. • novelty: it must express new treatments, new populations, new disease distribution, and new knowledge of the future (modelling). it does not simply state, “these findings confirm the work of...” • design: it should offer robust methodology with sufficient sample size (power), appropriate study design (controls, validation, assumptions), and some generalizability. • responsible reporting: it should have ethics approval, informed consent, pre-registration for trials, and adherence to guidelines such as the equator network.1 • definitiveness: it should have the last word, not necessarily a positive finding — relevant 53 o’neill sep 2018. christian journal for global health 5(1):52-56. negatives are acceptable. it should not simply state, “more research is needed.” • efficiency: it should avoid waste since 85% of research is a waste of time, money, and good will.2,3 developing research questions every good research endeavor starts with a systematic review of the literature before research design. the goal is to find a missing piece of the puzzle and pursue answers to important questions. the paper then explains how the findings add to useful knowledge. every good paper tells a compelling story. if the paper is poorly written, or the story is not supported by the data, it will be rejected. most editors welcome an e-mail with a proposal for a research project or paper, often 18-24 months prior to anticipated publication. basic paper structure research papers follow the imrad structure (introduction, methods, results, and discussion). the introduction presents the problem, what is published, and why research is needed. the method section describes exactly what was done, where, when, population, analysis, literature search method (if a review paper), and outcomes measured. the results only report on the findings of the research. the discussion gives the bottom line and what is next. in writing the manuscript, start with the data, then methods, conclusion, and introduction, then titles and abstract last. title informative but concise, the title must adequately describe content and study design, contain no technical jargon or abbreviations but only formal language, and attract the reader’s attention. abstract this should contain a single paragraph or two describing the article. this is often the only thing read. it is written last but read first. it must accurately reflect the paper, state the aim prominently, give enough detail to show what you did, and use flowing words so that it is easy to read even for the non-expert. conclusions need to be backed up by evidence presented. keywords must be specific enough for indexing (discoverability for researchers), give readers a quick idea of content, and use only abbreviations firmly established in the field of study. introduction this provides a brief context, summarizes previous research (based upon your own literature review), addresses the problem, identifies the solutions and limitations, outlines what your work is trying to achieve, and gives a perspective consistent with the nature of the journal. methods this section describes how you studied the problem — not why but what. include detailed information identifying the equipment and materials used (including literature search methods for review articles). it must contain ethics committee approval (institutional review board [irb]) and follow the helsinki declaration on studies involving human subjects.4 all methods need results. the equator network gives valuable structure for different research methods.5 results only present data of primary importance, use subheadings, be clear and concise, feature unexpected findings and highlight the main findings, provide statistical analysis, and include illustrations and figures that are not too crowded. images need to have clear resolution and have scale markers. this section does not interpret the data, just presents the results. discussion here the main findings can be summarized and interpreted. not just a repetition of results but an assessment of them. discuss relevance to prior work and how your results correspond to them. mention limitations (before reviewers point them out!), mention strengths, and do not present findings not 54 o’neill sep 2018. christian journal for global health 5(1):52-56. mentioned in the results section. do not make claims that are not supported by the results. do not use nonspecific expressions or new terms not already defined or mentioned in the paper, and do not speculate on possible interpretations based on imagination. finish with implications for implementation. conclusion the conclusion consists of concise statements that need to be clear and justify your work, not just a verbatim repetition of the abstract. it explains how your work advances the present state of knowledge and offers suggestions for future research. acknowledgements here one would recognize advisors, sources of financial support, suppliers of research materials, proof readers, assistants, etc... references do not include too many references (especially if only tangentially related), and fully absorb the material you are referencing. avoid excessive selfcitations or citations from the same author, institution, or region. reputable peer-reviewed references are preferred. conform to the reference style given in the author guidelines of the journal. supporting material these are surveys, data tables, and other supplemental information relevant to the study, but not required to be included in the body of the paper. the equator network gives vital links to reporting guidelines for every type of health-related research article,5 and the strobe checklist can be used in planning and reporting observational studies.6 choosing a journal in order to get the widest readership and citation among the target audience you wish to influence, a reputable journal that encompasses your content in its scope should be chosen. open access publishing offers significant advantages for discoverability and global reach.7 making research results more accessible contributes to better and more efficient science and to innovation in the public and private sectors, especially in lowand middleincome countries. however, advantages and disadvantages need to be considered.7 indexing in the directory of open access journals and pubmed central indicates reputability. caution should be taken to avoid predatory journals.9 a checklist is available for researchers to identify trusted journals for publication.10 publication ethics membership in the committee on publication ethics (cope) ensures publication ethics.11 ms. mullan noted that 58% of researchers were aware of others who were tempted to compromise, 26% were tempted themselves, and 31% felt rushed to publish. she described the “staircase of misconduct” from error to misconduct to fraud (fabrication, falsification, and plagiarism [figures and text without accreditation]). authors must use quotations for verbatim quotes and avoid “text-recycling” (selfplagiarism). authorship should follow the icmje definition: substantial design, writing, approval, and agreement to be accountable to all aspects of the work12 no “gifts or ghosts.” authors must declare any conflicts of interest (e.g., author of [retracted] 1998 mmr vaccine — autism study in lancet did not disclose he was funded by parents suing the vaccine manufacturer). there is also peer-review misconduct — use of confidential information for personal benefit, not declaring competing interest, or patently faking peer reviews. key points in research and writing • always consider, “what is the point?” • tell a compelling story. • checklists are your friends (reporting guidelines). • do not worry about perfect english, but it must be understood. 55 o’neill sep 2018. christian journal for global health 5(1):52-56. • choose a journal wisely (and follow information for authors). • focus on rigor, relevance, and ethical responsibilities. further resources authoraid has a mentorship program for developing country and emerging researchers.13 mendeley is a free resource to manage references, organize papers, and network with other researchers.14 elsevier’s research academy provides guidelines and educational tips for researchers.15 in addition to these resources mentioned in the workshop, who regional office in the eastern mediterranean produced a practical guide for health researchers, including a section on writing and publishing a scientific paper.16 research4life is “designed to enhance the scholarship, teaching, research and policy-making of the many thousands of students, faculty, scientists, and medical specialists, focusing on health, agriculture, environment and other life, physical and social sciences in the developing world, through free or low-cost access to academic and professional peer-reviewed content online.”17 references 1. equator network. enhancing the quaality and transparency of health research. available from: http://www.equator-network.org/ 2. chalmers i, glasziou p. avoidable waste in the production and reporting of research evidence. lancet. 2009;374:86–9. https://doi.org/10.1016/s0140-6736(09)60329-9 3. chinnery f, kelly md, van der linden b, westmore m, whitlock e. ensuring value in health-related research. the lancet. 03 mar 2018;391(10123): 8367. https://doi.org/10.1016/s0140-6736(18)30464-1 4. wma declaration of helsinki — ethical principles for medical research involving human subjects. world medical association. available from: https://www.wma.net/policies-post/wma-declarationof-helsinki-ethical-principles-for-medical-researchinvolving-human-subjects/ 5. equator network. enhancing the quality and transparency of health research. available from: http://www.equator-network.org/ 6. vandenbroucke jp, von elm e, altman dg, pocock sj, gøtzscheet pc, vandenbroucke jp. strengthening the reporting of observational studies in epidemiology (strobe): explanation and elaboration. plos medicine. 2007;4(10):e297. https://doi.org/10.1371/journal.pmed.0040297 7. carroll mw. creative commons and the openness of open access. n engl j med. 2013;368:789-91. https://doi.org/10.1056/nejmp1300040 8. open access.nl. pros and cons. available from: http://openaccess.nl/en/what-is-open-access/pros-andcons 9. clark j, smith r. firm action needed on predatory journals. bmj. 2015;350:h210. https://doi.org/10.1136/bmj.h210 [see also: identifying predatory journals. world association of medical editors. 18 feb 2017. available from: http://www.wame.org/identifying-predatory-orpseudo-journals] 10. think, check, submit. choosing the right journal for your research. available from: https://thinkchecksubmit.org/about/ 11. committee on publication ethics. available from: https://publicationethics.org/about 12. international committee of medical journal editors. defining the role of authors and contributors. available from: http://www.icmje.org/recommendations/browse/rolesand-responsibilities/defining-the-role-of-authors-andcontributors.html 13. authoraid. available from: http://www.authoraid.info/en/ 14. mendeley: your reference manager. elsevier. available from: https://www.mendeley.com/ 15. research academy. elsevier. available from: https://researcheracademy.elsevier.com/learn 16. fathalla mmf. a practical guide for health researchers. who regional office for the eastern mediterranean. cairo 2004. available from: http://www.who.int/ethics/reviewcommittee/emro_ethics_dsa237.pdf 17. research for life. access to research in the developing world. available from: https://www.research4life.org/ http://www.equator-network.org/ https://doi.org/10.1016/s0140-6736(09)60329-9 https://doi.org/10.1016/s0140-6736(18)30464-1 https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ http://www.equator-network.org/ https://doi.org/10.1371/journal.pmed.0040297 https://doi.org/10.1056/nejmp1300040 http://openaccess.nl/en/what-is-open-access/pros-and-cons http://openaccess.nl/en/what-is-open-access/pros-and-cons https://doi.org/10.1136/bmj.h210 http://www.wame.org/identifying-predatory-or-pseudo-journals http://www.wame.org/identifying-predatory-or-pseudo-journals https://thinkchecksubmit.org/about/ https://publicationethics.org/about http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html http://www.authoraid.info/en/ https://www.mendeley.com/ https://researcheracademy.elsevier.com/learn http://www.who.int/ethics/review-committee/emro_ethics_dsa237.pdf http://www.who.int/ethics/review-committee/emro_ethics_dsa237.pdf https://www.research4life.org/ 56 o’neill sep 2018. christian journal for global health 5(1):52-56. competing interests: none declared. correspondence: daniel w o’neill, christian journal for global health and university of connecticut school of medicine, united states of america. dwoneill@cjgh.org cite this article as: o’neill d w. the lancet global health academic writing workshop: navigating and getting noticed in the scholarly publishing world. christian journal for global health. sep 2018; 5(2):52-56. © o’neill d w. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:dwoneill@cjgh.org http://creativecommons.org/licenses/by/4.0/ conference report nov 2016. christian journal for global health, 3(2): 151-159. starting and resourcing family and internal medicine residency programs as integral mission stephen p merry a , bruce dahlman b , adam p sawatsky c , dennis palmer d , kevin c shannon e , thomas d thacher f a md, mph, consultant, department of family medicine/assistant professor, college of medicine, mayo clinic, united states b md, head, department of family medicine and community care, school of medicine and health sciences, kabarak university, kenya c md, consultant, department of internal medicine/assistant professor, college of medicine, mayo clinic, united states d md, program director, christian internal medicine specialization residency, mbingo baptist hospital, cameroon e md, associate professor, departments of family & preventive medicine, loma linda university school of medicine, united states f md, consultant, family medicine/professor of family medicine, college of medicine, mayo clinic, united states introduction graduate medical education is an excellent means of building the capacity of health care systems in low and middle income countries (lmic) and a growing way for physicians in high income countries to get involved in integral mission — the proclamation and demonstration of the gospel. in november 2015, 67 medical missionaries and academicians met in conjunction with the global missions health conference (gmhc) in louisville, kentucky. a subgroup of 33 physicians and educators held specific discussions about medical residency training programs in lmic settings and then reviewed the themes they identified with the entire group before sending a summary of those findings for further editing by those educators present as well as those unable to attend who were integrally involved in the development of family medicine and internal medicine residency programs. for ease of discussion, this article will collectively refer to these programs as “medical residency programs.” an overview of medical residency development in lmic the participants in the expert panel discussion came from varied academic contexts that reflect the variety of the medical residency programs that have started with medical missionary involvement in lmic the last 50 years. most of them have been family medicine residency programs. most of the participants involved in the discussion were of north american origin, some originated and resided on other continents, and most participants had spent years working professionally outside of north america. we reviewed the history of medical residency development, noting the variety of country and health system contexts in which they have developed. drs. calvin wilson and warren heffron chronicled the development of some of the early family medicine programs in a review article in 1994. 1 they noted that perhaps the first mission hospital general practice residency started in paraguay in 1951 at centro medica bautista, now a large multi-specialty private medical center. today, 152 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. there are multiple paradigms in which expats and national educators may be involved in integral mission. one option is the development of distinctly christian residency programs like at kabarak university in the predominantly christian country of kenya where one of us, bd (who initiated a related preconference discussion at the gmhc many years ago), is now head of the department of family medicine and director of the residency program that started in 2015. the residents come from kenya, south sudan, burundi, and democratic republic of congo and are recruited with a commitment to work in underserved areas and willingness to work outside of their home culture. another model is a medical residency in a church hospital that is not university-based in a predominantly christian country. examples are the family medicine program started by dr. calvin wilson at hospital vozandes in quito, ecuador in 1987 in conjunction with the catholic university of cuenca medical school. graduates of that program have established and have led the ecuador academy of family physicians. 2 in cameroon, the christian internal medicine residency program at mbingo baptist hospital was started and is still directed by one of us, dp, at a hospital owned and operated by the cameroonian baptist convention health board. there are some programs in mixed faith countries with a fair education infrastructure like the myungsung family medicine program starting in ethiopia. the program at evangel hospital in jos, nigeria sponsored by the evangelical churches of west africa, was established in 1982 and itself followed the development of family medicine programs at ogbomosho baptist medical center in 1977 and the program in eku, nigeria. 1 family medicine has now spread across the country of nigeria with many residency programs in church and government hospitals. in india, which at one time had some 500 christian mission hospitals, emmanuel hospital association which has reopened or taken over some 23 of these mission hospitals, has started a number of family medicine residency programs. 2 the family medicine residency started in 2009 by dr. milad hanna at germania hospital in aswan, egypt is an example of a christian hospital openly training with christian faculty in a muslim context. another of these is the family medicine program started at the cure international hospital in kabul, afghanistan in 2004. 2 there are christian educators working in government family medicine programs with outside funding like those with society for international missions (sim) at addis ababa university in ethiopia 2 or in a government hospital internal medicine residency program like drs. denis burkitt and richard goodgame at makerere university in kampala, uganda and our co-author, tt, who started and led the family medicine department and residency program at jos university teaching hospital in nigeria for many years before coming to mayo clinic. finally, there are many christian physician educators working to establish family medicine programs in closed-access nations (can). a complete review of all past and extant programs is beyond the scope of this article; rather this brief overview provides a panorama of the varied terrain in which the many different kinds of programs are growing and flourishing. formation the steps to formation and accreditation of family medicine residencies have been delineated in other documents. the who document on development of family medicine in the eastern mediterranean region details much of this process and notes that it will be necessarily different in each country. 3 it may develop through gradual evolution, starting with a prior acceptable model of general practice that may be quite truncated in 153 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. scope from american and european family medicine; and then depth and breadth may be added as allowed in that context moving from limited spectrum of outpatient medical care to fullspectrum family medicine — the “pluripotent” physician who capably practices the full breadth of in and outpatient adult medicine, pediatrics, ob/gyn, essential surgery, psychiatry, and has training in community medicine as well. especially in africa, this physician provides comprehensive care in a person-centered way while also overseeing the local public health system and community outreach of the hospitals, clinics, and dispensaries within its referral area, functioning as a “consultant to the primary care team” as other cadres provide the majority of first contact and continuity care. the path to recognition of family medicine is variable. family medicine may develop suddenly as a specialty as in nicaragua where full spectrum family medicine started de novo and was recognized by the government from its inception. 1 in mauritania, family medicine was first recognized as a specialty by the ministry of health (moh), and then, the first steps were taken to start the program. in ethiopia, influenced by developments in kenya and supported by north american academics from university of toronto and university of wisconsin (and elsewhere), the moh was approached early to seek reassurance that graduates would be provided with jobs and be recognized and paid as specialists on par with other post-graduate specialists. this was successful in launching family medicine training on an apparently sustainable trajectory. in other places, the recognition of family medicine as a specialty by the moh has been gradual, is still a work in progress, or has not been supported by the moh despite best efforts and at least in cameroon, resulted in the decision to establish an internal medicine with a pediatric training component rather than family medicine residency at mbingo hospital. the physician product a country’s history of primary care and its healthcare needs often determines what the final product of a residency in family medicine or internal medicine will look like. countries in africa which lack sufficient general surgery and ob/gyn specialists will necessarily train family medicine specialists to do essential surgery including c-sections. countries in the former soviet states will likely presently only accept a final product that resembles the primary care physician of the past — an outpatient-only care provider. in each country and need context, therefore, the curriculum must be adjusted. there will be no “one size fits all” curricular solution or uniform “international standard,” though the world organization of family doctors (wonca) does delineate competencies in the document, “wonca global standards for post-graduate family medicine education.” 4 this is not a matter of lowering standards, but of accommodating training to need and medical culture. integration or cooperation of residencies with local authorities the workshop participants discussed the international movement towards integration of faith-based health care structures in lmic with the moh and national medical education system. they recognized that faith-based organizations have been largely separated from governmental organizations for far too long, functioning in their own “silo” as discussed in a recent lancet article on faith-based health care in africa. 5 while the church hospital and healthcare systems largely pre-date governmental hospitals in sub-saharan african, india, and china, participants discussed that we want to avoid “neo-colonialism” by ensuring that we humbly pursue close partnerships with the moh, and local accrediting agencies while developing and maintaining the spiritual formation aspects of christian residency training. regional http://ac.els-cdn.com/s0140673615602513/1-s2.0-s0140673615602513-main.pdf?_tid=05113156-a4e5-11e5-b931-00000aacb35d&acdnat=1450374104_dfd763112b1af4825b373aa854f188fd http://ac.els-cdn.com/s0140673615602513/1-s2.0-s0140673615602513-main.pdf?_tid=05113156-a4e5-11e5-b931-00000aacb35d&acdnat=1450374104_dfd763112b1af4825b373aa854f188fd 154 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. bodies such as the african christian health associations platform (http://www.africachap.org) have worked to establish such relationships with ministries of health. such partnerships may require years of patient intentionality to build mutual trust and collegiality. establishment de novo of a single curriculum and standards used by all residencies which are based on american residency training standards would be unwise and unrealistic and would result in inadequately trained physicians to handle the very different spectrum of disease in lmic. rather, standards should be specific to the location with a large degree of overlap that will allow sharing of curricular elements but will require adaptation to the country and context of that region and will sometimes be dictated by the national accrediting body. training to “international standards” is an artificial construct in light of the dramatic variation in primary care roles around the world. the items that overlap, including knowledge content, multiple-choice questions, curriculum structure ideas, and many other items, can certainly be usefully shared. during a consultation held in rustenburg, south africa in 2009, african programs took the initiative to form a consensus statement regarding the unique character and roles of an african family physician which can guide future curriculum development for african family medicine residencies. 6 values-based educational elements are important to include in all residencies whether mission or government hospital in which we as christian physicians are teaching. this should include putting the needs of the patient first, professionalism, integrity, sanctity of life, stewardship of resources, performance excellence, and lifelong learning. these elements can be taught in many ways even in the can environment. embodiment of these values by the faculty is, of course, paramount. 7 organizations like prime international (uk) have curricula that encourage holistic care and attention to the emotional and spiritual needs of the patient. prime seminars have been successfully held in many contexts including secular universities and countries with suppressed christian minorities. 8 recruitment of high quality residents requires recognition that their future employability depends on recognition of their specialty training by the moh and licensing bodies as well as acceptance by the country’s medical culture. we believe that working within the constructs of the moh will result in programs that are ultimately the most sustainable and which successfully build health care capacity through increasing emphasis on training of family medicine, general internal medicine, and pediatric physicians. accreditation of programs will depend on location. where regional or national accreditation systems exist (e.g., west african college of physicians), applications or, at a minimum, consultations to these bodies must occur at the beginning of the process of program development to promote long-term collaborative working relationships. in an unusual case, an external accrediting body to provide supervision and quality assurance may be necessary. relationship with the national church sometimes the process of residency development meets difficulty as the national church organization affiliated with the hospital is perceived by hospital medical staff to be more concerned about the product — the revenue generated and the physicians educated to staff their hospitals — than valuing high-quality, educational programs. if the national church’s operating expenses are supported in part by hospital revenue, the national church may resist use of those revenues to fund medical education and enable the medical center and residency programs to grow. if the vision for the hospital by the two parties differs with missionaries envisioning progressive development of a tertiary teaching hospital and the national church relying on hospital revenues to fund their operating budget, http://www.africachap.org/ 155 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. crucial conversations conducted in prayerful humility will be necessary to maintain harmony. medical residencies in paacs hospitals one of the attractive locations for christian physician academics to be involved in starting medical residency programs and particularly family medicine are hospitals which have pan-african academy of christian surgeon (paacs) residencies in africa and now in asia at memorial christian hospital in bangladesh. 9 the presence of educational facilities and a tradition of education along with the potential for integrated and cooperative training with the general surgery residents can be synergistic. collegial relationships formed while training together may lead to general surgeon and family medicine teams being sent out to practice together, preventing burnout for both, and extending the reach of the fully qualified general surgeon. co-training would provide better surgical training for family medicine residents to handle common operative emergencies (i.e., csections, trauma stabilization, and where and when appropriate surgical management of acute abdomens — the most common conditions that might require a surgeon to get up at night). this sort of task-sharing of fully trained family medicine physician with a fully qualified surgeon with whom they train and with whom they would be sent out would naturally build on the historic model of such task-sharing that has been happening in mission and government hospitals for many decades. 10 the discussion of the group did not express an expectation of paacs to take on additional administrative responsibilities for these family medicine residencies, but simply to benefit from the potential synergies resulting from their presence alongside their general surgery residencies. in november 2015, the groundwork for creating a christian academy of african physicians (caap) began at loma linda university (llu) — the christian medical university in california that functions as the residency accrediting body for paacs. one of us, ks, has secured administrative support from llu administration to work with african family medicine and internal medicine academics and several of the authors of this review to develop caap to fulfill many of the same functions as paacs for primary care training programs in africa with potential expansion to asia. we anticipate such an organization would support programs in many hospitals where paacs programs presently exist. resourcing the residencies medical residencies must be resourced in order to develop. a commission in christian medical dental association (cmda) would have the advantages of ready name recognition and resources, but the obvious disadvantage of dangerous linkage to christianity for those working in can. therefore, the structure and tools which we envision being developed will need to be sensitive in content and hotlinks to any christian organizations that could endanger our colleagues in these settings and yet contain materials which would be uniquely helpful in developing residency programs that produce not just high quality physicians, but disciple physician christians. we envision a website that provides a wide variety of faith-neutral resources for residency development yet reflects the christian world view implicitly rather than explicitly and a second website at cmda that would provide discipleship materials for residencies. how educators from high income countries can assist in lmic can in his image (ihi) family medicine residency program in tulsa, oklahoma provides an exemplary model of how to be involved in residency development from their long experience developing eight residency programs in restricted or can. the process of starting a program begins for ihi when they receive a request for a consult. they 156 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. are invited and go in as guests to see who is involved and assess the needs as well as the desire and intent of the government or university — an inside out process rather than going in to suggest a particular product. they don’t commit long term until they see that developing a family medicine residency in that location will succeed based on the core resources or assets that are available to meet the needs. sometimes the formal invitation by the government for ihi to be involved has taken time and followed the government or university’s observation of medical education courses in which the scope of family medicine has been demonstrated (i.e., an advance life support in obstetrics course or other cme courses) before an invitation was extended. they recognize they are wanted some places and not others. they rely on god’s sovereignty and the spirit’s calling, knowing that it is god who opens and closes doors. like ihi, medical education international (mei) desires to partner with nationals and likewise go only when invited. specialty faculty a core of long-term faculty is the foundation that provides stability to a residency program. participants didn’t view faculty retention as a significant obstacle to long-term success and noted that most faculty members are recruited from program graduates. in addition to the core faculty, specialists teaching in the residency are important to bring expertise to medical training. predictably timed visits of national or expatriate specialists who commit to coming at a particular time each year to teach a particular portion of the curriculum is optimal. on years that specialists can’t be present, they will ideally be responsible for finding a samespecialty colleague to cover their “slot,” assuring that the lmic medical residency program is dependably resourced in that part of the curriculum. an online recruitment tool that lists opportunities searchable by specialty, country, and perhaps dates is needed to facilitate international networking of lmic residencies with specialists looking to use their professional skills in this capacity. some curricular components can be taught by visiting faculty in workshops including locally appropriate life-support courses. “advanced” courses may be at an inappropriate level for the resources available and the prior training of the participants and so should include some of the basic elements as well (e.g., bls should be taught before acls or atls). a comprehensive emergency skills course very appropriate for use in lmic, taught to a health care team at their own facility, called comprehensive advanced life support (cals) essentials, will soon become available from cals (www.calsprogram.org). the comprehensive cals manual is available in africa for mobile use on smart phone or tablet as part of the digital african health library developed by co-author bd (www.digitalhealthlibrary.net). timeframe development of a sustainable program with national faculty requires a long-term vision of 15 or more years to train high-quality generalists in critical thinking, to teach curriculum development and resident evaluation, and the rest of what comprises an excellent residency program. the principles of adult learning, observation and evaluation, patient-centered clinical methods, and research mentoring and facilitation are important aspects of faculty development that appear, in the experience of this workshop’s participants, to be often missing in national faculty experiences due to different approaches to education in lmic as compared to medical education in the united states. excellent faculty development opportunities exist in most areas through regional faimer institutes (www.faimer.org) and with regional health profession educators associations, such as the south african association of health educators (saahe) (http://saahe.org.za) or the eahpea in eastern http://www.calsprogram.org/ http://www.digitalhealthlibrary.net/ http://www.faimer.org/ http://saahe.org.za/ 157 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. africa, and participation in these should be encouraged to build capacity in these countries (https://sites.google.com/site/eamededucators). integral mission participants agreed that integral mission must be the goal of christian residency programs. postgraduate medical education is best done in the context of long-term clinical mentoring relationships for residents by and with faculty over the 3-4 year curriculum and is a great opportunity for spiritual discipleship. christian physician discipleship tools, such as provided by cmda, icmda and organizations like prime international (www.prime-international.org) and mentoring relationships linking physicians as is found on the gmhc website under the prior name of medical education missions (www.medicalmissions.com/network/education) will be essential in resourcing faculty to be involved in discipleship in these residency programs. the presently available mentoring medical education missions website has received few “hits” since inception. reasons for this may be that the resources provided do not meet felt needs, or the site may be at an unknown location that is not easily located by individuals with those needs, or the site has not provided enough information about what the user (prospective mentor or mentee) could expect. a formal needs assessment would clarify the situation. a residency development website located within gmhc or at cmda as part of a larger educational commission searchable by country, residency type, specialty needed, and resources needed (education, research assistance, patient care) could provide networking assistance to connect christian healthcare professionals with education institutions, including medical residencies worldwide. strategic opportunities in can should be emphasized. conclusion the preconference workshop participants concluded their session by sharing their vision for the outcome of the meeting to resource the development of high quality medical residency programs in response to god’s call and in his timing in order to build his kingdom. participants suggested doing this through the creation of two websites which can resource residencies: one acceptable to access in can with additional human resource networking and another providing christcentered educational resources perhaps hosted by cmda. these programs exist in varied contexts thus serving the variety of needs for capacity building in these countries. the final physician product of these residencies will depend on the degree to which a progressive view of a broadly trained physician capable of performing outpatient primary care as well as inpatient care and essential surgery has developed in each individual country. but, participants largely agreed that integration and cooperation with the country’s moh is essential for sustainable health development, recognizing that parallel mission and government health systems have been fairly labeled “neo-colonialism”, making such integration timely and imperative. recognition of family medicine as a specialty by the moh prior to starting training will prepare graduates of those programs for success in the country’s job market and health systems leadership. recognition by the national church of the unique needs of their mission hospitals’ educational programs to control their revenue in order to fund their programs’ growth and development exemplifies the common wisdom to provide authority and resources where responsibility for good outcomes is expected. co-training of general surgeons and medical residents who can provide essential surgical call coverage may lead to on-going synergies. medical and surgical subspecialists are essential in family and internal medicine residencies to provide the depth of instruction residents need to develop as excellent clinicians. dependable https://sites.google.com/site/eamededucators http://www.prime-international.org/ http://www.medicalmissions.com/network/education 158 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. scheduling of their specialty instruction allows residency program directors to assure inclusion of their content in the residency curriculum. in summary, participants agreed that teaching in medical residency programs in lmic present excellent opportunities for national and expat christian physician educators interested in integral mission. references 1. wilson c, heffron w. christian hospitals as family practice educational resources. educ res methods.1994;26(9):571-5. 2. heffron w, jenkins c. serving overseas: volunteer teaching [internet]. consultant. 2011;51(8): [cited 2016 aug 25] available from: http://www.consultant360.com/content/servingoverseas-volunteer-teaching 3. world health organization, regional office for the eastern mediterranean. conceptual and strategic approach to family practice: towards universal health coverage through family practice in the eastern mediterranean region . 2014.[cited 2016 aug 25] available from: http://applications.emro.who.int/dsaf/emropub _2014_en_1783.pdf?ua=1 4. wonca working party on education. wonca global standards for postgraduate family medicine education [internet]. 2013 june. [cited 2016 august 25] available from: http://www.globalfamilydoctor.com/site/defaultsi te/filesystem/documents/groups/education/won ca%20me%20stds_edit%20for%20web_250714 .pdf 5. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock f, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015;386(10005):1765-75. http//dx.doi.org/10.1016/s0140-6736(15)60251-3 6. mash r, reid s. statement of consensus on family medicine in africa. afr j prm health care fam med. 2010;2(1):art.#151. http://dx.doi.org/10.4102/ phcfm.v2i1.151 7. jones w, hanson j, longacre j. an intentional modeling process to teach professional behavior: students' clinical observations of preceptors. teach learn med. 2010;16:264-9. http://dx.doi.org/10.1207/s15328015tlm1603_8 8. prime-international.org [internet]. east sussex, uk; prime [cited 2016 september 19]. available from: http://www.primeinternational.org/. 9. pollock jd, love tp, steffe bc, thompson dc, mellinger j, haisch c. is it possible to train surgeons for rural africa? a report of a successful international program. world j surg. 2011;35(2):493-9. http//dx.doi.org/10.1007/s00268-010-0936-z 10. merry sp. re: is it possible to train surgeons for rural africa? a report of a successful international program. world j surg. 2011;35(9):2172-4. [author reply 2175-6] http://dx.doi.org/10.1007/s00268-011-1154-z competing interests: none declared. correspondence: stephen p merry, mayo clinic, united states. merry.stephen@mayo.edu bruce dahlman, kabarak university, kenya. bruce.dahlman@aimint.org adam p sawatsky, mayo clinic, united states. sawatsky.adam@mayo.edu dennis palmer, mbingo baptist hospital, cameroon. palmerdd47@gmail.com kevin c. shannon, loma linda university school of medicine, united states. kshannon@llu.edu thomas d. thacher, mayo clinic, united states. thacher.thomas@mayo.edu http://www.consultant360.com/content/serving-overseas-volunteer-teaching http://www.consultant360.com/content/serving-overseas-volunteer-teaching http://applications.emro.who.int/dsaf/emropub_2014_en_1783.pdf?ua=1 http://applications.emro.who.int/dsaf/emropub_2014_en_1783.pdf?ua=1 http://www.globalfamilydoctor.com/site/defaultsite/filesystem/documents/groups/education/wonca%20me%20stds_edit%20for%20web_250714.pdf http://www.globalfamilydoctor.com/site/defaultsite/filesystem/documents/groups/education/wonca%20me%20stds_edit%20for%20web_250714.pdf http://www.globalfamilydoctor.com/site/defaultsite/filesystem/documents/groups/education/wonca%20me%20stds_edit%20for%20web_250714.pdf http://www.globalfamilydoctor.com/site/defaultsite/filesystem/documents/groups/education/wonca%20me%20stds_edit%20for%20web_250714.pdf file:///c:/users/user/appdata/local/temp/http/dx.doi.org/10.1016/s0140-6736(15)60251-3 http://dx.doi.org/10.4102/%20phcfm.v2i1.151 http://dx.doi.org/10.1207/s15328015tlm1603_8 http://www.prime-international.org/ http://www.prime-international.org/ file:///c:/users/user/appdata/local/temp/http/dx.doi.org/10.1007/s00268-010-0936-z http://dx.doi.org/10.1007/s00268-011-1154-z mailto:merry.stephen@mayo.edu mailto:bruce.dahlman@aimint.org mailto:sawatsky.adam@mayo.edu mailto:palmerdd47@gmail.com mailto:kshannon@llu.edu mailto:thacher.thomas@mayo.edu 159 merry, dahlman, sawatsky, palmer, shannon & thacher nov 2016. christian journal for global health, 3(2): 151-159. cite this article as: merry sp, dahlman b, sawatsky ap, palmer d, shannon kc, thacher td. starting and resourcing family and internal medicine residency programs as integral mission. christian journal for global health (nov 2016), 3(2):51-59. ©merry sp, dahlman b, sawatsky ap, palmer d, shannon kc, thacher td. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ capacity building mar 2017. christian journal for global health, 4(1): 34-45. teaching quality improvement in tanzania: a model of interprofessional partnership for global health development john kvasnicka a , ken olson b , mufwimi saga c , ignas danda d , randy hurley e , gary moody f , cindy wilke g a md, mba, shoulder to shoulder, usa b md, shoulder to shoulder, usa c amo, christian social services commission of tanzania d amo, christian social services commission of tanzania e md, shoulder to shoulder, usa f md, shoulder to shoulder, usa g mha, global health administration partners, usa abstract background: education is a universal need in health care and a tool for quality improvement. we developed a two-day medical education conference in iringa, tanzania, that has now evolved to teach the basics of quality improvement to an inter-professional audience from the 28 hospitals in the southern zone of the tanzania christian social services commission (cssc). methods: we describe the planning, budget, implementation, evolution and evaluation of this on-going medical education conference. representatives from medicine, nursing, pharmacy and administration from all 28 hospitals were invited to attend. attendees evaluated the conference and individual lectures on a 5 point scale. in addition, attendees were asked to rate the most important learning aspect of the conference. results: over 100 tanzanian health professionals and administrators from the 28 hospitals in the southern zone of the cssc attended. evaluation forms were completed by 82 attendees. the 2016 conference received an overall rating of 4.0 on a 5 point scale. the individual lectures received an overall rating of 4.2 on a 5 point scale. quality improvement techniques and co-leadership topics were rated as most useful by attendees. conclusion: we provide a framework for developing a medical education conference that can be replicated in other settings. teaching the basics of quality improvement by having hospital leadership teams develop individual quality improvement projects is a highly useful method of instruction. 35 kvasnicka, olson, saga, danda, hurley, moody & wilke mar 2017. christian journal for global health, 4(1): 34-45. introduction education is a universal need in healthcare. one of the most effective ways to scale up human resources for healthcare to reduce the global burden of disease is through education and training programs. 1 developing effective global health education requires partners from developed and developing countries to work together to meet local educational needs. the supply of health workers in africa is inadequate and expected to worsen. the ultimate goal of education, of course, is to strengthen health systems. 2 this requires a global outlook, a multi-professional perspective, and a systems approach. 3 in this report, we describe the development and delivery of an ongoing healthcare education series through a partnership between faith-based organizations in the united states and tanzania. the conference is designed to emphasize principles of quality improvement and the application to quality improvement plans by attendees following the conference. the principles and organization of this conference can be replicated in other settings to promote healthcare education and christian service. background shoulder to shoulder is a christian nonprofit organization based in minnesota that has partnered with ilula lutheran hospital (ilh) in ilula, tanzania for the past 15 years to develop and improve the services provided to the local area by ilh. ilh is a 100-bed hospital in southern tanzania which serves as a district hospital. shoulder to shoulder has partnered with ilh over these years on multiple programs, including development of hospital expansion, laboratory, operating rooms, better access to water and electricity, and advanced training programs for staff. most recently, this partnership has supported the opening of a nursing school at the hospital. since 2014, shoulder to shoulder has presented the annual ilula-minnesota international healthcare conference. our first course was presented in january 2014 with 30 attendees representing referral hospitals in the southern zone of the christian social services commission (cssc), an ecumenical body formed to facilitate social services with the main focus on education and health services (http://www.cssc.or.tz/). based on the high degree of positive feedback from the initial conference, our partners in tanzania encouraged us to significantly expand the conference to offer this educational experience to a much larger audience of caregivers. as a result, we expanded the 2015 conference to include all 28 southern zone hospitals of the cssc with a total attendance of approximately 80 professionals. for the 2016 conference, we added an administrative track to our conference and invited over 100 attendees. this report describes the planning of the conference, outcomes, and feedback from participants. this description can serve as a starting point for organizations planning global health education programs. the reasons for developing this conference have been supported by several observations. table 1 lists the background observations and issues leading to the development of the conference. table 1. background  there is a great need for improved health care in developing countries.  education is a common and fundamental aspect of health development.  modeling education can help health care institutions develop an education culture and infrastructure.  effective programs should be able to scale and spread, and be sustainable. 4  effective programs build on long-term partnerships.  there is great interest among us health care workers in serving overseas, especially short term assignments.  actual service promotes greater engagement, lifelong commitment, and interest in global health service. 5  health care workers have limited ability to volunteer based on constraints in time, expense, and professional and family commitments.  building relationships and providing moral support are important components of many programs. http://www.cssc.or.tz/ 36 kvasnicka, olson, saga, danda, hurley, moody & wilke mar 2017. christian journal for global health, 4(1): 34-45. planning during the initial development of the program, the first priorities were to identify the purpose of the program and guiding principles. the purposes of the program were identified through the experiences of presenting educational opportunities at ilh over a number of years. in developing and presenting these programs, we iteratively defined a number of issues and opportunities that defined the purpose statements of our program. the purpose statements are listed in table 2. table 2. purpose statements  provide learning opportunities for physicians, nurses, pharmacists, and administrators who staff cssc hospitals in southern tanzania.  promote a culture of lifelong learning and education.  foster inter-professional teamwork between nursing, pharmacy, medicine, and administration.  foster relationships with international development partners.  develop actionable quality improvement plans.  foster sustainable improvement in medical care and the health of communities in southern tanzania.  engage interest among u.s. health care professionals and students in contributing to global health development.  foster education of u.s. students (medical, pharmacy, nursing, and healthcare administration students and resident doctors-in-training).  provide u.s. volunteers with opportunity to learn about medicine in the developing world. the next step in planning for the conference was the identification of guiding principles. through dialogue with our tanzanian partners, we identified five guiding principles for the conference, which would help in decision making as we develop and refine the conference (table 3). table 3. guiding principles 1. lifelong learning: we believe all professionals should contribute to a culture of learning and continuously learn to improve their practice. we include students and residents in preparation for and presentation of the conference. 2. inter-professional teamwork: we include nurses, pharmacists, administrators, and physicians in both the attendance and presentations. 6 we emphasize teamwork throughout the conference. we each bring unique knowledge and skills to share; specifically, tanzanian presenters emphasize tropical medicine and hiv, and american presenters emphasize the growing global problem of chronic and non-communicable diseases. 3. mutual respect: we emphasize the ability of all our participants to teach and learn from each other regardless of differences in practice setting, culture, and socio-economic situation. we include local leaders in planning the conference and select topics based on feedback from participants. 7 presentations are delivered by both u.s. and tanzanian professionals. we adhere to the highest international standards in the preparation of the educational content and accreditation of the program. 8 the program is based on the foundation of a longstanding and ongoing relationship. 9 4. continuous improvement: learning should drive improvement in practice. 10 we include education on principles and tools for developing quality improvement plans. each team prepares a specific quality improvement plan to implement upon returning to home hospitals. 11 5. sustainable impact: we believe that education and improvement are some of the most valuable ways to promote a lasting and sustainable positive impact on the health of our partner's communities. 12 the content of the initial course was based on discussions with our tanzanian colleagues. the content for subsequent courses has been based on learning needs identified by participants from the previous conference. general learning objectives are listed in table 4. 37 mar 2017. christian journal for global health, 4(1): 34-45. table 4. learning objectives  participants will learn current concepts and techniques in medical care in the acute hospital setting.  participants will be able to compare and contrast current practices in u.s. hospitals and tanzania hospitals. reasons for differences will be highlighted.  participants will develop quality improvement action plans for their own hospitals based on learning from the presentations and skills lab. learning formats included didactic lectures, question and answer sessions, skills labs, and group sessions to develop quality improvement plans. a total of 12.5 hours of instruction was provided. in planning the conference, we adhered as closely as possible to the highest international educational standards. 13 as such, the conference received approval from the education department at the healtheast care system to provide participants with continuing medical education (cme) credits for participation in this program. a planning committee is responsible for planning the conference and fundraising. this committee includes physicians, pharmacists, administrators, and nurses. we include healthcare professionals from both the u.s. and tanzania, and communicate via in-person meetings as well as email. a key element of the conference is including planning for quality improvement throughout the conference. principles of effective quality improvement in health care are covered early in the conference. throughout the conference, we emphasize utilizing the material to develop quality improvement plans. the conference concludes with teams selecting a quality improvement project based on material covered in the conference, and planning to implement the quality improvement plan upon returning to their home institutions. conference implementation the initial conference was presented at ilh in a conference room. subsequent conferences have required a larger space and have been presented at an educational facility in iringa, tanzania. facilities are available for classroom presentations, and separate areas are available for skills labs and presenter preparation. the conference occurs over two days in january each year. attendance is by invitation. we have invited the following from each of the 28 cssc southern region hospitals: 1 practicing physician, 1 pharmacist, 1 practicing nurse, 1 administrator. in addition to the above, we invite 6 staff from ilh, 10 staff from iringa government hospital, and 4 invited guests. due to limitations in resources in tanzanian hospitals, presentations focus on topics that are appropriate to the environment. presentations are designed to focus on pathophysiology, pharmacology, history and physical, diagnostics, and treatments appropriate to the local environment. in order to accommodate a variety of learning styles, the presentations feature didactic and skills instruction supported by peer-reviewed data, utilizing lecture and small-group discussion formats. learning topics are identified in partnership with our tanzanian colleagues and expertise of our volunteer faculty. we attempt to include tanzanian presenters. our ideal goal would be 50% u.s. and 50% tanzanian presenters, but we have not achieved this ratio yet. to date we have only had 10-20% of presentations by tanzanian health professionals. cme credit has been approved by an organization in the united states that is accredited by the acgme to provide level 1 cme credit. although this may not specifically be required, or even valued by participants, we feel it is important to adhere to the highest international educational standards in whatever environment the education is 38 mar 2017. christian journal for global health, 4(1): 34-45. delivered. this is the same standard we would require for cme in the united states. funding for the conference is provided from fundraising conducted throughout the year. we have attempted to maintain a diversified group of donors in order to sustain stable funding that is not dependent on a single donor. funding has been provided by foundations, nonprofit organizations devoted to global health, and generous individuals. most participants and faculty involved in the program have provided all services on a volunteer basis without any compensation, and have been fully responsible for all costs of their own transportation, travel expenses, and living expenses while volunteering to serve in this program. some faculty and students have conducted independent fundraising to support their travel expenses. ilula international conference provides support for attendees including bus fare based on their receipts and lodging. refreshments and lunches are provided at the conference. incidental expenses and additional meals, e.g., dinner, are the responsibility of the attendees or their home institutions. there is no per diem paid to attendees for attendance. total cost of the 2016 conference was $15,546. (this does not include cost of travel for expatriate volunteers who cover their own travel costs.) an example of our budget spreadsheet is shown in table 5. table 5. budget spreadsheet item number days cost/person total us$ travel costs reimbursed for attendees 118 tzs 60,000 tzs 7,080,000 $3,218 lodging costs reimbursed for attendees 118 3 tzs 150,000 tzs 17,700,000 $8,045 meals 153 2 tzs 31,000 tzs 4,743,000 $2,156 lecture hall rental tzs 200,000 $91 local course directors honorarium tzs 960,000 $436 honorarium for invited tz faculty 6 tzs 100,000 tzs 600,000 $273 local secretary tzs 40,000 $18 local car and fuel costs tzs 200,000 $91 copying costs 725 tzs 150 tzs 108,750 $49 folders 145 tzs 500 tzs 72,500 $33 writing books 118 tzs 1,500 tzs 177,000 $80 usb drives $500 pens $250 conference costs subtotal $15,241 wire transfer surcharge add 2% $305 total $15,546 results assessment of the value of the course is determined from attendee evaluations. attendees rated the value of the conference on evaluation forms at the end of the conference in january 2016. of 87 local attendees, 82 completed the evaluation forms at a 94% completion rate. the evaluation form is available in the appendix. all results presented here are evaluations from local tanzanian attendees, not from u.s. volunteers. overall evaluation results from our 2016 conference are as follows: when asked to rate the overall value of the conference on a scale of 1-5, responses averaged 4.0. individual lectures were evaluated on a 5 item likert scale (rating of 5 most valuable). the average lecture score was 4.2. all respondents felt that their competence had increased as a result of attending the conference. attendees were asked to answer comments, including the most important things they learned. the categories of the most important things learned from our 2016 conference in order of importance were: 1. quality improvement; 2. co-leadership; 3. 39 mar 2017. christian journal for global health, 4(1): 34-45. hand hygiene; 4. diabetes; 5. wound care and cancer (tie). attendees were also given the opportunity to provide open-ended comments. representative verbatim positive comments are shown in table 6. representative verbatim opportunities for improvement are shown in table 7. table 6. positive survey comments • very interesting, loved it • all i learned was very important • this presentation should be carried every year • good flow of presentation, it was well organized meeting • i want to learn more about quality improvement • you are doing a great job. please extend the time for the presentations. god bless you! • i like how was arranged this international meeting, meeting with other hospitals and exchange of ideas • keep it up so that the medical conference should be continuing for more updates • continue organization of this important conference • we appreciate you and we know your contribution to us. we'll come again next year table 7. opportunities for improvement • more learning on leadership, management in hospital • topics on quality improvement should have more time • reduce speed of teaching • per diem to be paid early to meet all expenses • please extend the time for presentations, 2 days are not enough • management of diabetes mellitus and cardiovascular diseases should be taught in detail • american english difficult • after each session, especially for disease, you have to elaborate more on drug of choice. • time for conference is too short (days) discussion we describe the principles and practical aspects of an international educational series based on christian principles to promote health in tanzania. this series is embedded within a longstanding relationship between a u.s. nonprofit organization and a health system in tanzania. 14 the partnership represents a longstanding mutual commitment based on common christian faith. historically, missionary medicine was focused on spreading religion as well as healthcare. today, many global health mission efforts are more secular. 15 this conference series is part of a core value of the partnership described as creating, “a culture of education.” one of the key elements of our program is a focus on inter-professional team work. the importance of collaborative team work has increasingly been recognized, and elements of interprofessional education and collaborative practice have been shown to be beneficial. 16 we intentionally utilize professionals from multiple disciplines within our teaching faculty, and invite teams with multiple professionals from each hospital to participate in the conference. throughout the conference, we emphasize the importance of teamwork, communication, collaboration, and mutual support. we have received anecdotal feedback that this emphasis has improved the functioning of teams when they return to their local hospitals. an important principle in the planning and execution of our conference is the focus on partnership and mutual respect. 17 studies have demonstrated a low-level alignment between curriculum in global health programs and local community health needs. 18 we recognize that the local health professionals are the experts, both in the local disease patterns, health issues, and availability of resources. we focus on shared 40 mar 2017. christian journal for global health, 4(1): 34-45. learning with each group bringing unique expertise to share. it has been recognized that the implementation and ethics of sending healthcare professionals from high income countries is often not in concert with the skills required upon arrival in the destination country. 19 assuring alignment with the needs of the local community requires partnership throughout the planning and implementation process. 20 continuous quality improvement is a major focus that has increased over the years during our conference. throughout the conference we emphasize utilizing the lessons from each of the lectures to develop specific quality improvement plans at the local level. one of the first lectures is on quality improvement utilizing the institute for healthcare improvement model for improvement focusing on plan-do-check-act cycles (pdca). 21 the final day of the conference devotes time for each team to develop a specific quality improvement plan to implement upon return to their local hospital. teams present these plans for shared learning purposes. 22 evaluation of global health education and training programs should include leadership development, effects on health care systems, and health outcomes. 1 so far our evaluation has been limited to surveying results from attendees. we have been working to expand the evaluation process through development of quality improvement plans as an integral part of the course which will ultimately include measurement of impact. 23 core competencies for engaging in effective health promotion have been identified. these include catalyzing change, leadership, assessment, planning, implementation, evaluation, 24 advocacy, and partnership. 25 other authors have identified required competencies and understanding the burden of global diseases, traveler’s medicine, and immigrant health. 26 we utilize extensive input from our tanzanian partners and feedback from attendees to identify learning objectives and course content to assure appropriate content. we intentionally adhere to rigorous u.s. standards for certification of our educational content to assure quality of education, and respect the importance of common standards. 9 a major part of our team represents students in various disciplines in healthcare from the united states who travel with our team and participate in the conference. 27 there has been a surge of interest in global health learning opportunities among the next generation of medical professionals. 16 this involvement of health professionals early in their career promotes an ongoing lifetime interest in global health. 28,29 we also believe this model demonstrates the importance of teaching and learning as part of professional obligation to our partners in tanzania. however, it should be recognized that including students and residents in presenting at the conference presents limitations and challenges in maintaining acceptable quality standards for educational content. all presentations by u.s. students and residents are approved by our cme sponsor and supervised by faculty to assure that the presentations meet educational standards. in addition to the benefits to patients and staff in tanzania, participation in this program provides a unique opportunity for volunteer u.s. physicians, nurses, pharmacists, administrators, and students by promoting engagement in the profession, providing an opportunity to serve and learn about medicine in the developing world, engaging interest in contributing to global health development, and fostering a culture of education. 30,31 the short duration of this program allows health care professionals to contribute to medical mission work with limited time commitment while avoiding the well-described potential unintended consequences of short term medical mission work. 32,33 by focusing on capacity building and education, rather than providing actual medical care, we have attempted to avoid the well-described risks of mission work which may actually degrade health system development. the financial aspects of the conference are important to note. we provide reimbursement for travel, lodging, and food expenses for local participants. the costs of this are funded by 41 mar 2017. christian journal for global health, 4(1): 34-45. generous donations from a variety of organizations and individuals in the united states. fundraising has been one of the ongoing challenges in creating a sustainable model. local custom in tanzania includes paying participants in the educational conferences a per diem fee, or “sitting fee.” this is not a common practice in the united states, and this issue has represented a cultural conflict in expectations. in particular, some of our funding organizations have policies against paying a per diem for educational conferences. as such, we have eliminated payment of the per diem. we are transparent about this issue with organizers and attendees; however, it has been an ongoing source of negative feedback from some of the attendees. in addition to development of the healthcare workforce, motivation of health workers to continue lifelong learning is a critical factor. financial incentives for participation are undoubtedly important. however, studies have demonstrated that financial incentives alone are not sufficient to motivate health workers. recognition is highly influential in health worker motivation. 34 we provide cme certificates to all attendees to recognize their participation. recognizing and understanding cultural differences have both been some of the challenges in organizing this effort, and some of the greatest rewards as we expand our horizons and overcome challenges. 15 our common faith tradition represents one of the deepest connections between cultures and has been an enduring source of strength in this effort. we are fortunate in that the language barrier has not been a significant issue since medicine is practiced in english in tanzania in spite of the national language being swahili. we do not need to use translators or interpreters in our conference. however, english skills are somewhat variable in our attendees, and we have received some feedback regarding difficulty in understanding some of the presentations. speaking slowly and clearly are ongoing challenges for our presenters. we intend this report to serve as a potential resource for global health workers serving in christian mission. the description of our principles and the program that has evolved can provide a starting point for individuals and organizations developing similar programs. ultimately, medical education should result in improved health. we hope to develop mechanisms to measure the impact this program has on multiple dimensions including health care system effectiveness, inter-professional teamwork, continuous quality improvement, and ultimately health benefits in southern tanzania. given resource limitations, we were unable to include such measurements. our assessment is limited to immediate feedback from attendees and anecdotal reports. in the future, we intend to ask participants to return with reports of the results of implementing the quality improvement plans developed at the conference. this will serve multiple purposes: measurement of outcomes, shared learning regarding implementation challenges, accountability, and encouragement in the difficult work of quality improvement. our efforts have been focused on aligning the curriculum with local health needs, focusing learning in community clinical settings, creating actionable plans based on lessons learned, and focusing on the needs of basic healthcare workers. 19 we believe that creating a culture of improvement and lifelong learning is one of the most sustainable ways to create ongoing improvements in health care throughout the world. 35 42 mar 2017. christian journal for global health, 4(1): 34-45. course participants references 1. kerry vb, ndung'u t, walensky rp, lee pt, kayanja vfib, bangsberg dr. managing the demand for global health education. plos med plos medicine. 2011aug;8(11). http://dx.doi.org/10.1371/journal.pmed.1001118 2. kotzee tj, couper id. what interventions do south african qualified doctors think will retain them in rural hospitals of the limpopo province of south africa? rural remote health. 2006;jul-sep;6(3):581. epub 2006 sep 6. http://www.rrh.org.au/articles/subviewnew.asp?articl eid=581 3. frenk j, chen l, bhutta za, cohen j, crisp n, evans t, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. the lancet. 2010;376(9756):1923–58. 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systematic review of the evidence. am j pub heal. 2014;104(7). http://dx.doi.org/10.2105/ajph.2014.301983 24. berry ns. did we do good? ngos, conflicts of interest and the evaluation of short-term medical missions in sololá, guatemala. social science & medicine. 2014;120:344–51. http://dx.doi.org/10.1016/j.socscimed.2014.05.006 25. barry mm, allegrante jp, lamarre m-c, auld me, taub a. the galway consensus conference: international collaboration on the development of core competencies for health promotion and health education. glob heal promo. 2009;16(2):05–11. http://dx.doi.org/10.1177/1757975909104097 26. houpt er, pearson rd, hall tl. three domains of competency in global health education: recommendations for all medical students. acad med. 2007;82(3):222–5. http://dx.doi.org/10.1097/acm.0b013e3180305c10 27. drain pk, primack a, hunt dd, fawzi ww, holmes kk, gardner p. global health in medical education: a call for more training and opportunities. acad med. 2007;82(3):226–30. http://dx.doi.org/10.1097/acm.0b013e3180305cf9 28. bills cb, ahn j. global health education as a translational science in graduate medical education. j grad med educ. 2015;7(2):166–8. http://dx.doi.org/10.4300/jgme-d-14-00319.1 29. strand ma, chen ai, pinkston lm. developing cross-cultural healthcare workers: content, process and mentoring. christ j glob heal. 2016;3(1):57. http://dx.doi.org/10.15566/cjgh.v3i1.102 30. iserson kv, biros mh, holliman cj. challenges in international medicine: ethical dilemmas, unanticipated consequences, and accepting limitations. acad emer med. 2012;19(6):683–92. http://dx.doi.org/10.1111/j.1553-2712.2012.01376.x 31. abram fy. reverse mission: a model for international social work education and transformative intrahttp://dx.doi.org/10.1093/intqhc/3.3.147 http://dx.doi.org/10.1080/01421590701814286 http://www.accme.org/news-publications/news/accme-and-globalization-continuing-medical-education 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http://dx.doi.org/10.1016/j.otohns.2010.05.011 34. willis-shattuck m, bidwell p, thomas s, wyness l, blaauw d, ditlopo p. motivation and retention of health workers in developing countries: a systematic review. bmc health serv res. 2008;8(1). http://dx.doi.org/10.1186/1472-6963-8-247 35. ott bb, olson rm. ethical issues of medical missions: the clinicians’ view. hec forum. 2011;23(2):105–13. http://dx.doi.org/10.1007/s10730011-9154-9 peer reviewed competing interests: none declared. acknowledgments: the authors would like to thank our parent organization, shoulder to shoulder, for support, organization and inspiration. we would like to thank our generous donors: global health ministries, peter j king family foundation, dale and patty andersen, arlene and dave tourville, and several anonymous donors. we would like to recognize mr. sylvester udope, christian social services commission southern zone manager, for his tremendous help in planning for the conference and assisting with conduct and presenting at the conference. we would also like to thank yunfa sovelo md, mr. alamu kikoti, mr. nayman chavalla, ritha tesha rn, and tuliwumi hingi rn for ongoing support and hospitality. we would like to thank our volunteer faculty for donating their time and resources to participate in our conference. finally, we would like to thank the entire staff and community at ilh for welcoming us to partner in improving the health of southern tanzania. correspondence: john kvasnicka, md, mba jkvasnicka@healtheast.org cite this article as: kvasnicka j, olson k, saga m, danda i, hurley r, moody g, wilke c. teaching quality improvement in tanzania: a model of inter-professional partnership for global health development. christian journal for global health. mar 2017; 4(1):34-45. © kvasnicka j, olson k, saga m, danda i, hurley r, moody g, wilke c this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1177/0020872805050490 http://dx.doi.org/10.1177/009182969302100305 http://dx.doi.org/10.1016/j.otohns.2010.05.011 http://dx.doi.org/10.1186/1472-6963-8-247 http://dx.doi.org/10.1007/s10730-011-9154-9 http://dx.doi.org/10.1007/s10730-011-9154-9 mailto:jkvasnicka@healtheast.org https://creativecommons.org/licenses/by/4.0/ 45 mar 2017. christian journal for global health, 4(1): 34-45. appendix evaluation form rating (rate 1-5) 1=not valuable 5=very valuable please rate the overall value of the conference 1 2 3 4 5 quality improvement: pfeiffer/jensen 1 2 3 4 5 keynote address: sterile technique: kitundu 1 2 3 4 5 co-leadership: plooster 1 2 3 4 5 wound care: hussein 1 2 3 4 5 cleaning, disinfection, and sterilization: holmuth 1 2 3 4 5 peripheral iv line insertion and maintainance: jennerjohn/gornall 1 2 3 4 5 insulin and goals of diabetes therapy: kayworth 1 2 3 4 5 cancer care: hurley 1 2 3 4 5 rheumatologic diseases: ramdass 1 2 3 4 5 hiv associated malignancies: rangaraju 1 2 3 4 5 bph: olson 1 2 3 4 5 public health and nutrition: saga 1 2 3 4 5 hand hygiene: holmuth 1 2 3 4 5 chikungunya: creech 1 2 3 4 5 pharmacy stock outs: hwang 1 2 3 4 5 hiv update: mziray 1 2 3 4 5 contraception: anderson 1 2 3 4 5 develop quality improvement plans 1 2 3 4 5 breakout: community based primary health care: jensen 1 2 3 4 5 breakout: administrative keynote: kikoti 1 2 3 4 5 breakout: cbphc workshop/learning circles 1 2 3 4 5 are you a… physician nurse pharmacist administrator other has your competence increased in objective 1, understanding concepts and techniques in medical care in the acute hospital setting? yes no please rate the value of each topic je uwezo wako umeongezeka katika lengo la kwanza has your competence increased in objective 2, understanding practices in us and tanzania hospitals? yes no has your competence increased in objective 3, developing quality improvement action plans? yes no je uwezo wako umeongezeka katika lengo la tatu was the presenter fair and free from bias? alikuwa mtangazaji wa haki na huru bila upendeleo yes no please tell us the most important things you learned tafadhali tuambie mambo muhimu uliojifunza strongly agree agree neutral disagree strongly disagree was the presentation fair and free from bias ? ilikuwa onyesho haki na huru bila upendeleo yes no je uwezo wako umeongezeka katika lengo la pili this activity has impacted my clinical practice, competence or patient care outcomes. shughuli hii imeathiri mazoezi kliniki, uwezo au kutawanya matokeo yangu. what else would you like us to know? ungependa nini kingine sisi kujua? what would you like to have us teach about next year? je utapenda tufundishe mambo gani kuhusu mwaka ujao? please tell us of any bias (upendeleo) you found tafadhali tuambie mapendeleo wowote ulio kutana commentary july 2018. christian journal for global health 5(1):4-15. why evangelical christians are supporting international family planning: a response to should evangelical christian organizations support international family planning? wiley henry mosleya a md, mph, professor emeritus, department of population, family and reproductive health, johns hopkins bloomberg school of public health, united states of america abstract the article by monique and jeffery wubbenhorst asks the question—should evangelical christian organizations support international family planning?1 the article’s response to this question shows a lack of understanding of the fundamentals of population dynamics in the modern world as well as of the critical role contraceptives play in preventing unintended pregnancies and abortions and promoting maternal and child health. these errors are compounded by selective citation and misrepresentation of the evidence in the scientific literature. this commentary seeks to provide a balanced view of the evidence and correct several unfounded assertions in order to document why evangelical christians and christian organizations are, in fact, providing family planning services around the world. specific points addressed are as follows: fundamentals of the global demographic transition including how the contraceptive revolution has slowed world population growth; the social, economic, and cultural forces driving couples to choose to control their fertility for the welfare of their families; the critical role of contraceptive practice in preventing unintended pregnancies and abortions as well as directly promoting safe motherhood and child health; the evidence that women and couples in less-developed countries desire to control their fertility as attested by the measurement of unmet need for family planning; and the reason why failing to provide poor women and couples in less-developed countries who want to control their fertility with the information and contraceptive methods of their choice is likely to lead to unintended pregnancies and more abortions. christian health professionals and organizations need to be in the world, working with people of all belief systems, since that is a powerful way for the world to be reached with the love of jesus and the gospel of salvation. key words: christian, family planning, contraception, abortion, international health, morality, safe motherhood, maternal mortality, public health, demographic transition, unmet need, unintended pregnancy 5 mosley july 2018. christian journal for global health 5(1):4-15. introduction the article by monique and jeffery wubbenhorst asks the question—should evangelical christian organizations support international family planning?1 while this could be a relevant question to ask, the commentary seemingly lacks an understanding of the fundamentals of population dynamics in the modern world. additionally, the contentions are supported with some unfounded assertions about contraception as well as selective citation and misrepresentation of evidence from scientific literature. this paper seeks to provide a balanced view of the evidence. there is a solid rationale for why christians and christian organizations from both the more-developed and less-developed countries support international family planning. a christian definition of family planning as a preface to this critique, there needs to be clarity as to what the international christian community commonly means by the term “family planning.” christian connections for international health (ccih), a coalition of 150 national and international christian organizations (both protestant and catholic, and spanning five continents) working in international health and development, has formulated a working definition of family planning, specifically: enabling couples to determine the number and timing of pregnancies, including the voluntary use of methods for preventing pregnancy — not including abortion — harmonious with their values and religious beliefs.2 it is important to note at the outset that “enabling couples to determine” and “voluntary use” by definition excludes coercive or strongly persuasive fertility control programs of any type. the focus is on “preventing pregnancy,” not “preventing births” since abortion is excluded. biblical foundations let us begin with a brief summary of some of the biblical foundations for evangelical christians to support family planning. the first chapter of genesis includes the narrative of god creating human beings, male and female, in his own image and commanding them to “be fruitful and multiply, fill the earth and govern it” (genesis1:28). in the second chapter of genesis, god established the institution of marriage, a teaching reinforced by jesus with a condemnation of the ease of divorce (matthew 19:3-9). god planned for humans to be stewards of his creation, but they failed in their relationship with him; so we now live in a fallen world. god has a plan for all human life, even before conception (psalm 139: 1316). god also created the beauty of sexual relationships as a bond between couples (song of solomon). st. paul, inspired by god, recognized the importance of this relationship in solidifying the marital bond without considering the procreation of offspring (1 corinthians 7:1-6). there are a number of references in the old testament to god’s people acting on childbearing desires, though in that historical period all the efforts at “family planning” were pronatalist with a strong desire for sons. for example, sarah gave abram her servant hagar to bear a child for her (genesis 16). jacob’s two wives, rachel and leah, competed with each other to bear children, resulting in the fathers of the twelve tribes of israel (genesis 29:31-30:24). tamar seduced her father-in-law, judah, to get a son to assure her of her rightful family inheritance. the son was perez, the ancestor of king david and ultimately jesus (genesis 38; ruth 4:18-22; matthew 1:3ff). hannah, one of elkanah’s two wives, childless for many years, made a vow to give her son to god’s service if he would give her a son. the next year her prayer was answered with the birth of the prophet samuel (1 samuel1:1-28). david “comforted” his wife bathsheba with another son to replace the child that died, leading to the birth of solomon (2 samuel 12:24). understandably, in those days, the “barren womb” was compared to “the grave” (proverbs 30: 15-16). however, it is 6 mosley july 2018. christian journal for global health 5(1):4-15. important to note that women were not only valued for their childbearing abilities. we see in proverbs 31:10-29 the virtuous and capable wife who was extolled for her industriousness, wisdom, and kindness. the demographic transition, contraception, and low fertility in the world today the article should evangelical christian organizations support international family planning? refers extensively to the negative views towards fertility control by historical secular and christian figures. but those historical positions, coming from a time period when infant, child, and maternal mortality rates were high, are hardly relevant to the present situation. more relevant is their review of the widely-varying secular and christian perspectives from the 20th century when the world’s population transition is well underway. it is in this context that the family planning perspective, articulated by the ccih and implemented by many christian organizations working around the world, will be supported in this commentary. to summarize, until the 18th century, human populations were characterized by high birth rates and high infant, child, and maternal mortality rates with life expectancies hardly over the age of 30 years; populations grew very slowly, if at all. 3 family and tribal survival depended on surviving children (psalms 127:3-5). no doubt, the wubbenhorsts’ argument that, “couldn’t a large number of children actually help families come out of poverty by having more working members in the family?” would have been relevant at a time when there were no health or educational opportunities and expenses, and children began working at a very early age to support the family. but this is not the situation in the modern world. with modernization, urbanization, technological advances, and increasing political stability beginning in the 18th century and accelerating in the 19th and 20th centuries, death rates began to decline so that families had more and more surviving children. 3 in the more developed countries of the western world, family size declined, and, initially, couples started controlling their fertility with abstinence, condoms, and other barrier methods as well as abortions.3 however, with families getting larger in the less developed countries because of improved health conditions, world population began to rapidly grow. by the end of world war ii there was concern in many quarters about a world population “explosion.”4 in the 1950s and 1960s, highly effective modern contraceptives were developed, beginning with the iud and then the contraceptive pill. these, and other new contraceptive methods became widely available, first in developed countries. then, as governments and international agencies began to provide foreign assistance programs, family planning became a part of the international development package. over the last 4 decades of the 20th century, contraceptives were steadily adopted in the less developed countries, particularly in latin america, asia, and north africa. this initiated the “contraceptive revolution.” world contraceptive use rose from less than 5% in the 1960s to about 65% at present, and world fertility fell from over 5 births per woman to the current level of about 2.5 births per woman.5 abortion was also a factor in this fertility decline, but this accounted for only about 15% of the reduction in fertility.6 noteworthy, these historical demographic realities contrast with the statement that, “one common motive for ‘family planning’ is to control population growth. though this is widely accepted as a present danger, the forecasts of catastrophic overpopulation have not occurred.” why has “catastrophic overpopulation... not occurred”?1 precisely because of the contraceptive revolution! in the context of concerns about evangelical christian organizations supporting international family planning, it is relevant to look at the current contraceptive practices of evangelicals and members of other religious groups in the united states. this can give some perspective on their question about 7 mosley july 2018. christian journal for global health 5(1):4-15. what evangelicals should be doing for the less developed countries. the 2006-2008 national survey of family growth conducted by the centers for disease control and prevention (cdc) and national center for health statistics (nchs) provides this information.7 the data are given in table 1 below. noteworthy, in the us where clinical contraceptive methods (sterilization, hormonal, and iud) require a physician’s consultation and informed consent, the vast majority of women are choosing to use “highly effective methods” with little distinction by religious affiliation. (note: the data are essentially the same for married and unmarried women.) table 1. percent contraceptive use, by method, among sexually-active women who are not pregnant, post-partum or trying to get pregnant, by religious affiliation: usa, 2006-2008. religious affiliation highly effective methods* natural fp other methods none all women 68 1 5 11 catholic 69 2 4 11 mainline protestant 73 1 4 10 evangelical 74 1 6 9 other 60 1 5 9 none 62 1 7 14 *sterilization, pill and other hormonal methods, iuds, condoms what are the messages for christians in the world today based on these basic demographic realities? first, most of couples around the world desire smaller families for their own family’s health and welfare, and the vast majority (approximately 1 billion women) are voluntarily choosing to practice some method of contraception to achieve this. this prevents around 230 million births a year.8 still, there are over 50 million induced abortions a year, mostly due to women not having access to a method of contraception to prevent unintended pregnancies, though some do follow contraceptive failure.6 indeed, in the past decades some countries themselves initiated family planning programs that were frankly coercive, notably china, in order to slow their population growth. but in the majority of countries, family planning is offered on the basis of an informed, voluntary decision, particularly in programs supported by christian organizations.9, 10 is there a “contraceptive mentality” that “leads to more abortion?” a critical issue for christians is being knowledgeable about the relationship between contraceptive practice and abortion. the wubbenhorst article claims that there is an “explicit connection between contraception and induced abortion” whereby there is an “inevitable progression of the contraceptive mentality, from preventing pregnancies with contraception to limiting or preventing births with abortion.” however, this reasoning leads to a false conclusion that “... more contraception tends to establish a ‘contraceptive state of mind’ which leads to absolving responsibility for children conceived which, in turn, leads to more abortion.” (emphasis added) what is the actual situation? in 1956, kingsley davis and judith blake developed a framework that was very informative in the study of human reproduction.11 basically, reproduction depends on a few fundamental “biosocial mechanisms” (behaviors that directly affect the likelihood of conception and the production of a live birth); in terms of human choices and actions, these may be grouped into four broad categories: • entering into and maintaining a sexual union (which may or may not be formalized by marriage) • practicing contraception to prevent a pregnancy (by any method, traditional or modern, including voluntary sterilization) 8 mosley july 2018. christian journal for global health 5(1):4-15. • procuring an induced abortion to terminate an unwanted pregnancy • practicing breastfeeding following a live birth (that biologically temporarily inhibits ovulation and can delay the next pregnancy for a period of time) there are other biological factors generally beyond the conscious control of couples like genetic infertility and disease processes that may inhibit conception or lead to spontaneous abortions. but the main point of davis-blake framework is to make it clear that it is various combinations of these four major practices that result in the level of fertility observed in a population. the underlying determinants of these practices are the very powerful social, economic, and cultural factors that influence how many children couples desire, when they desire to have them, and which of these practices they will use to control their fertility. critical to the actions that may be taken by couples to achieve childbearing desires are not only their socio-economic circumstances and beliefs and values, but also their knowledge of the fertility control options and their access to the methods of their choice. here the overwhelming empirical evidence is that in the absence of knowledge or availability of effective contraceptive methods to prevent a pregnancy, individuals and couples may often resort to induced abortions to terminate an unintended pregnancy.12 tragically, in too many cases in less developed countries, these are unsafe abortions, resulting in a very high risk of maternal deaths.13 correspondingly, the most effective way to prevent the practice of abortion as a means of birth control is to provide a wide range of easily accessible contraceptive methods that can satisfy a couple’s personal choices. (in the case where women have already had an induced abortion, post-abortion contraception should always be made available to prevent another unintended pregnancy and abortion.) the empirical evidence for contraception reducing abortions and saving lives is overwhelming.13 only a few national examples from the literature will be given here. as far back as the 1960s, chile began experiencing an “epidemic” of unsafe abortions as couples were seeking to control their fertility and contraceptives were mostly unavailable except to wealthy couples.14 20% of hospital beds were occupied by women with complications from unsafe abortions; unsafe abortions were the leading cause of maternal mortality, accounting for about 40% of maternal deaths. in 1964, benjamin viel began providing contraceptives (iuds and orals) to women from an area in santiago who were visiting two hospitals for delivery care or post-abortion complications.15 over a span of 3 years he provided contraception to almost 21,000 women and documented a sharp decline in fertility and an estimated 33% drop in the number of women arriving due to complications from abortions. finally, in 1965, the government made contraceptives available nationally as well as strengthened other public health services to combat the epidemic of induced abortions; by 1990, about 50% of women were using modern contraception.16 in the 15 years from 1965 1980, the fertility rate fell 46% (from 4.5 to 2.6 births per woman), the abortion mortality ratio declined 78% (from 90 to 20 per 100,000 live births), and the maternal mortality rate declined 88% (from 400 to 46 per 100,000 women of fertile age).17 in 2003, marston and cleland provided a comprehensive review of the empirical evidence from 13 countries demonstrating that the increasing practice of using modern contraception reduced the practice of abortion. as they note in their summary: in seven countries—kazakhstan, kyrgyz republic, uzbekistan, bulgaria, turkey, tunisia, switzerland—abortion incidence declined as prevalence of modern 9 mosley july 2018. christian journal for global health 5(1):4-15. contraceptive rose. in six others—cuba, denmark, netherlands, the united states, singapore and the republic of korea— levels of abortion and contraceptive use rose simultaneously. in all six of these countries, however, overall levels of fertility were falling during the period studied. after fertility levels stabilized in several of the countries that had shown simultaneous rise in contraception and abortion, contraceptive use continued to increase and abortion rates fell. the most clear-cut example is the trend in the republic of korea.12 they conclude: rising contraceptive use results in reduced abortion incidence in settings where fertility is constant. the parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly. 12 (emphasis added) marston and cleland’s article is particularly relevant to the reference in wubbenhorsts’ article that refers to the article by nuguyen and budiharsana documenting the “paradoxical” concurrent high rates of contraception and abortion in vietnam.18 this is misattributed to a “contraceptive mentality” that “cannot help but lead couples to turn to abortion when contraception fails.”1 indeed, as documented in chile and reinforced by the marston and cleland study, the vietnamese are resorting to abortion to achieve their desired family size, but this is not due to a “contraceptive mentality.” the study authors’ own interpretation of the reason for this seemingly paradoxical observation is because of a lack of knowledge and access to effective contraception. to quote the authors: ... [t]hese findings imply that women in general are still receiving poorly performed family planning counseling and inadequate information/communication about their method of choice, not to mention facing limited contraceptive access/availability.18 consequently, the study authors recommend: policy-wise, increasing the availability of modern contraceptive methods other than iuds, as well as providing quality information, will increase the use of effective modern family planning methods and decrease the use of traditional methods, leading to change the paradoxical situation of high use of contraceptives and high abortion in vietnam. 18 (emphasis added.) as a final note on this, i want to briefly point to my own experience in bangladesh. in the late 1970s, i initiated a series of studies with my indian and bangladeshi colleagues to develop a clientcentered family planning strategy offering a wide range of contraceptives along with surgical sterilizations to help couples achieve their fertility desires.19 in less than 2 years, over 30% of couples adopted a contraceptive method and fertility fell by 25%. this approach was adopted nationally in the 1980s, and to make a long story short, currently over 55% of women in bangladesh are using modern contraceptive, and fertility has declined from 6 births per woman to just over 2 births per woman.20 critically relevant in this context, there is direct empirical evidence from bangladesh that this family planning strategy not only reduced unintended pregnancies, but more significantly, reduced the practice of abortion among married couples. (note: early abortion is legal in bangladesh and is provided by the government but not by any of the research projects.) the evidence comes from a study by rahman, davanzo, and razzaque who compared two geographic areas in the 1980s and 1990s, one (mch-fp area) with the high quality comprehensive family planning program and the other (comparison area) with a substantially lower level of government-provided family planning services.21 in both areas, couples had a strong desire to limit childbearing and a high unmet need for 10 mosley july 2018. christian journal for global health 5(1):4-15. family planning. over time, the mch-fp area had a much higher level of contraceptive practice, resulting in a greater decline in fertility and correspondingly in unmet need for family planning leading to fewer unintended pregnancies and a much lower level of abortion. from a national perspective, the authors concluded: the remarkable fertility declines that have occurred throughout bangladesh have been achieved with much less abortion than other countries with similar fertility declines. the political priority that the bangladesh government has placed on fertility reduction and family planning services has helped to accomplish this. 21 the evidence is clear, contraception prevents abortion. given the opportunity to make a choice, couples would prefer to prevent unintended pregnancies rather than resort to induced abortions. furthermore, couples around the world practice contraception because they want to invest more in the children they have or will have, and are well aware that too many children limit the resources they may have to provide the nurturing, health care, and education they want for each child. additionally, most are well aware of the facts that birth spacing with contraception can improve the health and welfare of the mother and her young children.22 how is contraception related to maternal mortality? in a section in the wubbenhorst article entitled “saving lives?”, only select literature is reviewed which leads to some erroneous conclusions. the discussion is confounded by the failure to distinguish between the maternal mortality rate and the maternal mortality ratio. both measures count the number of deaths to women due to complications of pregnancy and childbirth, but the rate uses the total number of women of reproductive age in the denominator, while the ratio only uses the number of women having live births in the same period in the denominator. this critically important distinction is clarified below. the maternal mortality rate is measured as the risk of maternal death among all reproductive age women. from a population perspective, maternal deaths can occur only if the women have pregnancies. put simply, without pregnancies, the maternal mortality rate will obviously be zero; correspondingly, the more pregnancies women have in their lifetime, the higher will be the risks of death for individuals, and the higher the maternal mortality rate will be. it should be intuitively obvious that contraception, by preventing unintended pregnancies, will directly reduce a woman’s risk of maternal mortality. this, in fact, is part of what happened in chile in the case study cited earlier. in terms of the global impact of contraception on preventing maternal deaths, saifuddin ahmed and colleagues have estimated that among the approximately 1 billion women using contraception in 2008, about 230 million pregnancies were prevented, resulting in the estimated prevention of about 270,000 maternal deaths.23 the maternal mortality ratio is a measure of the risk of death among women experiencing pregnancy. this is due to many factors, including the health of women, their social and economic conditions, the availability and use of high quality childbirth care, and the practice of unsafe abortion for unintended pregnancies. again, as documented in chile, contraception can reduce the maternal mortality ratio to the degree that it can prevent unintended pregnancies that otherwise might be aborted under unsafe conditions. also, there may be additional benefits as in the case of women choosing to use contraception because of their poor health or a rapid succession of pregnancies. but the major reductions in the risks of death with pregnancy will primarily come about with improved maternal health conditions and the availability of high quality maternity care. this, of course, is in agreement with the wubbenhorsts’ on the need for quality maternity care. 11 mosley july 2018. christian journal for global health 5(1):4-15. the wubbenhorst article fails to clarify this critical distinction between the maternal mortality rate and the maternal mortality ratio. this results in their wholly erroneous conclusion that: . . . statistically speaking, reducing the number of pregnancies and live births does not decrease the maternal mortality rate; since in the absence of good maternity care the ratio of deaths remains the same even though the number of births (the denominator of the mmr) may be decreased.”1 (emphasis added) as explained above, the numbers of maternal deaths, therefore the rate, is definitely reduced by the use of contraception since it reduces the number of (unintended) pregnancies.23 indeed, the ratio could remain relatively unchanged without other health interventions. this being the case, of course, maternity care is also essential for a comprehensive and safe motherhood program. the wubbenhorst article goes on to conclude, “thus, the goal of reducing maternal mortality cannot be achieved through contraception alone: birth limiting—through abortion—is also required.”1 as already shown above, this statement is simply not true; contraception alone has had a profound effect in reducing maternal mortality. this is the reason that family planning has been recognized by the international community as the first of the “four pillars of safe motherhood,” the others being antenatal care, safe delivery, and the availability of essential obstetric care.24 is international family planning being imposed on developing countries by the west? christian public health professionals are working in international spaces to serve the preventive health needs of the people. family planning is one of these preventive needs since it is one of the “pillars of safe motherhood” as well as having other health and welfare benefits for families. in this context, the article asks the rhetorical question “... have the women in developing countries been asked whether they want contraception?” (emphasis added) and answers: “‘unmet need’ assumes, without considering women’s desires or wishes, that they need western people to tell them how to control their fertility.”1 following this, they refer to international family planning as “sexual imperialism” and “sexual colonialism.” unfortunately, this characterization of “unmet need” totally misrepresents the measurement of this sociological indicator. further, it shows a clear lack of understanding of its utility by family planning program managers in countries throughout the world. basically, “unmet need” is measured by asking married women capable of having a pregnancy and not using any method of contraception if they ever want to have another child, or, for spacing, the question is, do they want to delay their next pregnancy by more than 2 years.25 if these respondents do not want to have another child or want to space their children out, conceptually they are considered to have an “unmet need” for family planning. while it has been well established by social scientists that not all individual women who report that they want to space births or stop childbearing will actually consider accepting contraception, this measure is useful in assessing the overall level of “potential demand” for contraception in a population as well as in evaluating how well a family planning program is meeting that demand. typically, as more and more couples desire fewer children, the measure of unmet need will increase if they are not able to freely access contraceptives. correspondingly, a country with a high unmet need will ordinarily have a higher level of unintended pregnancies and more abortions; furthermore, the unmet need will decline along with unintended pregnancies and abortions as women gain more access to contraceptives. the bangladesh case study cited above documents these relationships. 21 as expressed by casterline and sinding: in making the reduction of unmet need a primary goal, population policies are 12 mosley july 2018. christian journal for global health 5(1):4-15. insisting that helping individuals achieve their personal aspirations is a primary objective of public policy.25 (emphasis added) is contraception a gateway to immoral behavior? in the section titled “avoiding the contraceptive mentality,” the wubbenhorst article, after opening with their earlier premise that “we have seen that the contraceptive mentality has been associated with increased likelihood of acceptance of abortion” infers that “a further case can be made that the acceptance of contraception leads to other things that the christian church has traditionally denounced.” here, they mention such behaviors as mutual masturbation, sodomy, anal intercourse, etc., even though all of these behaviors have existed since ancient times, far preceding the age of contraception. the implication of this line of thinking seems to be that the practice of non-procreative sexual relations, even among married couples, leads to “abortions and other moral problems.” actually, in this context, essentially all evangelical christians, catholic and protestant, approve of the fertility awareness method (fam) as a means of achieving non-procreative sexual relations.26 thus, one relevant question is, if fam is acceptable as a means of having non-procreative sexual relations, why not other contraceptive methods without any abortifacient properties? in fact, such methods are approved and provided by many christian organizations working in international health.27 more relevant, if nonprocreative sex intrinsically leads to abortion and other morally unacceptable behaviors, why is the practice of fam any less consequential? after all, since contraceptive failures occur with fam as with other methods—what is the evidence that couples with fam failures are less likely to choose to abort an unintended pregnancy than couples with any other method failure? on the positive side, god created the beauty of sexual relationships as a bond between couples (song of solomon). st. paul, inspired by god, recognized the importance of this relationship in solidifying the marital bond without considering the procreation of offspring (1 cor. 7:1-6). as summarized by barranco and soler, even catholic teaching recognizes the legitimacy of nonprocreative sexual relationships as important for the marital bond.26 a christian rationale for participating in international family planning programs in the lead to this commentary, i cited the definition of family planning as formulated by ccih. the wubbenhorst article extensively critiques this statement, much of which has been covered above. but their concluding point needs to be addressed since it would seem to essentially preclude christians from being engaged in providing family planning services, except to fellow christians. they state, “the vague mention of couples’ ‘values and beliefs’... means that a couple could have beliefs that might not be christian or could even be anti-christian. should christians support such values and beliefs as some have done?”1 jesus’ life and ministry provides the example of how christians are to live and serve others. jesus had a healing ministry serving all who came to him (mark 1: 32-34) as well as giving special attention to the care of children (matt. 19: 13-15). the parable of the sheep and the goats clearly shows how christians are to serve people in need (matt. 25:31-46). most relevant in this regard is jesus regularly reaching out to the outcasts and “sinners” in society. noteworthy, jesus responded to the religious critics of his practice with the observation, “healthy people do not need a doctor, sick people do. for i have come to call not those who think they are righteous, but those who know they are sinners.” (mark 2: 15-17, living bible) finally, jesus did not ask the father that his 13 mosley july 2018. christian journal for global health 5(1):4-15. followers be taken from the world, but that, “just as you sent me into the world, i am sending them into the world.” (john 17:15-18, living bible) what is the message for christian public health professionals going out into the world, particularly where most people are not christians, as i did in bangladesh? simply put, we are not going out to “support such values and beliefs” but to show the love of jesus by modeling his life of service and healing. this can be done these days with many powerful, lifesaving technologies, not the least of which is contraception, since this is such a fundamental public health intervention that can have a powerful influence on the health and welfare of couples and their children as well as on the roles and status of women. obviously, people being served should be fully informed about the risks and benefits of all interventions including the primary mode of action for all methods, but they should have the opportunity to choose or reject any intervention based on their own beliefs and values.28 this does not preclude christians seeking to encourage couples to choose effective contraceptive methods least likely to result in a fetal loss, but, as discussed earlier, failure to make available the method of their choice can result in unintended pregnancies and not infrequently unsafe induced abortions and even the loss of the mothers’ lives. christian health professionals and organizations need to be in the world, working with people of all belief systems, since that is a powerful way for the world to be reached with the love of jesus and the gospel of salvation. references 1. wubbenhorst mc, wubbenhorst jk. should evangelical christian organizations support international family planning? 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http://www.searo.who.int/entity/child_adolescent/topics/child_health/fp-ban.pdf?ua=1 https://doi.org/10.1016/s0140-6736(01)06182-7 https://doi.org/10.1016/s0140-6736(12)60609-6 https://doi.org/10.1016/s0140-6736(12)60478-4 https://doi.org/10.1016/s0140-6736(12)60478-4 http://apps.who.int/iris/bitstream/10665/63268/1/who_fhe_msm_94.11_rev.1.pdf http://apps.who.int/iris/bitstream/10665/63268/1/who_fhe_msm_94.11_rev.1.pdf http://www.jstor.org/stable/172400 https://doi.org/10.1080/13625187.2017.1295438 http://www.ccih.org/wp-content/uploads/2017/09/ccih-2008-fp-survey.pdf http://www.ccih.org/wp-content/uploads/2017/09/ccih-2008-fp-survey.pdf http://www.who.int/reproductivehealth/publications/fp-global-handbook/en%20/ http://www.who.int/reproductivehealth/publications/fp-global-handbook/en%20/ 15 mosley july 2018. christian journal for global health 5(1):4-15. acknowledgments: the author acknowledges and appreciates the assistance of douglas huber in reviewing an earlier version of this commentary. correspondence: wiley henry mosley, johns hopkins bloomberg school of public health, united states of america. hmosley@jhu.edu cite this article as: mosley w h. why evangelical christians are supporting international family planning: a response to should evangelical christian organizations support international family planning? christian journal for global health. july 2018; 5(2):4-15. https://doi.org/10.15566/cjgh.v5i1.205 © mosley w h. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:hmosley@jhu.edu https://doi.org/10.15566/cjgh.v5i1.205 http://creativecommons.org/licenses/by/4.0/ conference report mar 2017. christian journal for global health, 4(1):50-54. christian connections for international health (ccih) conference explores relationship between christian faith and sustainable development, and role of fbos in global health kathy erb a a communications manager, christian connections for international health, united states the ccih 30th annual conference was held june 17-19, 2016 at johns hopkins university in baltimore, maryland, usa with a theme of sustainability and how it intersects with our christian faith. the conference was the largest ccih conference yet, with 198 attendees from 18 nations. much of the focus of the conference was on how we can ensure our programs involve lasting change in communities. christians and the sustainable development goals in the opening plenary session, moderator pauline muchina, phd, umc-gbcs healthy families healthy planet, introduced the topic of christians and sustainability. doug fountain, vice president, operations support, medical teams international, said sustainable development occurs when the development outlasts the partnerships we create in our work. he cautioned against practices that interfere with our work becoming sustainable, including failure to partner with other organizations, experimental approaches that cannot be tested before implementation, and relying on technologies that may work in a developed nation but will not work in the field. mr. fountain also discussed the value we add to our work as christians, including honoring the dignity of the lives of people we support, our ethics, compassion, and holistic approach, as well as the transformative nature of our work and our stewardship (responsible care for the resources we use.) “through christ, we offer hope and grace for a world that is hurting. that is sustainable development,” said mr. fountain in his concluding remarks. 1 karen sichinga, msn, mph, executive director of the churches health association of zambia and chairperson of the africa christian health associations platform, explored scripture related to sustainability in her presentation, including isaiah 51:6 and matthew 24: 35-36. mrs. sichinga addressed how the christian faith is present in even remote areas of zambia, http://www.medicalteams.org/ http://www.medicalteams.org/ http://www.chaz.org.zm/ http://www.chaz.org.zm/ http://africachap.org/en/ http://africachap.org/en/ 51 erb mar 2017. christian journal for global health, 4(1):50-54. making christian organizations critical partners in development at all levels, particularly at the community level where change needs to take place. according to mrs. sichinga, christian missionaries who came to africa decades ago used three major elements to further development: education, healthcare, and evangelism. church-related education and health systems have worked closely with the health ministry to improve the health status of the zambian people for more than 100 years, and christian health organizations have shown their commitment to serving the needs of the vulnerable. turning to the 17 sustainable development goals (sdgs), released in 2015, mrs. sichinga outlined key steps to ensure the faith-based organization (fbo) community handles the sdgs better than the mdgs, saying the faith community must:  embrace partnership without losing our identity,  demonstrate our ability to manage large-scale programs that address diseases,  be innovative (it has been done before with home-based care for hiv/aids in zambia.),  invest in human resources for health and sustain our workers. fbos must not hire church leaders solely because they are leaders; they must also be qualified,  document our successes,  maintain our identity (we should be confident and defend our faith; it is what sets us apart.),  work with governments and sustain those relationships, and  sustain our faith. daniel o'neill, md, ma(th), managing editor of cjgh, explored why christians are well positioned to bring health across the globe in a sustainable manner, commenting on christian identity and quoting the apostle paul’s remarks about the fundamental christian value that love will endure. in addressing the sdgs, dr. o’neill stated that many of the goals developed by the united nations have been informed by a christian world view. the transformational aspirations and inclusiveness in leaving no one behind are in line with christian values. christians are in a unique position to serve the healthcare needs of the underserved due to a number of factors, including the faithful presence of christians in areas of human need. dr. o’neill also stated that the strength of the christian faith in troubled areas of the world is being recognized by many in the secular global health community. furthermore, the church is expanding in its influence and is growing in areas where it has not existed before. according to dr. o’neill, the church is a gathered community but we are also scattered across the globe in our daily lives, increasing the places of influences around the world. faith groups are also capable of resource mobilization, and christians share global and universal goals, and care about people from all “tongues, tribes and nations.” however, dr. o’neill said it is not enough to have goals. we must have “fuel for the machine” to accomplish the goals. faith, the spirit, and devotion to the teachings of the lord jesus christ are fuel for the machine. 2 saving lives of mothers and children: an interactive panel session a plenary session on maternal and child health featured lisa firth, mb, bs, mph, health technical advisor, salvation army world service office; cindy uttley, rn, msn, cnm, community health advisor, samaritan's purse; lauren vanenk, mph, program officer, institute for reproductive health at georgetown university; and victoria graham, senior technical advisor, office of population and reproductive health, bureau of global health, usaid. dr. firth discussed the benefits of family planning to space pregnancies in order to protect the health of mothers and children, and explained how those benefits extended to strengthen entire families and communities. she shared successful strategies to introduce family planning into communities, such as starting with areas where there is common http://www.un.org/sustainabledevelopment/sustainable-development-goals/ http://www.un.org/sustainabledevelopment/sustainable-development-goals/ http://journal.cjgh.org/cjgh/index.php/cjgh/index https://sawso.org/ https://sawso.org/ https://www.samaritanspurse.org/ http://irh.org/ http://irh.org/ https://www.usaid.gov/ 52 erb mar 2017. christian journal for global health, 4(1):50-54. ground and relying on scripture that supports health. being prepared to address myths and misconceptions regarding various contraceptive methods was also stressed. ms. uttley covered a variety of family planning methods, including natural family planning, and examined the barriers that keep many couples from using methods to space pregnancies, such as access to services, availability, cost, and partner cooperation. ms. vanenk discussed current initiatives working with faith-based organizations to provide and promote family planning, and suggested ways of introducing services to new communities. looking forward, ms. graham explored opportunities that greater involvement of the faith community in helping families could have on healthy pregnancies and space births. ms. graham stated that the faith community has a very important role to play in creating an ongoing dialogue to change social and gender norms, which is crucial for empowering women to be able to time and space their pregnancies. faith leaders are influential in their communities, and the strong infrastructure of churches, including health facilities and education systems in many communities, makes their involvement providing and promoting family planning critical to its success. effective partnerships with fbos to fight communicable and noncommunicable diseases and advance sustainable development how faith-based organizations are forging innovative partnerships to address both communicable and non-communicable diseases was explored in a plenary session featuring samuel mwenda, md, executive director, christian health association of kenya; franklin baer, drph, senior advisor, ima world health; and jean duff, mph, ma, faith for international assistance and the joint learning initiative on faith and local communities. dr. mwenda shared how faith-based organizations have been working in kenya to address the country’s growing epidemic of noncommunicable diseases, including diabetes, heart disease, high blood pressure, and cancer. fbos, he said, have been involved in raising awareness, screening for, referring, diagnosing and treating diseases. dr. baer shared the history of faith-based involvement in health, including the significant expansion of fbo-managed health care in the democratic republic of congo and the evolution of partnerships among faith entities and governments. ms. duff explored opportunities for even greater involvement of faith-based actors through partnerships with existing faith networks, academic institutions, donors, and local and international organizations. faith journeys following worship on sunday morning, three high-level leaders in global health and development shared stories of their personal faith journeys, and how their careers and faith have intersected. we heard from ambassador and former congressman, tony hall, executive director emeritus for the alliance to end hunger; dick day, regional director for africa, u.s. peace corps, and phyllis joy mukaire, phd, ma, development consultant and former executive director of the christian health association of sudan. the speakers shared how their faith had anchored and strengthened them through the difficult decisions and personal challenges that led them to where they were that day and also gave advice to young professionals beginning their careers on how to integrate faith and work. http://www.chak.or.ke/ http://www.chak.or.ke/ http://imaworldhealth.org/ http://www.faithforinternationalassistance.org/ http://jliflc.com/ http://jliflc.com/ http://jliflc.com/ http://alliancetoendhunger.org/ https://www.peacecorps.gov/ 53 erb mar 2017. christian journal for global health, 4(1):50-54. living our faith through pandemic prevention and strong public health systems in the closing plenary, jonathan quick, md, mph, ceo of management sciences for health, explored the history of disease outbreaks from the spanish flu to hiv/aids and ebola. dr. quick shared the early warning signs that an outbreak could become an epidemic and assessed how international agencies had responded to threats throughout history. he also spoke of the importance of involving communities and faith actors in detecting and responding to outbreaks. research and publishing among other breakout sessions, elliott larson, md, editor in chief of cjgh moderated a session on research, communication and publishing. this included a presentation from dr. nathan grills, associate editor of cjgh, on tips for publishing. 3 jean sack, mls, of jhpiego and the johns hopkins public health library discussed accessing global health research. 4 dr. samuel mwenda of the christian health association of kenya named christian international health champion dr. samuel mwenda was selected by the ccih board of directors to receive the 2016 ccih christian international health champion award at the conference. dr. mwenda serves as the general secretary of the christian health association of kenya (chak). he was nominated by rick santos of ima world health and dr. henry mosley of johns hopkins university school of public health. according to rick santos, “dr. mwenda has been a transformational leader for faith-based organizations in kenya and the african region. he has used his skills and passion to build capacity of emerging health leaders and to advocate for the significant role of fbos in delivering quality health services to the most vulnerable populations in africa.” on receiving the award, dr. mwenda said, “i believe that this award is not just a recognition of my passion, commitment, and contribution to church health work but my conviction that there is hope and a great future for the contribution of church health services to the global health agenda and the under-served communities of the world from the christian perspective.” dr. mwenda rose to become the head of chak and certain events in his career sparked his passion for developing highquality health systems. 5 all powerpoint presentations and videos from the conference can be accessed here: http://www.ccih.org/2016-annual-conferencepresentations. 2017 ccih annual conference to explore integration of faith and health the ccih 2017 conference will be held july 13-15 at johns hopkins university in baltimore, maryland, usa. our theme is ‘strengthening global health: faith at the center’, a concept closely linked to ccih’s core focus area of integrating faith and health. at the conference, we hope to explore how our christian faith guides our work and address such questions as:  what is our role as christians in ensuring all people have access to community-based care and preventive services, especially marginalized communities?  what programs have we launched that protect and empower women and children, and strengthen families?  how do we sustain and strengthen evidencebased and people-centered health systems.to ensure high-quality care for all? learn more about the conference at www.ccih.org. http://www.msh.org/ http://www.chak.or.ke/ http://www.chak.or.ke/ http://imaworldhealth.org/ http://imaworldhealth.org/ http://www.jhsph.edu/ http://www.ccih.org/2016-annual-conference-presentations http://www.ccih.org/2016-annual-conference-presentations http://www.ccih.org/ccih-annual-conference/31st-annual-conference-july-2017.html 54 erb mar 2017. christian journal for global health, 4(1):50-54. references 1. fountain d. sustainability from a christian perspective. available at: http://www.slideshare.net/ccih/sustainability-froma-christian-perspective-doug-fountain 2. o'neill d. the key to sustainbility: theological reflections on the global goals. available at: http://www.slideshare.net/ccih/key-tosustainability-theological-reflections-on-globalgoals-dan-oneill 3. grills n. publishing tips from the field. available at: http://www.slideshare.net/ccih/publishing-tipsfrom-the-field-nathan-grills 4. sack j. practiical tips on research. available at: http://www.slideshare.net/ccih/practical-tips-onresearch-jean-sack 5. mwenda s. ccih 2016 health campion acceptance speech. available at: http://www.ccih.org/samuelmwenda-acceptance-speech competing interests: none declared. correspondence: kathy erb, christian connections for international health, united states. kathy.erb@ccih.org cite this article as: erb k. christian connections for international health (ccih) conference explores relationship between christian faith and sustainable development, and role of fbos in global health. christian journal for global health. mar 2017; 4(1):50-54. © erb k this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.slideshare.net/ccih/sustainability-from-a-christian-perspective-doug-fountain http://www.slideshare.net/ccih/sustainability-from-a-christian-perspective-doug-fountain http://www.slideshare.net/ccih/key-to-sustainability-theological-reflections-on-global-goals-dan-oneill http://www.slideshare.net/ccih/key-to-sustainability-theological-reflections-on-global-goals-dan-oneill http://www.slideshare.net/ccih/key-to-sustainability-theological-reflections-on-global-goals-dan-oneill http://www.slideshare.net/ccih/publishing-tips-from-the-field-nathan-grills http://www.slideshare.net/ccih/publishing-tips-from-the-field-nathan-grills http://www.slideshare.net/ccih/practical-tips-on-research-jean-sack http://www.slideshare.net/ccih/practical-tips-on-research-jean-sack http://www.ccih.org/samuel-mwenda-acceptance-speech http://www.ccih.org/samuel-mwenda-acceptance-speech mailto:kathy.erb@ccih.org https://creativecommons.org/licenses/by/4.0/ original article june 2014. christian journal for global health 2014, 1(1): 34-43. the fire is coming: an hiv prevention intervention contextualized to the maasai people of tanzania holly freitasa and marcia a nayakb a rn, mph medical ambassadors international and reach tanzania b phd, rn medical ambassadors international abstract “the fire is coming” film is an innovative hiv-prevention intervention contextualized to the maasai people of tanzania through use of a traditional maasai story. the intervention was developed and implemented in partnership with maasai pastoralists for education and development (maped). although there have been numerous knowledge-attitude-practice (kap) surveys conducted among the maasai, this is the first control-group comparison study designed to measure the effectiveness of an hivprevention intervention contextualized specifically to the maasai people of tanzania. we will first discuss the background and context in which the intervention was developed and methods used to develop the intervention. we will then discuss the evaluation methods, results, and implications of a retrospective knowledge, attitudes, practices (kap) two-village comparison survey (n=200) for “the fire is coming” hiv-prevention intervention among maasai people. there was a significant effect for hiv-related attitudes, t(16) = 2.77, p <0.05, regarding willingness to care for an hiv infected person, willingness to be tested for hiv, self-efficacy toward hiv-prevention, married women’s ability to use condoms, unmarried girls’ ability to refuse high-risk sexual behaviors, married men’s ability to use condoms, and married men’s ability to limit sex to their spouses. there was a significant effect for hiv-related behavior changes, t(8) = 2.89, p <0.05, with reported family decisions made, esoto (the ritualized sexual initiation of pre-pubescent girls) stopped, sexual behaviors changed, blade-sharing stopped, and other traditional custom changes reported. although knowledge rates were often higher in the intervention area than in the comparison area, there was no significant difference in hiv-related knowledge, t(12)=1.85, p >0.05. implications: belief in one’s ability to do something is often the pivotal point for behavior change. the results of the survey denote a highly effective intervention in changing hiv-related attitudes and behaviors. it is promising for replication among other maasai communities and for adaptation with indigenous people groups in other regions. background and context hiv infection rates are rapidly rising in maasai regions.1,2 although actual hiv rates are difficult to obtain due to governmental restrictions on census and data collection differentiation by tribal identification, sexual traditions and social norms place the maasai people of tanzania at high risk for sexually transmitted diseases. maasai norms and traditions include esoto (coerced sexual initiation of pre-pubes35 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. cent girls), encouragement of multiple sexual partners among teenage males, polygamy, marriage of young girls to older men, wife sharing, the obligation for wives to show hospitality by engaging in sexual behaviors with traveling male visitors, and male circumcision using a common blade.1,2,3,4 among the maasai, the exchange of reproductive fluids is considered essential to both mental and physical health; intentionally high levels of procreation limit the acceptability of condom use for either birth control or prevention of sexually transmitted disease.1,2 significant barriers to health education messages have resulted in limited hiv-related knowledge, misconceptions regarding hiv, and continuance of high-risk, hiv-related behaviors. language, limited education, and distance from health services make up some of the barriers that keep tanzania’s national efforts to reduce hiv transmission from reaching the maasai people. approximately 20% of maasai people speak the national language or have any formal education.5 all public health campaigns in tanzania, including hiv education, are conducted in swahili, leaving non-swahili speakers uninformed.4,6 furthermore, all national hiv surveillance efforts, including kap studies, have been conducted in swahili,7 leaving non-swahili speakers uncounted, their voices unheard, and their plight unknown to both national and international organizations concerned with hiv and aids.8,9 most maasai people in tanzania live in rural areas distant from city hubs where hiv prevention, testing, and treatment services can be obtained. poorly conditioned and infrequently traveled roads limit public transportation. maasai people generally travel by foot or in the open-bed of delivery trucks on weekly transportation routes from the village areas to the city hub and back. additional barriers limit the effectiveness of standard abc (abstinence, be faithful, and condom) messages.2,4,10 many maasai people believe that they, as a people group, are immune to hiv or that their traditional medicines will cure the disease. the lack of accessibility and acceptability of condoms further complicates the effectiveness of the abc message.4,11 finally, many of the commonly used hiv education methods, which promote individual behavioral change are rendered ineffective within the traditional maasai top-down and group-level decision making structure.2,4,6 in late 2006, a small maasai organization, maped (maasai pastoralists for education and development), of the olbili sub-village in simanjioro district, tanzania, became aware of the threat of hiv. intent on protecting their people, they sought hiv education. in 2007, sixteen of their young maasai warriors attended an intensive hiv training course which met both international and tanzanian hiv education standards. the young warriors recognized the dangers of high-risk maasai traditions and sexual practices and determined to make changes, not only to protect themselves and their families but also to educate other maasai about hiv to preserve their tribe. intervention and methods the young warriors, together with maped, determined that a public health education intervention was necessary to inform and educate the maasai people. in response, an educational program was designed to meet three goals: 1) to bring contextualized hiv prevention education to the maasai, 2) to increase the awareness of vulnerability to hiv infection due to traditional and common hiv-related behaviors, and 3) to facilitate dialog within maasai communities that would ultimately result in modification, adaptation, or discontinuation of high-risk, hiv-related behaviors. a participatory process was used to identify the preferred learning medium for hiv prevention education among the maasai. it was noted that the existing local public-health education was ineffective in maasai areas for several reasons. first, written health information is inaccessible to a majority of maasai who are oral learners. second, health information given via radio is also inaccessible to a majority of maasai, because all official public-health announcements in tanzania are made in swahili — not 36 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. the maasai language. third, maasai perceive national public-health announcements in swahili as non-applicable to themselves because of cultural differences. through discussions and the review of previous hiv-related kap studies, the maasai leaders and hiv education team determined that the preferred learning medium for hiv prevention education was audiovisual and chose to create an educational film using maasai spokespersons, traditions, and storytelling. a private donor provided a sum of money to medical ambassadors international for hiv education in africa. this donation, in turn, was directed toward the proposed intervention. the next step in the process was to identify traditional maasai stories that could effectively convey the hiv-prevention message. maasai stories were collected from every available source. after review of many stories, a widely-known traditional maasai story was selected which tells about a foolish man who knew that a great fire was coming across the land, posing great risk to his homestead, family, and animals. after many warnings, the man still did nothing to protect himself and was overwhelmed by the fire. the story elicits much laughter among the maasai people, and they find re-telling of the man’s obvious foolishness a source of great humor. the story provided a perfectly contextualized analogy to emphasize the importance of hiv awareness and preventive action among the maasai. “the fire is coming” video production began in 2008. maasai elders, political leaders, warriors, and other tribe members were briefed in the basic story-line and then participated to create the unscripted footage, telling the story in their own words, providing hiv prevention education, advocating for change of high-risk cultural practices, and warning of the dangers of ignoring the issue. film editing was conducted in cooperation between media 7, a volunteer hiv educator from medical ambassadors international, and maped. field-testing was conducted in 2009, and the film was released for facilitated public viewing in the maasai community in 2010. the target level of the intervention was the sub-village level, where general decision-making is done and social and behavioral norms are established. a participatory, adult-learning approach was chosen in conducting the intervention. the approach relied on the intervention’s problem-posing nature and on discussions guided by trained volunteer maasai facilitators from maped following public viewings of “the fire is coming” video to achieve the intervention goals of changing hiv knowledge, attitudes, and behaviors in each village. evaluation in 2011, after one year of active implementation by maped in the local maasai community, an evaluation was scheduled as part of the assessment and quality improvement for the on-going program. the aim of the evaluation was to determine the effectiveness of the intervention in bringing contextualized hiv prevention education and awareness to the maasai people and to influence change in both attitudes and high-risk behaviors associated with hiv transmission. an additional aim of the evaluation was to determine whether the intervention influenced change in cultural and social norms in the intervention area. a baseline study had not been done prior to the beginning of the intervention; therefore, a twovillage comparison survey was designed to obtain hiv-related knowledge, attitudes, and behaviors among villagers whose community received the intervention and compare them to survey responses from villagers whose community did not receive the intervention. the evaluative nature of an on-going public health education intervention by a tanzanian registered non-government organization did not require approval by tanzania’s institutional review board. a knowledge, attitudes, practices (kap) survey instrument was developed for the evaluation using the following operational definitions as defined by tanzania commission for aids (tacaids). hiv-related knowledge: tacaids defines hiv-related knowledge as knowing that: using condoms and having just one uninfected, faithful partner can reduce the chance of getting hiv; a healthy looking person can have hiv; an infected mother can 37 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. transmit hiv during childbirth and breastfeeding. additional hiv-related knowledge included rejecting the two most common myths about hiv transmission: “people get hiv from mosquito bites” and “people can be infected with hiv by sharing food with someone sick with aids.”7, 12 hiv-related attitudes: we adapted questions from the tanzania hiv/aids indicator survey to measure three areas of attitude regarding hiv/aids. 1) accepting attitudes toward those living with hiv/aids, 2) attitudes toward negotiating safer-sexual relationships with husband/wife, and 3) attitudes of adults toward educating youth about condoms to prevent hiv.7 within our definition we also include attitudes toward self-efficacy in reducing hiv risk, vulnerability, or risk in contracting hiv and willingness to be tested for hiv infection. hiv-related behaviors: the concept of hiv risk behaviors includes all hiv-related behaviors that allow for hiv transmission. these practices include esoto (the ritualized sexual initiation of unwed girls), multiple and concurrent sexual partners of the same or opposite sex, the sharing of blades or sharp instruments that penetrate the skin, and other traditional customs such as sexual hospitality practices.12 the survey included both closed-ended, sociodemographic questions and open-ended questions modified from international and national kap studies to capture data relevant to maasai specific hivrelated knowledge, attitudes, and behaviors. survey questions also assessed hiv-related knowledge (i.e. condom use) that was not directly addressed in “the fire is coming” video intervention, allowing the evaluators to further ascertain the impact of the intervention. presumably, there would be little if any difference between the intervention and comparison villages on these items. in order to protect informants, no questions regarding personal sexual activity or sexual practices were included in the survey. survey questions were originally written in english, translated to kimaasai, and back-translated to ensure understandability and conceptual translation accuracy. pilot testing and revision of surveys was done prior to data collection to ensure inter-rater reliability and enhance consistency among data collectors. survey data was collected using semi-structured face-to-face individual interviews conducted in the maasai language by a trained, bilingual maasai data collector. prior to any data collection, maped sought and received permission to conduct the survey from village elders and leaders and sub-village leaders. data collectors received permission from both boma (home cluster) leaders and individuals prior to each interview. each interview took approximately one hour and occurred over a ten-day period from may 2 to 12, 2011. intervention and comparison village data were collected simultaneously by four maasai speaking, trained research assistants, none of whom had visited the villages prior to data-collection. sample a cluster sampling process was used for the evaluation. two maasai villages were selected using purposive sampling to control for location, village size, proximity to the city, and available health services. a distance of approximately 200km between otherwise homogeneous villages controlled for potential intervention crossover effect. within the villages, a convenience sample of 100 respondents each from sub-villages within the intervention and comparison area, respectively (n=200), were surveyed. (note: all figures represent the number of respondents who directly answered the respective survey questions.) demographically, there were 54 female and 45 male respondents documented in the intervention area compared with 52 females and 46 males in the comparison area. the age range of study respondents was 13-70 years-of-age, with an average age of 31 years in intervention area and 37 years in the control area. adolescents were included in the study based on documented cultural norms of very early sexual debut, especially for girls.1 in the intervention area, 73 respondents (11 comparison) reported attendance at an hiv prevention event in their community. christian religion was claimed by 98 respondents in the intervention area and by 80 respondents in the comparison area. 38 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. results hiv-related knowledge sixty respondents from the intervention area (34 comparison) were able to correctly identify two routes of hiv transmission, with sexual intercourse and sharing of blades being listed most frequently. in the intervention area, 48 respondents (63 comparison) correctly stated that hiv infection cannot be identified by a person’s appearance (figure 1). two respondents in the intervention area (23 comparison) were unable to identify any hiv transmission routes. knowledge regarding hiv prevention practices was as follows: abstinence and/or faithfulness to marital partners (77 intervention, 60 comparison), not sharing blades (52 intervention, 30 comparison), and condom use (19 intervention, 23 comparison). in the intervention area, 74 respondents (38 comparison) reported that women are tested for hiv during pregnancy; 34 respondents (21 comparison) said that hiv transmission from mother to infant can be prevented. two respondents in the intervention area (4 comparison) listed medication as a possible hiv-prevention strategy for mother to child hiv transmission, and 82 respondents (56 comparison) stated that traditional maasai medicine does not cure hiv. knowledge that maasai are not immune to hiv was high in both intervention (96) and comparison village areas (85). a two-tailed t-test was conducted to compare hiv-related knowledge between the intervention and comparison area respondents regarding condom use, faithfulness to partner, hivtransmission routes, perceived maasai immunity to hiv, cure by traditional maasai medicines, and maternal-child transmission. although on most survey items knowledge rates were higher in the intervention area, there was no significant hiv-related knowledge difference between intervention and comparison village areas, t(12)=1.85, p >0.05. fig. 1. hiv related knowledge (n=100) 39 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. hiv-related attitudes in the intervention area (figure 2), 81 respondents (71 comparison) stated they would care for an hiv infected person. willingness to be tested for hiv infection was indicated by 83 intervention area respondents (67 comparison); 84 intervention area respondents (25 comparison) stated that maasai can do something to reduce the risk of hiv. conversely, 54 respondents in the comparison area stated the belief that maasai are unable to reduce the risk of hiv. levels of concern about hiv in the community were “very concerned” (39 intervention; 81 comparison), “concerned” (52 intervention; 8 comparison), and “unconcerned” (8 comparison). few respondents agreed that women can refuse sex with their husbands (10 intervention, 10 comparison); however, 67 respondents in the intervention area (50 comparison) stated that women are able to refuse sex with others and can negotiate use of a condom with their husbands (33 intervention; 20 comparison) and with others (53 intervention; 34 comparison). in the intervention area, 69 respondents (48 comparison) reported that married men are able to limit their sexual activity exclusively to their wives. in the intervention area, 70 respondents (38 comparison) stated that unwed girls can refuse to have sex or participate in esoto. in the intervention area, 37 respondents (39 comparison) stated that unwed girls can buy and use condoms. a two-tailed ttest analysis was conducted to compare the intervention and comparison area respondents’ hiv-related attitudes regarding willingness to care for an hiv infected person, willingness to be tested for hiv infection, self-efficacy toward hiv-prevention, married women’s ability to use condoms, unmarried girls’ ability to refuse high-risk sexual behaviors, married men’s ability to use condoms, and married men’s ability to limit sex to their spouses. there was a significant effect for hiv-related attitudes t(10) = 2.89, p <0.05. hiv-related behaviors esoto, the ritualized sexual initiation of unwed girls, was reported stopped by 85 respondents (figure 3) in the intervention area (41 comparison). a family decision to decrease the risk of hiv was reported by 59 intervention area respondents (12 comparison). participants reported they stopped sharing blades (30 intervention; 9 comparison), changed sexual behaviors (60 intervention; 26 comparison), and changed high-risk traditional customs (87 intervention; 47 comparison). a two-tailed t-test analysis was conducted to compare the intervention and comparison area respondents reported behaviors regarding family decisions made, esoto stopped, sexual behaviors changed, blade-sharing stopped, and other traditional custom changes. there was a significant effect for hiv-related behavior changes, t(8) = 2.89, p< 0.05. 40 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. fig.2. hiv-related attitudes (n=100) fig. 3. hiv-related behaviors (n=100) 41 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. discussion the most significant attitude difference between the intervention and comparison villages was that of collective self-efficacy, or the belief that they as maasai people are able to reduce the risk of hiv in their community. self-efficacy has been found by researchers to be one of the key factors involved in behavior change. those who believe that nothing can be done are likely to do nothing, while those who believe they are able to do something are significantly more likely to take preventive action. self-efficacy, or collective self-efficacy in this case, when combined with risk perception translates into behavior change in ways that knowledge alone does not.13 maddux14 reported data consistent with our findings, that low self-efficacy has been associated with higher levels of anxiety. the high number of comparison area respondents who reported being “very concerned” about hiv is matched with a low number of comparison area respondents who believed that something could be done about hiv. in the comparison area, respondents may have had a perceived helplessness regarding hiv and, therefore, reported the highest levels of concern. conversely, respondents in the intervention area demonstrated high levels of self-efficacy regarding their ability to reduce the risk of hiv and positive action taken by their community; thus, they reported being “concerned,” but not “very concerned.” in our attempts to collect and analyze the data, we have applied national standards of comprehensive hiv knowledge, attitudes, and behaviors. however, we must consider the cultural context in which the intervention took place and the very nature of participatory community based research and development. the hallmark of community-based participatory interventions is a process wherein awareness of an issue is raised in the community; the community then discusses the issue and arrives at culturally appropriate and, therefore, contextualized solutions to the problem. among the maasai communities in this study, a great number of families live in polygynous relationships; early and extramarital sexuality has been sanctioned by the society; and a high birth rate is desirable. solutions that have come from within the maasai community focus on the reduction and elimination of extramarital sexual partnerships, elimination of blade sharing practices, and mutual encouragement for hiv testing. in response to the evaluation results, maped continues to work toward their goals of hiv prevention with a focus on increasing hiv-related knowledge and strengthening the positive outcomes in hiv-related attitudes and behaviors among maasai communities. it is within the context of these community developed solutions that maasai can be successful in changing both attitudes and behaviors that lead to the reduced risk of hiv in the community. study limitations although the results of the program evaluation are indicative of a highly effective intervention, we recognize there are limitations to this evaluation study. selection of a pre-experimental design does not allow us to unequivocally establish a causal relationship between the independent (hiv intervention) and the dependent (hiv-related knowledge, attitude, and practices) variables.15 after controlling for demographics, access to health facilities, distance (to limit cross-contamination), and other variables, we show that there are notable, statistically significant differences between the intervention and comparison maasai groups. one possible confounding variable may be present in the selection of communities that were either selected by the program implementers (comparison area) or self-selected (intervention area was in the community where the request originated for an hiv prevention intervention). either of these two methods of selection may indicate greater interest or awareness of hiv among the intervention communities and, thus, potentially a greater willingness to change hiv-related behaviors prior to the intervention. lastly, the highly sensitive nature of the study questions may have inhibited some of the respondents from answering survey questions, thereby limiting or skewing the data and analysis. although some 42 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. evidence of behavioral changes can be observed, many reported hiv-related sexual and traditional behavior changes are impossible to validate and, therefore, may not be a true representation of actual behaviors. our findings are limited to the study area, and are not directly generalizable to other maasai or indigenous groups, however the results of the survey denote a highly effective contextualized intervention. it is promising for replication among other maasai communities and for adaptation with indigenous people groups in other regions. references 1. coast e. wasting semen: context and condom use among the maasai. cult health sex. 2007;9(4);387401. http://dx/doi.org/10.1080/13691050701208474 2. mbugua t. the maasai: preserving culture and protecting girls. global aidslink. 2007 jan/feb; 101:12-3. 3. coast e. maasai demography [ph.d. thesis]. university of london; 2001. 4. coast e. (ereto-npp). hiv/aids in ngorongoro district. report. [internet] itad, lion house, ditchling common industrial estate hassocks (england); 2002 oct 7. accessed from: http://www.eretonpp.org/download_documents/coast_2002_hivaids_in_ngorongoro_district.pdf 5. may a, ole ikayo f. wearing illkarash: narratives of image, identity and change among maasai labour migrants in tanzania. dev change. 2007; 275-98. 6. coast e. local understandings of, and responses to, hiv: rural-urban migrants in tanzania. [internet] soc sci med. 2007; 63(4):1000-10. available from http://eprints.lse.ac.uk/archive/0000817. http://dx.doi.org/10.1016/j.socscimed.2006.03.009 7. tanzania commission for aids (tacaids). tanzania hiv/aids and malaria indicator survey. dar es salaam, tanzania: national bureau of statistics (nbs). 2008. 8. united nations. permanent forum on indigenous issues (fifth session), special theme: the millennium development goals, and indigenous peoples—redefining the goals 9. peter cm. human rights of indigenous minorities in tanzania and the courts of law. int j minor group rights. 2007; 14:455-87. http://dx.doi.org/10.1163/138548707x247428 10. kulzer jl. socio-cultural norms and acceptability of hiv/aids prevention strategies in the simanjiro district of tanzania. j public and int affairs-princeton. 2002; 13:82-103. available at: http://www.princeton.edu/jpia/past-issues1/2002/5.pdf 11. may a. maasai migrations: implications for hiv/aids and social change in tanzania. boulder (co): institute of behavioral science; 2003, jan 23. available from: http://www.colorado.edu/ibs/pubs/pac/pac20030001.pdf 12. united nations. indicators for monitoring the millennium development goals: definitions, rationale, concepts, and sources. new york (ny): united nations publication; 2003. available from: http://mdgs.un.org/unsd/mdg/resources/attach/indicators/handbookenglish.pdf 13. the united republic of tanzania’s prime minister’s office. national multisectoral hiv prevention strategy 2009-2012: ‘towards achieving tanzania without hiv’. november 2009. available from: http://aidstar-one.com/sites/default/files/prevention/resources/national_strategic_plans/tanzania_2009-2012_prevention_strategy.pdf 14. maddux j. self-efficacy: the power of believing you can. in: snyder cr, lopez sj, editors. handbook of positive psychology. new york (ny): oxford university press; 2002. p. 277-87. 15. depoy e, gitlin ln. introduction to research. in: understanding and applying multiple strategies, 3rd ed. st louis, mo: elsevier mosby; 2005. p. 241-52. http://dx/doi.org/10.1080/13691050701208474 http://www.ereto-npp.org/download_documents/ http://www.ereto-npp.org/download_documents/ http://www.ereto-npp.org/download_documents/coast_2002_hivaids_in_ngorongoro_district.pdf http://www.ereto-npp.org/download_documents/coast_2002_hivaids_in_ngorongoro_district.pdf http://eprints.lse.ac.uk/archive/0000817 http://dx.doi.org/10.1016/j.socscimed.2006.03.009 http://dx.doi.org/10.1163/138548707x247428 http://www.princeton.edu/jpia/past-issues-1/2002/5.pdf http://www.princeton.edu/jpia/past-issues-1/2002/5.pdf http://www.colorado.edu/ibs/pubs/pac/pac2003-0001.pdf http://www.colorado.edu/ibs/pubs/pac/pac2003-0001.pdf http://mdgs.un.org/unsd/ http://mdgs.un.org/unsd/ http://mdgs.un.org/unsd/mdg/resources/attach/indicators/handbookenglish.pdf http://aidstar-one.com/sites/default/files/prevention/resources/national_strategic_plans/tanzania_2009-2012_prevention_strategy.pdf http://aidstar-one.com/sites/default/files/prevention/resources/national_strategic_plans/tanzania_2009-2012_prevention_strategy.pdf http://aidstar-one.com/sites/default/files/prevention/resources/national_strategic_plans/tanzania_2009-2012_prevention_strategy.pdf 43 freitas and nayak june 2014. christian journal for global health 2014, 1(1): 34-43. this article was peer reviewed. competing interests: none declared. correspondence: holly freitas, united republic of tanzania. holly.freitas@efca.org cite this article as: cite this article as: freitas h, nayak, ma. the fire is coming: an hiv-prevention intervention contextualized to the maasai people of tanzania. christian journal for global health 2014, 1(1): 34-43. © author freitas and nayak. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:holly.freitas@efca.org http://creativecommons.org/licenses/by/4.0/ commentary may 2016. christian journal for global health, 3(1): 77-85. love in a time of ebola: reflections on theology of medicine in resource-challenged environments andrew sloane a a mbbs, bth, dipmin, thd, senior lecturer in old testament and christian thought, director of post graduate studies; morling college, australia (australian college of theology and university of divinity) abstract this paper presents a much needed (philosophical and) theological framework for the practice of christian medicine in resource-challenged environments. while “health and healing” are often seen as determining the nature and goals of medicine, i believe that this distorts our understanding and practice of medicine. rather, medicine is about care: it is an expression of a community’s solidarity with people whose inherent vulnerability and finitude is exposed by the physical or psychological disruptions occasioned by disease, disability, or disaster; it aims to so care for them that their inherent worth as members of the human community is affirmed and that they are able to function well in community, where possible, and to the best of our ability in the circumstances in which we find ourselves. this both requires costly service in contexts of scarcity and informs the kind of care that ought to be provided to those in need. introduction i live in australia and, like most “western” countries, our media is somewhat fixated on medicine and health.  we hear of wonderful new advances in cancer treatment; of photogenic children’s lives at risk because they don’t have access to it; of some new multi-resistant superbug that threatens western civilisation, and so on and so forth. fixated, but also self-absorbed. for these stories are about us, about the possibilities and problems of medicine in our affluent environment. but for a brief period in 2013/4, these issues were pushed off the front page by a health crisis in west africa: ebola. for a little  a fuller treatment of this topic and related issues can be found in my vulnerability and care. while, even australians felt they might be susceptible to a plague such as had not been seen since the eradication of smallpox. the time of ebola is, thankfully, mostly over. while 28,571 people have been infected with the virus since the outbreak began, and, tragically, 11,299 have succumbed, there have been few new cases in recent weeks. 1 the crisis has passed for now and is off our front pages. but, the realities remain. despite its sprawling illdiscipline, a novel like marquez's love in the time of cholera reminds us in the west how much endemic disease is a fact of human existence and of the ways it shapes people's lives, 2 the desperate decisions it makes necessary, and the tragedies it renders unavoidable. these realities warrant careful reflection, for ebola, or 78 sloane may 2016. christian journal for global health, 3(1): 77-85. its like, will return. and, as a christian, such reflection, i believe, necessarily takes theological form. reflection on medicine and medical practice tends to ignore underlying questions of the nature and goals of medicine; however, a christian response to medical care in resource-challenged environments ought to reflect those fundamental christian commitments that inform the practice of medicine, even as those contexts challenge us to develop an appropriate theological framework that might inform practice. this paper uses issues facing medicine in a global context as an entry point for philosophical and theological reflection on the nature and goals of medicine. i will begin with two case studies drawn from the recent ebola crisis in west africa before discussing some recent contributions to theology of medicine. having noted gaps and weaknesses in those contributions, i will move on to outline a philosophical-theological account of medicine focusing on its nature and goals. i will close by returning to the practice of medicine in resourceconstrained conditions, aiming to suggest forms that christian love might take in a time of ebola. a time of ebola let me begin with two contrasting “case studies.” kent brantly is an american doctor who worked with samaritan’s purse in west africa during the ebola epidemic. dr brantly joined the agency shortly after graduating from indiana university and was deployed to liberia to engage in medical care and relief in october 2013 prior to the outbreak of ebola in west africa. when the disease spread to liberia in june 2014, he stayed in the country and, along with another doctor, was engaged in the care of people with the virus. although he took appropriate precautions, he contracted the disease in july 2014 and was treated in monrovia before being evacuated to the us on 2 august 2014. after receiving sophisticated medical care at emory university hospital, much of it unavailable in monrovia (including the controversial and experimental drug zmapp), he made a full recovery and was discharged on 21 august 2014. 3 brantly’s is a good news story; the second case presents a tragic contrast. sheik umar khan was a sierra leonean doctor who worked with the ministry of health in sierra leone during the ebola epidemic. dr kahn completed his training in medicine in 2001 at the university of sierra leone in freetown. he practiced in infectious diseases in west africa, focusing on haemorrhagic fevers such as lassa fever. when the ebola epidemic struck, he played a major role in response through government and other agencies such as who and msf. despite known risks and limited resources, he continued to care for patients and implement public health measures. although he, too, took appropriate precautions, he tested positive to the disease on 22 july 2014. in response to treatment, his condition initially improved, but despite hopes for a full recovery he rapidly deteriorated and died on 29 july at the ebola treatment centre in kailahun. 4 so, what can we learn from these cases about medicine in resource-constrained environments? i want to leave aside questions relating to whether zmapp should have been used in the treatment of dr khan (or dr brantly) and focus on the circumstances of their treatment. for their different treatment reflects the disparities in medical services and treatment resources available to patients in the western and “majority” worlds. khan was treated at the ebola treatment centre in kailahun, a field hospital in sierra leone; brantly was treated at emory university hospital, a tertiary teaching hospital in the us. the disparities are clear: emory’s sophisticated diagnostic and therapeutic resources are simply unavailable, in fact almost unimaginable, in kailahun. indeed, the kind of care available to patients in a tertiary level icu cannot be accessed in most parts of the “developing” world. this does not mean that no care is available or that the care available makes no difference — far from it — but the disparities are clear. however, other questions are raised by these cases. for we often think of medicine as being about fighting disease and forestalling death; we believe that is its nature and its goal. if that’s the 79 sloane may 2016. christian journal for global health, 3(1): 77-85. case, then we must conclude that those who treated brantly succeeded, while those who treated khan failed. that can’t be right. indeed, that would imply that in the 40% of cases where patients die (and so, necessarily, medical care lost the fight against disease; it did not forestall death), the extraordinary efforts made in caring for patients with ebola by brantly and khan and countless others ought to be considered failures of medical care. surely not – tragedies, yes; failures, no. moreover, if we think of medicine as being about improving people’s health or that of their communities, then neither case can be viewed as a success. this is clear enough in khan’s case; he died, after all. but equally, brantly’s recovery came at a cost in time, materiel, etc., that cannot be reasonably borne by all who face serious tropical disease. indeed, the very focus on acute care, be it in kailahun or emory, distracts us from the fact that such care makes no significant impact on containing the spread of the disease, let alone the serious underlying health concerns of a region like west africa. deploying a similar amount of resources in the provision of, say, public health, sanitation, clean water, infrastructure, and even policing, would have a much greater impact on the health of these communities than if they were used in acute medical care. 5 providing safe water and sanitation alone would reduce around 9% of the global burden of disease. 6 if medicine is about improving health, then once again, it does not seem to do its job terribly well. please don’t get me wrong. i am not saying that the care provided to brantly and khan was inappropriate — nor was the care provided by them (or that it did not benefit many of the people they treated). nor am i making the (wildly implausible) claim that health and related concerns are not medicine’s concern. my point is that their cases raise important questions about the nature and goals of medicine that are not adequately addressed by defining medicine’s nature and goals in terms of health. we are, i would suggest, using the wrong categories and asking the wrong questions, and so finding the wrong answers. thinking about health if a crisis like ebola raises questions about the nature and goals of medicine, so does the very different context of the west, with its increasing commodification of health care as a consumer product and the loss of notions of the inherent morality of medicine as a profession. 7,8 most attempts to answer these questions also use “health” and “healing” as their primary categories. this means it is important to squarely address that approach in order to draw on the riches of those discussions and question their adequacy as an account of medicine. so, let me turn to the recent work of neil messer. 9 messer seeks to provide a foundation for bioethics and the ethics of medicine by drawing on recent philosophy of medicine and disability theory, interpreting it in light of the theological resources of the christian tradition. he shows that “health,” “disease,” and “illness” are both valueladen and logically fuzzy concepts and proposes “flourishing” as the key to a properly christian view of health. flourishing, he argues, is both distinct from health and related to it. drawing on barth’s view that health is “strength for human life,” he notes that social, political and economic systems all impact on human flourishing. he also insightfully argues that suffering, limitation, and even death are inescapable features of the human condition and so must be included in any theory of health. drawing on aquinas’ view that transcendent ends must be included in our theology of human creaturely existence, he brings those ends to bear on his own understanding of flourishing and health. messer argues that, theologically, bodily integrity is a good of human life and a contributor to its flourishing, but it is neither our ultimate good nor necessary for human flourishing. our ultimate good is found in salvation in christ and the eschatological fulfilment of human existence, and so health may be trumped by other concerns. furthermore, we can find forms of flourishing in the midst of disability and infirmity, and even when facing death. illness, suffering, and death are (relative) 80 sloane may 2016. christian journal for global health, 3(1): 77-85. evils; but they also reveal the vulnerability, finitude, and dependence that inhere in human bodily existence. 10,11 messer has contributed significantly to our understanding of medicine. nonetheless, in light of the concerns i raised earlier, i believe he is mistaken to see health as the key to our understanding of medicine. we need an alternative theology of medicine that neither ignores questions of health and the alleviation of suffering nor is bound by them. i have presented such accounts elsewhere. 12,13 let me briefly rehearse the main lines of the argument before i return to the question of what christian love might look like in a time of ebola. a theology of medicine medicine is primarily an expression of care for vulnerable human beings whose finitude and frailty have been exposed by physical or psychological ailment and whose ability to function in meaningful relationships have been compromised. its goal is to care for such vulnerable people so as to demonstrate our solidarity with them as suffering persons and seek to enable them to return to a reasonable level of functioning in relationships.  theologically, medicine is an appropriate expression of a well  a word of clarification is in order. the forms of human vulnerability that medicine addresses are, broadly speaking, “health-related.” it may seem, then, that health and healing ought to be seen as one of the goals of medicine. this, i think, is a mistake, for a number of reasons. first, as outlined earlier, there are many good instances of medical care that do not contribute to a person’s health and healing (or the health of their community). second, health is notoriously difficult to describe, let alone define, making it unsuitable as a yardstick for measuring the effectiveness of medical care. third, treating it as the goal of medicine (or one of them) makes it the noun rather than the adjective in our descriptions and understandings of medicine. as an adjective it works very well: it describes the primary concern of medicine (care for vulnerable human beings), qualifying the kinds of care that might or might not be in medicine’s purview. as a noun, it works poorly, as it distorts our understanding of medical practice and misdirects its aims. formed community’s care for vulnerable members of the community, a reflection of the character of god and an anticipation of the final transformation of all things to which god is drawing us and all things. such a view emerges, i believe, from the shape of the biblical story. a biblical-theological rationale creation grounds our quest for knowledge and skill in the orderly character of god and the world and establishes limits on the kind of technical mastery we should seek: we are finite creatures and always will be; there is no faithful escape from the exigencies of creatureliness. the brokenness of the world as it now is limits our capacity to know truly and to care faithfully, for we are as broken as the world we seek to understand. yet it necessitates our attempt to understand the world and shapes our efforts to change it; for the god who both made and judges the world also seeks to redeem and transform us and calls human creatures to be agents of god’s work of fixing a broken world. in jesus’ life, ministry (including his healing miracles), death, and resurrection, we see both the clearest expression of that transforming work and the anticipation of its final state. in him, we also hear the call to be transformed and mobilised in god’s great free-making mission, as, enabled by the spirit, we work to see glimpses of our final destiny and his perfect future in our fleeting and flawed projects. such a theological perspective requires that we understand the limits of our endeavours: any change we make to the world or needy people in it will be partial and temporary at best; we are still subject to death, and the world will only be made new by the sovereign work of god, not the labour of our hands. we build signposts to that final transformation, and occasionally plant oases on the road towards it: the garden-city for which we long and to which we seek to witness by word and deed will be the gift of god. 14 81 sloane may 2016. christian journal for global health, 3(1): 77-85. a christian view of medicine and its practice physical and psychological illness, injury, or disability are problems because they adversely affect people and interfere with their ability to function in relationships, exposing their vulnerability and diminishing their flourishing. patients are in a position of relative weakness, requiring the doctor’s knowledge and skill in caring for their frail flesh. 15 this power differential generates a moral call: for christians, power and privilege generate a corresponding responsibility to serve (matt 20:25–28). medicine exists in and for a given community and aims to care for people in their weakness and vulnerability, deal with the disruption caused by disease processes, injury, or deformity, and return people to proper functioning in their relationships and as persons, as far as this is practicable. this both justifies the existence of medicine and establishes its goal. while fighting disease and improving a community’s health are important, they are means rather than the ends of medicine. medicine is a matter of health care, not of health care. medicine’s goal is to provide care for this frail flesh and, where this is possible and as far as this is practicable, to remove impediments to human flourishing, restoring people to proper personal and relational functioning. it is a primary expression of a community’s commitment in solidarity to our vulnerable fellow humans, rather than abandoning them in their frailty. 11,16 macintyre’s notion of “social practice” contributes to our understanding of medicine. 17,18 as a social practice, medicine has a set of institutional frameworks that foster the qualities and behaviours that count as good medical practice, aiming at achieving the goods that are internal to medicine as a profession, which arise out of the ends proper to it. as noted earlier, medicine’s goal is not “health,” but to care for vulnerable people in such a way that a doctor’s expertise meets a patient’s need. these needs are the result of physical or psychological disruptions to their ability to function well as persons in community. the aim of the doctor’s care is the patient’s restoration to a reasonable level of relational functioning, or when this is not possible, to enable them to cope as well as they can with their ailment. this is medicine’s goal: the expression of appropriate care for vulnerable people. the nature of medicine reflects this. it is an expression of a community’s solidarity with and care for its members whose inherent frailty has been exposed by physical or psychological disruption. such a perspective both articulates and enhances the moral character of medicine and enables us to resist the “technological imperatives” that can overwhelm personal concerns for the sake of technical possibilities. 7,8,19 it also raises questions concerning what kind of medical care is appropriate in what circumstances and what justifies those decisions. some implications this vision of medicine has clear implications for its practice, both in the resourcerich individualistic consumerist west and the resource-constrained contexts in which the ebola epidemic raged. medicine not only expresses a particular vision of community, it also exists as a concrete expression of actual communities’ care for their vulnerable members. a christian vision of human community suggests that every society has the obligation to provide goods and services that enable its members to function well in it: to flourish, 9 to enjoy a measure of shalom 20 . medicine is one such service and is enabled by a given society’s commitment to meet the health needs of its members. indeed, the very existence of medicine, the training and ancillary services that doctors need to care for their patients, is funded by those communities. the range of health-care options available in the west outstrips the resources available even in those affluent societies, let alone those available in the “developing” world. this means it’s important to consider the range of services that a society can be rightly expected to provide for its members. this brings us to the notion of sustenance rights. sustenance rights are those goods and services that a society must provide its members 82 sloane may 2016. christian journal for global health, 3(1): 77-85. if they are to function as persons and in relationships. people are entitled to such basics as food, water, housing, education, and basic health care, for without these basics, people are unable to function meaningfully in relationships or pursue the goals of human existence — let alone enjoy shalom. 20 a society may determine that it should provide more than these sustenance rights; but, it cannot rightly do less. health care sustenance rights, i would suggest, include community health resources and the services that are associated with a good general practice. a number of factors suggest this. first, medicine is an expression of a community’s refusal to abandon its vulnerable members to their plight, but rather to stand alongside them in solidarity and care. second, the clinical encounter between doctors with their knowledge and skill and patients in their need and vulnerability is at the heart of medical practice. good gp services embody a community’s solidarity with the vulnerable and provide care that might enable the relational dysfunctions occasioned by a patient’s illness or infirmity to be overcome. what that general practice looks like will vary. social and economic circumstances, other demands on a community’s resources, and so on, will directly impinge on what can rightly be counted as a health care sustenance right. a gp in suburban australia will be able to refer his or her patient for sophisticated investigations in the immediate vicinity; in rural australia, such services may be at the end of a four-hour drive. a rural health worker in nepal or angola is unlikely to have access to any investigations due to distance, time, cost, and even availability. a more basic level of medical treatment is appropriate. nonetheless, all people are entitled to such services. we ought to be scandalised that even where a government notionally provides, say, rural health clinics, they are often under-resourced and/or under-, incompetently-, or even un-staffed. a christian understanding of medicine sees this as intolerable. even so, it is important to recognise that there are many good and useful things that a community may provide for its members that go beyond sustenance rights. the kinds of services available in a tertiary level icu require a degree of social infrastructure and capital investment that cannot be provided outside a major metropolis, and so, ipso facto, cannot be universally accessible. while it is not wrong for a community to provide them, i find it hard to see how such sophisticated services can be counted as an entitlement. they may be justified for some people in some circumstances, but only if providing them gives a reasonable chance of returning someone to a reasonable level of functioning in community and does not interfere with the provision of other sustenance rights. but that’s another large question. 21 nonetheless, the level of basic care that counts as a sustenance right in a given community must be provided to all its members. this brings us back to the resource-constrained context with which i began. what does love look like in a time of ebola? conclusion: (christian) love in a time of ebola it seems to me that no christian could rightly argue against providing basic medical services wherever people might live, be it new york or free town, no matter the circumstances. our understanding of god and god’s purposes, our theology of human community, require it. but healthcare is both complex and costly and is only one of a number of sustenance rights a community must provide. and so, if we are concerned about the provision of medical sustenance rights, we need to be equally concerned about the provision of the others. this also makes practical sense: for only in a stable society and a functional economy can resources be deployed to train doctors and sustain medical systems; only there will conditions exist in which patients can access — and trust — the services provided. even those primarily concerned for medicine must care more broadly about the state of the societies and economies in which it’s practiced. this is only reinforced when we remember that our concern for adequate medical services arises out of a concern for shalom, and 83 sloane may 2016. christian journal for global health, 3(1): 77-85. that even a narrow focus on health requires an awareness of its social determinants. our vision of medicine, then, must encompass larger questions of justice within and between nations and economies, and acknowledge the bitterly ironic fact that, despite the scattered generosity of western nations, the net flow of money and expertise (including trained doctors and nurses) is from the majority world to the west. 22,23 once again, medicine is not quarantined from bigger questions of justice and our responsibilities in a globalised world: any legitimate reflection on christianity and medicine needs to come to grips with these broader question, and so, too, must our practice. let me return to our case-studies. while brantly’s was self-consciously an expression of christian love and khan’s was not (at least, not to my knowledge), both men’s commitment to the care of people with ebola was not only justified from a christian perspective, it was mandated, as was that of the women and men with whom they served. questions have been raised about whether it is right, let alone required, for doctors to take such risks, and whether people outside these resource-constrained environments have an obligation to act. 24 i fail to see how such risky action is other than an expression of love in a time of ebola, and one that the christian community is obliged to provide, as it has recognised throughout its history. 25 a christian vision of community requires that everyone is free to flourish: anything less falls far short of the shalom that is god’s creational and redemptive purpose for human community. this is not bound by national borders, as if the country on our passport marks the boundaries of our care. flourishing is god’s intention for all human beings, for every human community. we are all diminished whenever we accept less than this for any of god’s children. and so, while not all of us are called into medical mission, or the aid and development work with which it must be associated, some of us are. this is a representative, missional response to god’s call on our communities. this has implications for all of us: we who do not go have responsibilities to those who do. they are our representatives, signs to the world that god and god’s people actually care about the love and fidelity and justice that we say are our ideals. and so when those who care fall prey to the conditions they seek to address, then we must care for them as if they were our own, as, in fact, they are. the seemingly extravagant cost of medical evacuation to tertiary hospitals gives them access to the services we enjoy and which they would otherwise have had. the treatment brantly received was justified. so too, was the care khan received, given his different circumstances. more to the point, so was the kind of care that they both sought to express in difficult and dangerous conditions of constraint. so, while a willingness to risk life and wellbeing in caring for others is controversial and has been rejected by people from galen to contemporary bioethicists, it has typified christian care for the sick from the earliest times. furthermore, it expresses something important about medicine and the cultural imagination that makes an enterprise like modern medicine possible. whether or not it delivers desired health care outcomes, this is what love looks like in a time of ebola. references 1. who. ebola situation report, 2015 november 4: who; 2015. 2. marquez gg. love in the time of cholera. new york: alfred a. knopf; 1988. 3. a miraculous day. [internet]. 2014 [cited 6 nov 2015]. available from: http://www.samaritanspurse.org/article/samaritanspurse-doctor-recovered-from-ebola/ 4. profile: leading ebola doctor sheik umar khan. [internet]. 2014. [cited 6 nov 2015]. available from: http://www.bbc.com/news/world-africa-28560507 5. baum f. the new public health. 3rd ed. south melbourne: oxford university press; 2008. http://www.samaritanspurse.org/article/samaritans-purse-doctor-recovered-from-ebola/ http://www.samaritanspurse.org/article/samaritans-purse-doctor-recovered-from-ebola/ http://www.bbc.com/news/world-africa-28560507 84 sloane may 2016. christian journal for global health, 3(1): 77-85. 6. cdc. global wash fast facts.[internet]. 2014 [cited 6 nov 2015]. available from: http://www.cdc.gov/healthywater/global/wash_statistic s.html 7. mckenny gp. to relieve the human condition: bioethics, technology, and the body. albany: university of new york press; 1997. 8. shuman j, volck b. reclaiming the body: christians and the faithful use of modern medicine. grand rapids: brazos; 2006. 9. messer ng. flourishing: health, disease, and bioethics in theological perspective. grand rapids: eerdmans; 2013. 10. macintyre a. dependent rational animals: why human beings need the virtues. london: duckworth; 1999. 11. hauerwas s. suffering presence: theological reflections on medicine, the mentally handicapped, and the church. edinburgh: t&t clark; 1986. 12. sloane a. christianity and the transformation of medicine. in: crisp od, d’costa g, davies m, hampson p, editors. christianity and the disciplines: the transformation of the university. london: t&t clark; 2012:85-99. 13. sloane a. vulnerability and care: christian reflections on the philosophy of medicine. london: bloomsbury t&t clark; 2016. 14. wright t. surprised by hope. london: spck; 2007. 15. pellegrino ed, thomasma dc. helping and healing: religious commitment in health care. washington: georgetown university press; 1997. 16. hauerwas s. naming the silences: god, medicine, and the problem of duffering. grand rapids: eerdmans; 1990. 17. macintyre a. after virtue: a study in moral theory. 2nd ed. notre dame: university of notre dame press; 1984. 18. macintyre a. whose justice? which rationality? london: duckworth; 1987. 19. bishop jp. the anticipatory corpse: medicine, power and the care of the dying. notre dame, in: undp; 2011. 20. wolterstorff n. until justice and peace embrace. grand rapids: eerdmans; 1983. 21. sloane a. painful justice: an ethical perspective on the allocation of trauma services in australia. the aus and nz jf surg. 1998;68:760-3. 22. the state of finance for developing countries. [internet]. 2014. [cited 4 nov 2016] available from: http://eurodad.org/finance_for_developing_countries 23. crisp n, chen l. global supply of health professionals. new engl j med. 2014;370:950-7 http://www.nejm.org/doi/full/10.1056/nejmra111161 0 24. ebola: should doctors be forced to treat infected patients? [internet]. 2014. [cited 9 nov 2015] available fromp: http://www.theweek.co.uk/worldnews/ebola/60994/ebola-should-doctors-be-forced-totreat-infected-patients 25. stark r. the rise of christianity. new york: harpercollins; 1996. peer reviewed competing interests: none declared. correspondence: andrew sloane, morling college, australia. andrews@morling.edu.au http://www.cdc.gov/healthywater/global/wash_statistics.html http://www.cdc.gov/healthywater/global/wash_statistics.html http://eurodad.org/finance_for_developing_countries http://www.nejm.org/doi/full/10.1056/nejmra1111610 http://www.nejm.org/doi/full/10.1056/nejmra1111610 http://www.theweek.co.uk/world-news/ebola/60994/ebola-should-doctors-be-forced-to-treat-infected-patients http://www.theweek.co.uk/world-news/ebola/60994/ebola-should-doctors-be-forced-to-treat-infected-patients http://www.theweek.co.uk/world-news/ebola/60994/ebola-should-doctors-be-forced-to-treat-infected-patients mailto:andrews@morling.edu.au 85 sloane may 2016. christian journal for global health, 3(1): 77-85. cite this article as: sloane a. love in a time of ebola – reflections on theology of medicine in resourcechallenged environments. christian journal for global health (may 2016), 3(1):77-85. © sloane a this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ original article nov 2016. christian journal for global health, 3(2): 60-71. a qualitative study of provider perspectives on the barriers to contraceptive use in kaliro and iganga districts, eastern central uganda constance sibongile shumba a , jonathan miyonga b , judith kiconco c , patrick kerchan d , tonny tumwesigye e a research and grants manager, uganda protestant medical bureau, uganda b monitoring and evaluation specialist, uganda protestant medical bureau, uganda c family planning officer, uganda protestant medical bureau, uganda d head of programmes, uganda protestant medical bureau, uganda e executive director, uganda protestant medical bureau, uganda abstract background: family planning confers unique benefits including preventing unintended pregnancies, improving maternal and child health outcomes, and increasing women’s access to education and economic opportunities. however, uganda has a low contraceptive prevalence rate of only 30%, and progress in improving maternal and child health outcomes is slow. objective: this assessment explores community health workers’ and facility-based health workers’ qualitative perspectives on the use of contraceptives in the iganga and kaliro districts in eastern central uganda. methods: the baseline assessment used a qualitative approach with a focused sample of communityand facility-based health workers aged 20-60 years. two focus group discussions with community health workers and four key informant interviews with facility-based health workers were conducted. thematic content analysis was done manually. results: the main factors influencing contraceptive use in these communities were preference for large families, perceived inadequate knowledge of family planning and fear of side effects, inadequate spousal and family support, male domination and risk of violence, divorce and polygamy, inadequate human resource capacity and low motivation, and user fees. conclusion: the study findings suggest that there is low use of contraceptives for family planning in the kaliro and iganga districts in uganda. recommendations include developing a strong focus in exploring policy options to build the capacities of trained health workers to offer long-term methods in order to increase the availability of family planning options. family planning interventions should increase the availability of contraceptive methods using gender-sensitive strategies, including community mobilization. 61 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. introduction sub-saharan africa (ssa) has the least contraceptive use globally of only 29%. uganda has a low contraceptive prevalence rate of 30% and is among the countries with unmet need for family planning. 1-4 the vast benefits of family planning programs are not appreciated in some low income countries (lics) with huge implications for improved maternal and child health from birth spacing and reducing the total fertility rate, and for financial and human resource allocation decisions. as a result, it is necessary to expand family planning interventions and increase access in lics through accurate and affordable family planning information and methods. there is a great need for family planning interventions in lics, although they perform poorly due to limited funding and lack of enabling policy environments in most cases. 2 funding for family planning programs has declined significantly in the last two decades, in part due to the redirection of resources to the hiv epidemic which was a more pressing problem. 5 however, there has been renewed interest in family planning in the last two years through initiatives such as the family planning 2020 and increased emphasis on family planning as part of health service integration. family planning confers unique benefits including preventing unintended pregnancies, improved maternal and child health outcomes, and increased women’s access to education and economic opportunities. 6,7 the aim of this qualitative baseline assessment was to ascertain the use of family planning services; to understand the barriers to use, from the community and facility-based health workers’ perspective, among communities in the iganga and kaliro districts; and to tailor an intervention package to address these barriers. methods this baseline assessment used qualitative approaches with a targeted selection of community health workers (chws) and facility-based health workers aged 20-60 years. a total of four key informant interviews (kiis) with facility-based health workers and two focus group discussions (fgds) with chws in the iganga and kaliro districts in eastern central uganda were conducted. this followed the award of a pilot grant from the david and lucile packard foundation to develop and test a family planning intervention package in these districts. setting data, from a targeted sample, was collected from two pilot health centers in the kaliro and iganga districts in eastern central uganda in january 2014. the health facilities are faith-based, private-not-for-profit, and part of the uganda protestant medical bureau network comprising 278 member health facilities. more than 20% of these 278 health facilities are found in east central uganda. this region, in particular the busoga region, has one of the highest fertility rates (6.9%), which is above the national average of 6.2% for women. there is a high unmet need for family planning (42%), greater than the overall unmet need in the country (34%), among married women. 3 unmet need for family planning is defined as the proportion of productive women who are not using contraception, but who desire to postpone the next birth (spacing) or who wish to stop childbearing altogether (limiting), 21% and 14%, respectively. 3 unmet need is high in east central uganda, meaning that 42% of productive women desire to postpone birth or stop childbearing. it was therefore deemed a suitable pilot area to test a family planning intervention package. two health facilities out of the six assessed were chosen for family planning intervention as they had no existing support for family planning from other partners and showed potential to successfully implement a pilot 62 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. intervention package. the assessment of the health facilities aimed to identify capacity strengths and challenges in order to establish capacity building priorities. it focused on four key areas: family planning services provision, infrastructure, stores management, and staff capacities in family planning service provision. the two health facilities had a combined catchment area population of 14,000 within 24 villages, each village served by a community health worker. key informant interviews four individual key informant interviews (kiis) with two health workers from each of the two participating clinics were conducted to learn about family planning services and barriers to increasing contraceptive use within the catchment population of the selected health facilities. three nursing assistants and one clinical officer participated in the facility interviews. all interviewers had worked for a minimum of two years at the facilities. the health workers interviewed were conveniently sampled due to their availability during the assessment. we examined service availability, current use of family planning services, and provider perspectives. the key informant interviews were conducted in english as all the health workers were proficient in the language. interviews were tape recorded and additional notes taken on non-verbal cues. focus group discussions (fgd) two fgds were convened, with 20 chws from the catchment area of each health facility to gather qualitative data on their perspectives on community attitudes and barriers to use of family planning services. chws are volunteers and have varying levels of education and training, mostly below high school, and are required to be able to read and write. their main role is to carry out community health education, home visits, community sensitization, and also conduct community-based distribution of contraceptives and anti-malarial medicines. the ministry of health in uganda is currently reviewing their eligibility criteria, and it is anticipated that all chws will have completed the fourth year of high school at the minimum and will receive some remuneration to motivate them. purposive sampling was used to select participants, and explicit considerations were made to ensure that a good mix of men and women were included among the community health workers in each fgd. the participants for the fgds were 11 men and 9 women, aged 24 to 60 years. table 1 is a summary of the chws’ sociodemographic characteristics. table 1. community health workers’ socio-demographic characteristics characteristic n=20 % mean age (maximum) 48.8 (60) years mean number of children (maximum) 6 (10) children marital status married 19 95% single 1 5% sex male 11 55% female 9 45% 63 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. data analysis the discussions were conducted in lusoga, and the facilitators later translated and transcribed the discussions from audio recordings of the sessions into english. transcripts from the key informant interviews and focus group discussions were read several times, guided by the research questions from the topic guide. the topic guide explored understanding of child spacing and the perceived advantages and disadvantages, decisionmaking on child spacing, methods used for child spacing in the community, perceived advantages and disadvantages, availability and accessibility of the methods, and community informational needs and strategies to improve use of family planning methods. themes were identified post hoc through thematic content analysis by one member of the research team. 8 codes were also developed manually, and direct quotes, notes, and observations and voices were used to illustrate the findings. ethical considerations the baseline assessment was conducted as part of a family planning program planning activity with the aim of informing program strategies and designing an appropriate intervention package. the assessment was approved by the mengo hospital research ethics committee (665/2-15) and uganda national council for science and technology (ss 3772). oral consent was obtained, both for participation and for making audio recordings of the focus group discussions. prior to data collection, each data collector underwent training in research ethics adapted from the family health international curriculum. all participants were given information on the purpose of the baseline assessment, and informed consent was sought from all of them. the participants were assured that the data would not be linked back to them, and all information would be kept confidential and used only for the purposes of designing appropriate family planning interventions for the community. no identifying characteristics of participants were recorded during data collection, and audio recordings of fgds were kept securely under lock and key after transcription. participants were given light refreshments during the interviews, and no payments were given for participating in the study. results findings of this qualitative assessment are presented according to the different themes identified during the data analysis. these main themes were: (i) perceived inadequate knowledge of family planning and fear of side effects; (ii) preference for large families; (iii) inadequate spousal and family support; (iv) male domination and risk of violence, divorce, and polygamy; (v) inadequate human resource capacity and low motivation and; (vi) user fees. table 2 shows the main themes. table 2: main themes main themes source group exemplar quotes perceived inadequate knowledge of family planning and fear of side effects both chws and facility-based health workers “people in the community are not really educated on family planning.” “people in the community believe that women can become infertile, get cancer and complications due to family planning methods.” preference for large families chws “people like large families because of the risk of remaining childless in the event of accident.” inadequate spousal and family support both chws and facility-based health workers “elderly people in the community want the young ones to have many children.” “most women are hindered by their husbands who stop them from taking up family planning methods because they want them to produce [give birth to] many children.” 64 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. male domination, risk of violence, divorce and polygamy both chws and facility-based health workers “the husbands do not want to hear about family planning because they want many children. very few men accept to hear about family planning. they say that when women go for family planning they do not get pregnant so they cheat on the husbands with other men but when they do not use contraceptives they do not cheat because they will be afraid to get pregnant with other men.” “men do not like family planning and women think their husbands will leave them for other women if they use contraceptives and the husband does not agree with it.” inadequate human resource capacity and low motivation both chws and facility-based health workers “we do not have a doctor to do tube ligations and iuds so we cannot offer these.” “permanent methods are not accessible because they are not available at the health facility and there are no health workers who can do them. they require a doctor to run the procedure but they are not available.” user fees both chws and facility-based health workers “the community has been paying 1000-1500 ugx [40-60 us cents] for contraceptives so this deterred them from accessing family planning.” “it is not easy, you have to pay to access the service and people don’t have the money.” use of current family planning services all health workers interviewed at the time of assessment reported that their health facilities offered family planning services: mainly progesterone only pills (pops), combined oral contraceptives (cocs), condoms (male only), and depot medroxyprogesterone acetate (dmpa) products. the most preferred method by clients was the male condom followed by dmpa products, pops, and cocs. the chws also attested to the availability of these methods in both facilities. one facility was already offering intra-uterine devices (iuds) and implants, while the other facility highlighted the need to provide these. both facilities were reported to have expressed the need to provide permanent methods (tubal ligations and vasectomies) due to some demand from the community: “we get clients who are interested only in iuds, tube ligation, and vasectomy but we do not offer these here so they cannot get the service.” female facility-based health worker in kii perceived inadequate knowledge of family planning and fear of side effects all the participants reported that there was inadequate community awareness about family planning services. the lack of awareness was attributed to lack of access to information, and this posed a barrier to use of family planning services and reflected the difficulties encountered by the healthcare workers in providing family planning and reproductive health. while it is the chws’ and facility-based health workers’ roles to conduct community education, in reality there are hindrances to doing this, including financial constraints to conduct community outreaches and lack of incentives to motivate chws who currently hold a volunteer status and are therefore not remunerated. “people in the community are not really educated on family planning.” chw in fgd and facility-based health workers in kii the providers also reported that myths and misconceptions were rife in the community leading to reticence in using family panning methods. these myths and misconceptions included the belief that family planning causes infertility and that the pops and cocs and oil from condoms accumulated in the body, resulting in cancer. in addition, there was a common concern that the use of contraceptives led to congenital abnormalities. “people in the community believe that women can become infertile, get cancer and complications due to family planning methods.” male facility-based health worker in kii 65 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. “people believe in the community that pills pile up in the body, and one can be taken for an operation and that oil on condoms causes cancer for women and girls, and they are not willing to use them, because when the oil remains inside, it can cause one to die.” female chw in fgd “when a child is born with birth abnormalities, people blame this on use of family planning.” female chw in fgd a majority of the participants in both the kiis and fgds reported that fear of side effects, such as excessive bleeding and reduced sexual drive, deterred contraceptive use, especially the dmpa product, pops, and cocs. both chws and facilitybased health workers pointed to the fact that the fear of excessive bleeding and reduced sexual drive that would potentially affect the community members’ sexual lives discouraged the use of contraceptives. “people in the community have been worried about the side effects of family planning methods. for example, some experience excessive bleeding when on injectaplan [dmpa product].” female facility-based health worker in kii “pills cause dizziness and loss of sexual appetite.” male chw in fgd chws reported that community members shunned permanent methods as they believed that vasectomy would reduce their sexual drive while women would experience backache as a result of tubal ligation. this would all prevent them from enjoying sex due to the decreased sexual drive and persistent backaches. “men believe that vasectomy reduces their sexual drive and they cannot enjoy sex as before and women with tube-ligation complain about backache.” male chw in fgd preference for large families the chws also reported a general preference for large families in the community. commonly cited reasons were that in case of negative life events such as death of children, people would still have children. those who have less would have none if calamity befell their children. “people like large families because of the risk of remaining childless in the event of accident.” male chw in fgd in addition, childbearing was seen as a race against the biological clock for women, who would reach menopause without getting the desired number of children if they opted to use family planning methods. “one can end up with less number of the desired of children by reaching menopause before getting the desired number.” female chw in fgd inadequate spousal and family support the health workers in the kiis cited lack of partner and family support as a barrier to family planning use. most men were reportedly against their wives’ use of contraceptives because they wanted many children and had fertility concerns if their wives used contraceptives. “most women are hindered by their husbands who stop them from taking up family planning methods because they want them to produce (give birth to) many children.” female facility-based health worker in kii “some husbands complain that when their wives come for family planning they become barren. for example, they say after two years when they want another child the women cannot get pregnant.” male facilitybased health worker in kii the chws also referred to the pressure from the older community members who believe in large numbers of children and promote this within the community. furthermore, in-laws were seen as desiring many children, and if this was not fulfilled, they put a lot of pressure on the men to marry other wives. the facility-based health workers in the kiis also confirmed that women were pressured to have many children because of the fear that their 66 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. husbands would be pressured by relatives to get other wives. “elderly people in the community want the young ones to have many children.” male chw in fgd “if you use family planning, there is pressure from in-laws asking your husband to marry another wife.” female chw in fgd male domination, risk of violence, divorce and polygamy the health workers in the kiis also reported that non-use of contraceptives is used as a tool by men to keep their wives under control and prevent them from cheating. this is due to the fact that the men believe that if women use contraceptives, they will have extra-marital partners. in contrast, if they do not use contraceptives, they will be forced to be faithful, as they will not want to conceive with their extra-marital partners. “the husbands do not want to hear about family planning because they want many children. very few men accept to hear about family planning. they say that when women go for family planning, they do not get pregnant so they cheat on the husbands with other men. however, when they do not use contraceptives they do not cheat because they will be afraid to get pregnant with other men.” female facility-based health worker in kii chws also reported that when women use contraceptives without their spouses’ permissions, there would be a risk of violence, and out of fear, many women would not attempt this. in addition, it was also perceived that in general, if a woman disobeys the husband and uses contraceptives against his will, this would lead to the husband taking on another wife. “when the decision on the choice of family planning methods is not taken as a couple there can be violence.” female chw in fgd “men do not like family planning, and women think their husbands will leave them for other women if they use contraceptives and the husband does not agree with it.” male chw in fgd. for some women, to avoid conflict and separation, they would reportedly use contraceptives discreetly without the husband’s knowledge, especially dmpa product. “women use injectaplan [dmpa product] method because men cannot find out that their wives are using it.” male chw in fgd inadequate human resource capacity and low motivation facility-based health workers in the kiis reported that health facilities lacked the qualified personnel to offer some of the family planning services such as iuds and permanent methods that require skilled staff to conduct them. the two facilities had constrained human resource capacity since the two facilities had mostly nursing assistants who did a short nursing certificate course of about 3-6 months. they mainly helped with bedside nursing such as wound dressing, bathing patients, preparing trolleys for procedures, and immunizations. they also offered health education and carried out patient observations. others, who had some training in family planning, also dispensed oral contraceptives, dmpa product, condoms, and referred clients. one facility had a clinical officer who could insert iuds, but could not offer permanent methods due to a policy that stated that this can only be done by doctors. clinical officers had a diploma in clinical and community medicine and headed lower level health facilities with the capacity to conduct deliveries, prescribe for basic ailments, and perform minor surgeries. they also provided all contraceptive methods except the permanent voluntary surgical methods. the chws in the fgds reiterated that the lack of qualified staff to offer permanent methods was hindering access in the community. 67 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. “we do not have a doctor to do tube ligations and iuds, so we cannot offer these.” female facility-based health worker in kii “permanent methods are not accessible because they are not available at the health facility, and there are no health workers who can do them. they require a doctor to run the procedure, but they are not available.” male chw in fgd user fees both chws and facility-based health workers cited user fees in the health facilities as a barrier to the use of family planning by the community. while considerably small amounts, these fees were not affordable for these rural communities. “the community has been paying 1000-1500 ugx [40-60 us cents] for contraceptives, so this deterred them from accessing family planning.” male health worker in kii “it is not easy. you have to pay to access the service and people don’t have the money.” male chw in fgd discussion the assessment reveals that, in general, the use of family planning in the target communities was very low. nonetheless, the most preferred contraceptive methods from the providers’ perspectives were short-term, mainly condoms, pops, cocs, and injectables, and this could possibly be due to the fact that these methods are readily available in the communities. similarly, a study conducted in urban kampala found that most of the participants preferred condoms as they have limited side-effects, are cheap and accessible, and prevent sexually transmitted infections. intrauterine devices (iuds) and injectables were also preferred, but their cost was reportedly prohibitive. 9 in our assessment, long term methods were also preferred by some community members, although inaccessible due to lack of health provider availability and capacity in offering these. the health workers attributed the observed demand for long term methods to another agency that had been conducting occasional outreaches in the communities but had withdrawn due to funding problems. low knowledge and the fear of side effects of family planning also hindered contraceptive use among community members. this is consistent with findings indicating that concerns about the safety of methods continue to dominate the discussion on family planning barriers. 10 in our assessment, contraceptives were blamed for loss of fertility and fears that these methods led to congenital abnormalities, reduced sexual desire, and caused back pain in women. individual and communitywide misconceptions about the side-effects and safety of contraceptives have also been cited by providers as barriers to improved family planning use, pointing to the need for investments in community education to dispel these misconceptions. 9,11 providers reported how women were frustrated by side effects due to family planning such as excessive bleeding leading to the discontinuation of the use of contraceptives. evidence from another study conducted in central uganda suggests that men are often reluctant to allow their wives to use contraceptives due to low knowledge, myths and misconceptions, preference for large families, and real or perceived side effects. 7 the myths and misconceptions reveal a general lack of family planning knowledge in the community and could be based on limited experiences and secondary information. health workers must have a heightened awareness of the cultural sensitivity and improve their capacity to understand and address myths and misconceptions of family planning in the community. the preference for large families was driven by the concept of fatalism and uncertainty about child survival. the health workers cited that many people in the communities believe that if calamity strikes, all the children may die, so it is necessary to have a large number to prepare for such 68 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. eventualities. in the literature explored, this was substantiated with evidence that having many children in the african society is a way of guarding against extinction of the family line; a desire to perpetuate the lineage results in large families. 13 additionally, in uganda, patrilineal tradition promotes preference for larger families. the chws and facility-based health workers also cited social and spousal disapproval as barriers to contraceptive use. these findings corroborate other studies that have shown a number of social and cultural barriers to family planning including the need for women to seek partner approval. 7,11 unmet need due to disapproval by partners, women, and significant others is high in ssa and women with low education, and residing in rural areas have high unmet need. rural women were reportedly afraid of their partners’ opposition to contraceptive use, and in such communities, contraceptive use decisions are taken by men because women usually have low education and economic status level. 6 women’s empowerment is strongly linked to the ability to make independent decisions including contraception use, but in patriarchal societies with a high degree of male dominance, contraception use decisions are often made by men. clandestine use was reported in our study by participants and similarly the gendered power dynamic resulted in clandestine contraceptive use in women in kenya and mali. 10,11,14 evidence suggests that in ssa, 6-20% of contraceptive use is done secretly by women due to unequal power relations with men. 5 male partner disapproval of family planning use has been proven to be a strong predictor of non-use of family planning methods. 11 it is within this context that male engagement in family planning interventions is increasingly recognized as important by providers. this has implications for gender-sensitive approaches to family planning programs that promote safe environments and equitable decision-making. other authors proposed that in contexts where women use contraceptives without their partner’s knowledge, there may be no yield in involving men in family planning programs in the short-term, and it might not also be appropriate to target couples as the units of intervention and analysis. 14 this might explain why the chws in our study fgds recommended targeting men and women separately. family planning programs focusing on women only have been shown to be ineffective, 7 and our findings suggest that women and men both need to be targeted but prefer to be targeted separately. it is therefore important to respect this and ensure that both men and women are given the necessary information without assuming that information will trickle to the men from women. engaging men in family planning is crucial, yet developing messages that appeal to them is challenging. other authors suggest that targeted messages which emphasize both economic and health benefits of family planning are more persuasive than those highlighting the health benefits only. 7,15,16 targeted community sensitization and education of men should underscore the benefits of family planning for the entire family. it is also important to understand the root causes as to why men object to their partners’ use of contraception in order to promote mutual decision-making between couples in regard to family planning. 14 our study findings indicate that chws and facility-based health workers believe that men disapprove of their partners’ use of family planning due to the fear that it promotes extra-marital affairs. this is consistent with findings in kenya and uganda suggesting that female use of contraceptives was perceived by men as promoting promiscuity. 7, 17 women’s use of contraceptives was viewed as a way to be unfaithful, avoid getting pregnant in extramarital relationships, and was often associated with commercial sex and, thus, not considered suitable for married women of good standing. fear of spousal retaliation through violence, separation, or polygamy prevents women from using contraceptives against their husbands’ wishes. similarly, most rural ethiopian women believed that if male partners oppose contraception, 69 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. the decision must be held in respect of their culture. 6 inadequate human resource capacity and availability were found to be barriers to family planning use in this assessment. the facilities did not have adequately qualified health workers who could offer long-term methods. mal-distribution of health workers has been cited as one of the health workforce challenges that impedes successful implementation of family planning programs. 2 it is important to put in place the appropriate human resource capacity to provide contraceptives. 5 for instance, in uganda, only doctors can provide permanent methods, and yet, they are not available to serve at lower level units, with the implication that affordable referral mechanisms need to be strengthened for the population to access services. the health service providers reported that cost of accessing contraceptives was a barrier for the rural communities, as the two health facilities charged a small user fee for family planning services. other authors have also reported that many women and men in low income countries still have an unmet need for contraception due to the prohibitive cost of such commodities and provider fees for health services. 4,10,12,18 it is necessary to remove user fees barriers to increase family planning service use and close the gap on the unmet need for contraception in resource constrained settings. low community mobilization efforts contributed to low contraceptive use in this assessment, yet the benefits of community mobilization in raising awareness on service availability are indisputable. 19 sustained community mobilization has potential to improve use of family planning methods and should aim at increasing access to those most in need whilst also addressing the underlying norms that impede progress. limitations the main limitation of the study is that the perspectives of women and men with unmet need for contraception were not examined, as the study focused on the perspectives of the facility-based healthcare providers and community health workers. however, we do not feel that this is likely to significantly impact the findings of this study as chws were chosen from among the community members. they have a deep knowledge and understanding of the health needs of their communities and, thus, hold a strong insider position. limited generalizability to other villages in uganda may also be a limitation as there are different cultural belief systems and capacities among healthcare facilities in other districts. conclusion the study findings suggest that there is need to reduce the barriers identified from the chws’ and facility-based health workers’ perspectives that hinder increased use of family planning services in the two districts. overall, our findings revealed that providers perceive that there is low use of family planning methods in the communities owing to social determinants and beliefs among men and women. there is need to increase community sensitization efforts to create demand. in the long term, it will be important to build the capacities of clinical officers to offer long-term methods in order to increase the availability of family planning options. based on the findings, it was proposed that the project intervene by offering family planning camps in the communities with qualified doctors hired for the specific periods to make these family planning options accessible. access to family planning could also be improved through removal of user fees that impede access to services within the faith-based health facilities. the faith-based health facilities obtain small grants from the government for primary health care and donations from well-wishers, but these are not sufficient to sustain the services they offer. therefore, they usually charge small user fees, although some very poor communities are not able to afford these fees. this often puts the health facilities in a difficult position as they rely on user fees to continue service provision. 70 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. the proposed project intervention was to provide family planning services without levying fees on clients and all family planning commodities were provided free of charge to the health facilities. the project proposed implementation of community and interpersonal education interventions to address underlying socio-cultural norms over time. this was done in recognition of the need for health service providers to promote gender-sensitive ways of engaging communities and addressing the underlying gender disparities that affected decisionmaking abilities of women with regard to family planning, including mutual discussions on family planning between spouses. this is a major cultural intervention which will ultimately take a great deal of time to achieve. the proposed intervention to reduce unmet need for family planning and improve maternal and child health outcomes was also to implement a package to strengthen capacity of religious leaders. this involved equipping them with knowledge on health timing and spacing of pregnancies and providing guidance on key messages they can incorporate in their sermons advocating for use of fp in their communities as well as providing counselling and referral support to community and facility-based health workers. references 1. population reference bureau. 2014 world population data sheet [internet]. available from: http://www.prb.org/pdf14/2014-world-population-datasheet_eng.pdf [cited 2016 june 5] 2. prata n. making family planning accessible in resource-poor settings. philos t roy soc b. 2009;364(1532):3093–9. http://doi.org/10.1098/rstb.2009.0172 3. uganda bureau of statistics (ubos) and icf international inc. uganda demographic and health survey 2011. kampala, uganda: ubos and calverton, maryland: icf international inc. 2012. 4. population reference bureau. unmet need for family planning [fact sheet]. 2012. available from: http://www.prb.org/publications/datasheets/2012/worldpopulation-data-sheet/fact-sheet-unmet-need.aspx [cited 2016 june 5] 5. bongaarts j, sinding sw. a response to critics of family planning programs. int perspec sex repro health. mar 2009;35(1). 6. bogale b, wondafrash m, tilahun t, girma e. married women’s decision making power on modern contraceptive use in urban and rural southern ethiopia. bmc public health. 2011;11(342). http:/dx.doi.org/10.1186/1471-2458-11-342 7. kabagenyi a, jennings l, reid a, nalwadda g, ntozi j, atuyambe l. barriers to involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women’s perceptions in two rural districts in uganda. reproductive health. 2014;11(21) http://dx.doi.org/10.1186/1742-4755-11-21. 8. braun v, clarke v. using thematic analysis in psychology. qual research psych. 2006;3(2):77-101. [issn1478-0887]. http://dx.doi.org/10.1191/147888706qp063oa available from: http://eprints.uwe.ac.uk/11735 [cited 2016 may 23]. 9. wanyenze rk, wagner gj, tumwesigye nm, nannyonga m, wabwire-mangen f, kamya mr. fertility and contraceptive decision-making and support for hiv-infected individuals: client and provider experiences and perceptions at two hiv clinics in uganda. bmc public health. 2013;13(98). http://dx.doi.org/10.1186/1471-2458-13-98 10. harrington ek, newman sj, onono m, schwartz kd, bukusi ae, cohen cr et al. fertility intentions and interest in integrated family planning services among women living with hiv in nyanza province, kenya: a qualitative study. infect dis obstet gynecol. 2012;809682. http://doi.org/10.1155/2012/809682 11. newmann sj, mishra k, onono m, bukusi ea, cohen cr, gage o, et al. providers’ perspectives on provision of family planning to hiv–positive individuals in hiv care in nyanza province, kenya. aids res treat. 2013;2013(915923). http://dx.doi.org/10.1155/2013/915923 http://www.prb.org/pdf14/2014-world-population-data-sheet_eng.pdf http://www.prb.org/pdf14/2014-world-population-data-sheet_eng.pdf http://doi.org/10.1098/rstb.2009.0172 http://www.prb.org/publications/datasheets/2012/world-population-data-sheet/fact-sheet-unmet-need.aspx http://www.prb.org/publications/datasheets/2012/world-population-data-sheet/fact-sheet-unmet-need.aspx http://dx.doi.org/10.1186/1471-2458-11-342 http://dx.doi.org/10.1186/1742-4755-11-21 http://dx.doi.org/10.1191/147888706qp063oa http://dx.doi.org/10.1186/1471-2458-13-98 http://doi.org/10.1155/2012/809682 http://dx.doi.org/10.1155/2013/915923 71 shumba, miyonga, kiconco, kerchan & tumwesigye nov 2016. christian journal for global health, 3(2):60-71. 12. graffy j, goodhart c, sennet k, kamusiime g, tukamushaba h. young people’s perspectives on the adoption of preventive measures for hiv/aids, malaria and family planning in south-west uganda: focus group study. bmc public health. 2012;12(1022). http://dx.doi.org/10.1186/1471-2458-12-1022 13. makinwa-adebusoye p; population division. department of economic and social affairs. united nations secretariat. socio-cultural factors affecting fertility in sub-saharan africa. workshop on prospects for fertility decline in high fertility countries. new york; 2001 july 9-11. 14. castle s, konate mk, ulin pr, martin s. a qualitative study of clandestine contraceptive use in urban mali. stud family plan. 1999 sept;30(3):241-8. http://dx.doi.org/10.1111/j.1728-4465.1999.00231.x 15. kululanga li, sunby j, malata a, chirwa e. striving to promote male involvement in maternal healthcare in rural and urban settings in malawia qualitative study. health. 2011; http://dx.doi.org/10.1186/1742-4755-8-36 16. shattuck d, kerner b, gilles k, hartmann m, ng’ombe t, guest g. encouraging contraceptive uptake by motivating men to communicate about family planning: the male motivator project. am j public health. june 2011;101(6):1089-95. http://dx.doi.org/10.2105/ajph.2010.300091 17. kenya national bureau of statistics and icf macro. kenya demographic and health survey 2008-09. calverton, maryland: knbs and icf macro. 2010. 18. mutyaba t, faxelid e, mirembe f, weiderpass e. influences on uptake of reproductive health services in nsangi community of uganda and their implications for cervical cancer screening. bmc repro health. 2007;4(4). http://dx.doi.org/10.1186/1742-4755-4-4 19. gazi r, hossain ss, zaman k, koehlmoos tp. community mobilization for safe motherhood. cochrane db syst rev. 4 (2011): cd009091 peer reviewed competing interests: none declared. acknowledgments: this baseline assessment was funded by the david and lucille packard foundation through africa christian health associations platform (achap) for a pilot project to which uganda protestant medical bureau was a sub-grantee in the two baseline assessment districts. author contributions: cs designed the study while jm, pk, tt and jk gave input into the tools. cs, jk, and jm were responsible for data collection, coding, and analysis. cs wrote the draft manuscript. jm, jk, pk, and tt critically reviewed the draft, adding substantial intellectual content. correspondence: constance sibongile shumba, uganda protestant medical bureau. konstansezw@gmail.com cite this article as: shumba sc, miyonga j, kiconco j, kerchan p, tumwesigye t. a qualitative study on provider perspectives on the barriers to contraceptive use in kaliro and iganga districts, eastern central uganda. christian journal for global health (nov 2016), 3(2):49-60. © shumba sc, miyonga j, kiconco j, kerchan p, tumwesigye t. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1186/1471-2458-12-1022 http://dx.doi.org/10.1111/j.1728-4465.1999.00231.x http://dx.doi.org/10.1186/1742-4755-8-36 http://dx.doi.org/10.2105/ajph.2010.300091 http://dx.doi.org/10.1186/1742-4755-4-4 mailto:konstansezw@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ poetry nov 2017. christian journal for global health 4(3):102 broken for you reena georgea touch life tenderly like seed cotyledons, with warm, safe fatherly hands that deliver, embrace and set free. heal life grace-fully like seed cotyledons that shed body and blood for striving, footholdseeking vulnerability. surrender life trustfully like seed cotyledons, transformed in consecrating, the sacrament of the present moment. photograph by manjithkaini.[cc by-sa 3.0 (https://creativecommons.org/licenses/bysa/3.0)], via wikimedia commons . a tamarind seedling in kerala, india. [cited 2017 oct 20]. available from https://upload.wikimedia.org/wikipedia/commons/a/a9/a_tamarind_tree_seedling.jpg acorrespondence: reena george, mbbs, md, ma (christian studies), professor, palliative care/radiation oncology, christian medical college, vellore, india reena.vellore@gmail.com cite this article as: george r. broken for you. chr jour glob hlth. nov 2017; 4(3):102. https://doi.org/10.15566/cjgh.v4i3.195 © george r. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:reena.vellore@gmail.com https://doi.org/10.15566/cjgh.v4i3.195 http://creativecommons.org/licenses/by/4.0/ book review june 2014. christian journal for global health 2014, 1(1):66-67. in the company of the poor: conversations with dr. paul farmer and fr. gustavo gutiérrez, edited by michael griffin and jennie weiss block, orbis books, maryknoll, ny, 2013. w meredith long a a drph, senior advisor for international health and integral mission, world concern as a young man, fr. gustavo gutiérrez, a dominican priest, ministered to the poor people of his parish in the slums of lima, peru. as he accompanied them in their suffering, he sought the counsel of biblical teaching concerning the poor and, in response, wrote foundational theological reflections that shaped liberation theology. now in his 80s, he teaches at notre dame university. dr. paul farmer, a physician and medical anthropologist, is the founding director of partners in health and, now, the chair of the department of global health and social medicine at harvard universty. as a young american doctor working in haiti, he came face-to-face with the suffering and early, preventable death of the rural poor. in the company of the poor is less of a conversation between these two extraordinarily passionate men than dr. farmer’s reflections on the writings and experiences of fr. gutiérrez that, in turn, shaped his understanding and approaches to health care among the poor. partners in health grew as a response to the deep inequities in access to medical care among the rural poor of haiti and the societal structures that actively or passively sustained this injustice. both men have mourned the deaths of close friends and colleagues who have either been murdered or died as a result of injustice — death squads and diseases. in chapters 3-5, the passionate and pragmatic activist responds to the reflections of the equally passionate priest of his father’s generation. in chapters 2 and 4, selections from fr. gutiérrez lay a biblical and theological foundation for a christ-like response to the poor. chapter 2 focuses on the key question of liberation theology, how best to demonstrate god’s love to the poor and chapter 4 on the necessity of conversion, a decision to follow christ that is not only personal but social in its impact. followers of jesus reflect their deep love of god in company with the poor and marginal. dr. farmer responds in chapters 3 and 5. he first explains how fr. gutiérrez influenced him and shaped his own vocation and the mission of partners in health. then, citing his own experience and evidence-based arguments of the fatal impact of personal and structural injustice, he persuasively argues for excellence in health for the poor. like dr. farmer, i, too, discovered that fr. gutiérrez gives words to my own experience as a follower of christ in health ministry to the poor. his words drawn from catholic social teaching are different than the words of my own evangelical protestant tradition. i often found myself thinking, “i’m going to have to read that several times before i get it.” also, because of the heated political arguments that emerged from the conflicts in latin america in the closing decades of the last century, readers of my age and faith tradition have to read patiently and graciously. as i progressed through the book, i discovered that the strong biblical foundations of fr. gutiérrez’s insights resonated with my own experience in health and development ministry. as a writer, fr. 67 long june 2014. christian journal for global health 2014, 1(1):66-67. gutiérrez’s humility and authenticity retain the bewilderment, sorrow, and longing for transformation of a young pastor confronted with the suffering of his impoverished congregants.  i, too, believe in god’s preferential option for the poor, not because god loves the poor more or they are more deserving of his grace, but because he hates the sin that affects them. one of my early discoveries in bangladesh was that, “a poor man’s field may produce abundant food, but injustice sweeps it away” (proverbs 13:23). dr. farmer responds with extensive evidence that disease and early death also have a preferential option for the poor, something that is part of the everyday experience of those of us who minister to the poor.  i, too, believe that conversion in response to jesus’ love for us is essential, that we would be lost without god’s “gratuitous love” toward us, and that our process of conversion continues throughout our lives and finds expression not only in love and service but in opposition to sin that holds others in bondage.  i, too, believe that sin shapes the principalities and powers of the world, that we all are called to challenge the oppression caused by this sin in response to the vocation god has given us.  i, too, believe that followers of christ must accompany the poor in the journey, that joining them in community is essential to their transformation.  and, i believe that anyone called into health care and service will face core issues of life and death, justice and oppression, healing, and suffering and that those of us who are followers of christ are called, first of all, to be centered in him. dr. farmer is essentially an activist, a doer, who remains uncomfortable with the foundational truths of christian experience, grace, conversion, suffering, and a living faith. at least in this book, dr. farmer sips selectively from the spring that has clearly given life to fr. gutiérrez for over 80 years. dr. farmer uncharacteristically gave no response to fr. gutiérrez’s final chapter, “the option for the poor arises from faith in christ.” fr. gutiérrez’s chapters reflect his response to the poor in light of biblical teaching: dr. farmer’s chapters reflect his response to poverty, more specifically related to health, in the light of fr. gutiérrez’s teachings. together, however, the passionate, pragmatic activist and the passionate, reflective theologian challenge those of us involved in health to a biblical and holistic understanding and response to the suffering and early death of the poor. competing interests: none declared. dr. long is a member of the editorial board. correspondence: w meredith long. world concern. 19303 fremont avenue north, seattle, washington 98133 usa. meredithl@worldconcern.org cite this article as: long, wm. book review: in the company of the poor: conversations with dr. paul farmer and fr. gustavo gutiérrez. christian journal for global health (august 2014), 1(1): 66-67. © long, wm. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:meredithl@worldconcern.org http://creativecommons.org/licenses/by/4.0/ book review march 2017. christian journal for global health 4(1):46-49. healing in the gospel of matthew: reflections on method and ministry by walter t. wilson, fortress press, december 2014 brian c. labosier a a mdiv, thm, phd, professor of biblical studies, (bethel) seminary of the east (retired) and dean of new england christian study center. walter wilson, a professor of new testament at candler school of theology (emory university in atlanta, ga) wrote this book to help us gain new insights on the topic of healing by looking at familiar stories in scripture. health and healing are important priorities in the broader culture around us today. the topic also has implications for the christian faith and touches on such disciplines as “christology, soteriology, discipleship, mission, and eschatology” (page xiii). wilson challenges us to think more broadly and in new categories in our reading of scripture, especially the healing narratives in the gospel of matthew. his approach is an interdisciplinary one built around both traditional and newer approaches to biblical criticism. he describes these approaches in chapter 1 entitled “methodology,” where he begins unpacking some of the more traditional types of gospel criticism:  historical criticism: locating the gospel narratives historically in the first-century world using insights not only from typical historical studies but also from both sociology and the study of redemptive history  form criticism: exploring typical motifs and conventional literary forms of narrative storytelling  source and redaction criticisms: building on comparisons of the synoptic gospels to locate both the original sources of matthew’s healing stories (following the standard assumption of markan priority and the hypothetical q document), and how matthew uniquely edited and shaped his material in these healing stories. to these more traditional approaches of gospel criticism, wilson has added a number of newer disciplines:  narrative criticism: ascertaining how the individual healing stories are woven together into the larger unit of matthew 8-9 and then how this unit fits within the broader structure of matthew’s gospel  reader-response criticism: exploring how these healing stories invite the reader to enter into the narrative world of matthew’s gospel  feminist criticism: searching for insights into possible gender-related perspectives on this topic of healing  disability studies: demonstrating a sensitivity to how such social constructs as disease and disability as well as health and healing are described in the new testament world  medical anthropology: exploring the distinction between disease as a biomedical disorder and illness as a socially recognized construct imputed to disease 47 march 2017. christian journal for global health 4(1):46-49. by a given culture both in the ancient world and, by implication, today put simply, his interdisciplinary approach challenges us to use these different approaches to biblical criticism to help us see new connections between diverse areas of knowledge. (by the way, if you bogged down reading the descriptions of the different approaches listed above, you will also bog down reading the rest of his book.) wilson spends the vast bulk of the book, chapters 2-13 (pages 37-288), illustrating his eclectic methodology in the twelve sections of biblical text he has isolated in matthew 8-9. he outlines how these different sections were apparently organized by matthew into three sets of parallel triads: matthew 8:1-17; 8:239:8, and 9:18-34. the first triad consists entirely of healing stories; the second, a nature miracle, an exorcism, and a healing; and the third, a series of progressively shorter episodes. wilson also discusses how the intervening connecting narrative material located between these triads gives purpose and direction to the structure of this two-chapter narrative in matthew. (he summarizes this structure and its significance in the final “conclusion” chapter.) it is important to see that wilson’s book is more methodologically driven than it is theory or theologically driven. matthew 8-9 is the longest and most concentrated section of material to be found anywhere in the gospels dealing with jesus’ healing miracles. matthew’s distinctive editorial style also makes this passage an obvious choice for wilson to illustrate his multifaceted approach. thus, wilson time and again finds himself wrestling with the question of why matthew brought these stories together and edited them as he did. at the same time, it should also be noted that wilson’s focus on matthew’s healing narratives sheds light on more than simply matthew: they open the door to the broader topic of illness and disease elsewhere in the ancient world. wilson adopts a fairly typical approach to the standard critical approaches of historical criticism, form criticism, and source and redaction criticism. he is more creative (and probably more controversial) in his approach to some of the newer disciplines of narrative criticism, reader-response criticism, feminist criticism, disability studies, and medical anthropology. certainly, since he surveys such a wide swath of different approaches, not everyone is going to agree with all of his conclusions. some of us might weigh these different methodologies of biblical criticism differently and potentially come to some different conclusions in some of the details of his exegesis. still, he comes at things from a broadly evangelical stance with few real surprises in his treatment of these passages from matthew’s gospel. there are several clear strengths in his treatment. first, he reminds us of the importance of what we could call theological reflection. there is always a benefit in pausing to stop and explore some of the implications and broader meanings in these otherwise familiar passages of scripture. there is no substitute for meditating on scripture and looking for connections between the biblical text and contemporary life situations. the second benefit is that wilson reminds us that the bible is relevant to life today. this relevancy is a basic presupposition of his entire text-based approach. there are always benefits in being pointed to god and his word. there is something meaningful and significant in god’s word for understanding contemporary issues in health and healing. sometimes learning to think in biblical categories can help us better analyze the events of everyday life. 48 march 2017. christian journal for global health 4(1):46-49. a third benefit is that wilson has challenged us to think about the intersection of medical practice and christian faith. a chart on page 29 contrasts four different sectors of health care: supernatural ones such as cultic (organized and official — the temple priests, for example) and charismatic (unofficial and spontaneous — like jesus himself) versus natural ones such as professional medical doctors as well as more informal folk medicine practitioners. yet in matthew’s healing stories, we find a blurring of these categories where jesus healed supernaturally to be sure, but also in ways that were meaningful in his culture. a fourth benefit is that wilson has provided us with a detailed commentary on this two-chapter portion of matthew. his work is on par in quality and depth of analysis with standard commentaries on matthew. no one commentary does everything. but this book seriously wrestles with unpacking the text of these two chapters. all in all, this book is definitely a well-researched work. the author has marshaled insights from a whole host of different disciplines, including many that are not normally included in most commentaries. another strength is that the author has done his homework well in terms of familiarizing himself with medical terminology and perspectives, both ancient and modern. it does not appear that the author has any explicit training in the medical world, but he is able to pair his biblical studies approach with an ability to think medically. the author writes like a biblical scholar addressing others with similar backgrounds. still, he writes clearly enough and simply enough to be meaningful to informed lay people. in terms of potential weaknesses, there are only a few areas where the present reviewer had hoped for something more or different. one of these was a desire for a more conservative approach to biblical criticism where the bible is more clearly viewed as the self-revelation of a holy god. yet in fairness to the author, it should be noted that he has positioned himself within the broad mainstream of contemporary biblical scholarship. another area that could have had a clearer focus was the supernatural power of god to heal and how healing fits into his broader kingdom purposes. perhaps one could say that these lessons were at least implicit in the present volume even though they were not as explicit as they might have been. but then we often learn the most from others who come from different positions from our own. if wilson’s goal is to challenge us all to think more broadly and in new ways about both the topic of healing and the text of scripture, it is fair to say that he has achieved his goal. this book is not a magic answer. any of us can take the time to get out our bibles and try to do the very thing that the author here is suggesting. we too can pause, reflect, and meditate on what we read in scripture. still, there are benefits in looking at the author’s analysis of these different passages of scripture. it is always good to be challenged to think more broadly than we otherwise might, and wilson has helped fulfill that service for us. competing interests: none declared. correspondence: dr. brian labosier, new england christian study center, auburn, ma labosier@gmail.com mailto:labosier@gmail.com 49 march 2017. christian journal for global health 4(1):46-49. cite this article as: labosier bc. healing in the gospel of matthew: reflections on method and ministry by walter t. wilson, fortress press, december 2014. christian journal for global health mar 2017; 4(1): 46-49. © labosier, bc. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ short communications may 2016. christian journal for global health, 3(1): 86-88. teleradiology service for mission hospitals: initial experiences in ethiopia and kenya matthew larrison a , stanley g. cheng b and stephen mcmanus c a md, assistant professor, department of radiology, uab hospital, usa b southern california permanente medical group department of radiology, san diego, ca, usa c atlanticmedical imaging, usa introduction throughout their history, mission hospitals have provided high quality and lifesaving medical care to regions of the world where medical care is sparse. these hospitals are generally built and equipped through a combination of governmental and non-governmental sources. as advances in diagnostic medical imaging have progressed and become mainstream in the developed world, mission hospitals have adopted advanced imaging modalities. these modalities provide early diagnosis and treatment options for their patients. in addition to the installation and operation of advanced imaging equipment, the need for professional expert interpretation of these studies remains a challenge for mission hospitals. historically these hospitals have used either voluntary services on site or paid for interpretations from local radiologists; however, with the introduction of high speed internet, teleradiology has become a possibility. while there have been published accounts of using teleradiogy for review of radiography and ultrasonography in the developing world, there is little, if any information published describing the use of teleradiolgy for computed tomography (ct) in similar settings. 1,2,3 this article describes the teleradiology experience of two mission hospitals in rural africa. soddo christian hospital soddo christian hospital is located in the southern portion of ethiopia and serves a regional population of approximately 2 million. through the generosity of a norwegian non-profit, a ct scanner was installed at the hospital in 2014. since its installation, dr. karl roth, a norwegian radiologist, has worked at the hospital performing ct interpretations. when dr. roth returns home to norway, usually for a few months at a time, the hospital typically does not have on-site radiology coverage; therefore, teleradiology services for interpretation were needed for continued care of their patients. through a partnership between the university of alabama at birmingham (uab) hospital department of radiology and soddo christian hospital, ct examinations are evaluated when there is no radiologist on site. this partnership began in early 2015 with a signed memorandum of understanding that outlined the expectations of both institutions. a direct internet virtual private network (vpn) was established between soddo christian hospital and university of alabama at birmingham (uab) radiology. through this connection, ct examinations are sent to an onsite archive at uab. approximately 8 ct studies are performed each day of the work week. each day, the ct technologist at soddo uploads a patient roster to the secure file sharing server. several subspecialty trained radiologists at uab then review the ct examinations and produce and upload their report to the secure server that is accessible by the 87 larrison may 2016. christian journal for global health, 3(1): 86-88. soddo hospital physicians. through this partnership, the patients at soddo christian hospital are able to receive quality, sustainable care. at the same time, the faculty, residents, and fellows at uab are provided the opportunity to evaluate disease processes such as advanced cancers and extra pulmonary tuberculosis that are not commonly seen in the united states but are seen with regularity at soddo christian hospital. this provides a unique learning opportunity for uab radiology. tenwek hospital tenwek hospital is located in bomet, kenya, 230 km west of nairobi, near the borders of uganda and tanzania. it was founded in 1937 and has since grown to become one of the largest mission hospitals in africa. tenwek serves a local population of approximately 800,000. in addition to the local population, tenwek is also a referral center for 8.5 million people as well as a training facility for african doctors and nurses. radiology services at tenwek had humble origins with an x-ray machine operated by the single doctor on site in 1960. after a consistent power source was established in the late 1980s through the construction of a hydroelectric dam, more advanced technology became feasible. in 2011, toshiba america medical systems donated a refurbished ct scanner to tenwek. at the time, it was the only ct scanner in the region and allowed for significant improvement in patient care. there is no full-time on-site radiologist at tenwek hospital. world medical mission (medical arm of samaritan’s purse) coordinates visiting radiologists. on-site radiologist coverage varies from year to year based on volunteer availability. typically, 60-70% of the year is covered by on-site volunteer radiologists. when no radiologist is on-site, ct scans need to be read remotely. prior to 2014, this was achieved by sending cts to a nairobi radiology group, at a cost of approximately $10 per report. as of 2014, a group of radiologists who had previously served at tenwek initiated a coverage system to provide volunteer teleradiology coverage from the united states. volunteer radiologists who maintain kenyan medical licenses and are credentialed as staff at tenwek hospital rotate to provide ct reads during weeks when no radiologist is on-site. anywhere from 515 ct scans are read per day by a team of 5-6 radiologists. administrative support for medical licensure and hospital credentialing is provided by world medical mission. in the initial phase of teleradiology at tenwek, ct scan dicom (digital imaging and communications in medicine) format files were uploaded manually to a cloud drive and then downloaded onto each volunteer radiologist’s personal computer. radiologists then imported them into a dicom image viewer. this system encountered numerous technical difficulties on both ends of the workflow. in 2015, teleradiology was transitioned to a web-based secure image exchange service called radconnect, donated for tenwek’s use by statrad (san diego, ca). following installation of statrad’s image uploading server, ct scan uploads to their secure cloud-based server was automated and radiologists could view images through the radconnect secure web-based viewer. this has streamlined the process tremendously with a much lower rate of technical issues. the bandwidth at tenwek was originally 3.5 mbps, but was upgraded to 40 mbps. the images are viewable in the us through the web-based viewer using a standard internet connection, even 4g cellular connections. since its inception in may 2014, over 2200 patients’ ct scans have been read by u.s.-based volunteer radiologists. beyond providing quality 88 larrison may 2016. christian journal for global health, 3(1): 86-88. ct interpretations and saving tenwek hospital valuable monetary resources, teleradiology has also provided a wonderful opportunity to serve in missions for the nearly 40 volunteer radiologists. many of the volunteer radiologists have served (and continue to serve) on short term missions at tenwek. serving with teleradiology throughout the year has also allowed these radiologists to remain connected with tenwek consistently throughout the year. future direction access to the internet is taken for granted in the united states. most people have high speed internet in their home and on their cellphones. in africa, the penetration of the internet has been slower, particularly in rural areas; nonetheless, access has improved. this access is the commonality between the teleradiology systems of soddo christian hospital and tenwek hospital. the internet allows us to connect patients living in mud huts in remote regions of africa with radiologists living in the united states. as internet access improves, more opportunities will arise. as more mission hospitals acquire ct equipment and arrange partnerships with radiologists throughout the developed world, having a group of radiologists provide service would be recommended, as a single radiologist would likely not have the appropriate time to read the typical eight to fifteen exams each day. we are hopeful that the success we have had will encourage other radiologists to come along side as these opportunities open up. references: 1. coulborn rm, panunzi i, spijker s, brant we, duran lt, kosack cs, et al. feasibility of using teleradiology to improve tuberculosis screening and case management in a district hospital in malawi. b world health organ. 2012;90:705-11. http://dx.doi.org:10.2471/blt.11.099473 2. andronikou s. pediatric teleradiology in low-income settings and the areas for future research in teleradiology. front public health.2014 august 21;2:125. http://dx.doi.org/10.3389/fpubh.2014.00125 3. stanton k, mwanri l. global maternal and child health outcomes: the role of obstetric ultrasound in low resource settings. world j prev med. 2013;1(3):22-9. competing interests: none declared. correspondence: dr. matthew larrison, assistant professor, uab hospital department of radiology, united states. mclarrison@gmail.com cite this article as: larrison m, cheng sg, mcmanus s. teleradiology service for mission hospitals: initial experiences in ethiopia and kenya. christian journal for global health (may 2016), 3(1):86-88. © larrison m this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org:10.2471/blt.11.099473 http://dx.doi.org/10.3389/fpubh.2014.00125 mailto:mclarrison@gmail.com http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ book review july 2017. christian journal for global health 4(2):100-102. faith-based development: how christian organizations can make a difference by bob mitchell, foreword by bryant l myers, orbis books, 2017 dean h pallanta a bsocsci, dth, director of the international social justice commission, the salvation army, new york, ny, usa we live in uncertain times with global, political and economic alliances under strain and nationalistic ‘me-first’ politics gaining significant support in a number of countries. this is not the time for christian organizations to retreat from the world nor is this the time to merely ape secular actors. this book is a timely, readable, and practical promotion of faith-based development that answers a critically important question: how can christian organizations make a difference? the author, bob mitchell, brings to this task an impressive and diverse background – legal qualifications, a partner at an international accountancy firm, an executive with world vision australia, an anglican clergyman, and a phd in applied theology. he marshals his wide experience to help readers understand the complex issues swirling around “faith” and “development” without using complex academic language. this results in a practically rich and theoretically well-informed book. “development” is a word with many meanings. secular development specialists, one of the audiences mitchell seeks to engage, consider the objective of development “‘to advance human dignity, freedom, social equity and selfdetermination’ and that a lack of development involves ‘social exclusion, poverty, ill-health, powerlessness and a shortened life expectancy’” (pxxii). mitchell critiques secular development as often being too western, arrogant, and having too narrow an economic focus. in contrast, mitchell promotes a wide appreciation of human flourishing from a christian perspective. mitchell recognizes that the resources of faith are too often suppressed in development practice, even in christian-based organizations, due to the “cult of modernity” (p166). international development as “an academic discipline has tended to marginalize religious viewpoints” (p119). the tools of rationality are prioritized over the resources of faith. international development is still impacted by the “secularization thesis” promoted by significant 20th century thinkers—karl marx, sigmund freud, max weber, emile durkheim—that faith and religion will diminish as people “develop” into rational beings. this has proven to be a false presumption and yet many development agencies continue to work with this paradigm resulting in the sidelining of faith and religious dimensions of life. “faith-skeptical” attitudes have even impacted christian organizations, mitchell argues: “many european fbos have engaged in this kind of dichotomous thinking, allowing faith to dissipate so they can become more ‘professional’.” while some fbos are distancing themselves from the resources of faith, there is an increasing awareness by politicians and secular development professionals that faith and religion have something to contribute in the fight to end extreme poverty and promote sustainable development. faith-based organizations (fbos) plus religious congregations and their institutions have an extensive reach into many of the most vulnerable communities. more 101 pallant july 2017. christian journal for global health 4(2):100-102. than 80 per cent of people in the world have “a religious affiliation and worldview” (p8) and as former archbishop of canterbury, dr rowan williams, argues, “there has been a very belated recognition that the majority of the world’s population does have religious convictions and to ignore these is to push against the grain.” (p8) this new interest in faith and religion has risks. mitchell notes that organizations formed by people of faith can be coopted as an instrument to be used rather than as a partner to be valued and appreciated. the majority of the book is dedicated to building up the capacity of christians and their organizations as faithful partners. mitchell describes the richness of a christian theology of development, and shows how it connects and contrasts with the secular development theory and practice. he theologically reflects on prevalent theories of change, the importance of narrative and ‘kingdom now’ theologies. mitchell references some of the giants of contemporary theology—nt wright, jurgen moltmann, and miroslav volf—but he does not give an in-depth analysis of their theologies. it is sufficient for his argument to acknowledge the reliable foundations upon which he builds and move on to discuss practical applications. mitchell addresses issues that prevent fbos from being faithful in a clear, readable, and coherent argument. his proposal develops resources for fbos. he does not reject the academic discipline of development studies but presents an insightful and balanced critique of science, human rights, and secularism arguing that they can enrich christian practice without compromising faith. he warns that fbos can engage with any relevant academic discipline but should assess the worldview upon which it is based and compare it with their christian worldview. mitchell calls for a renewed level of intentionality by fbos to use the resources of their faith tradition. mitchell explains the importance of ‘inner transformation’ in the process of development, the contribution of prayer and spiritual disciplines, and the special relationship that needs to be strengthened between fbos and the local church. there are also sections discussing how to engage people of other faiths such as muslims and followers of african traditional religion. the weakness of the book is a lack of detailed research methodology. in the foreword, professor bryant myers, hails mitchell’s work as “the first systematic, field-based academic research on the theory and practice of faith-based development done by a christian organization” (px). mitchell uses eight world vision evaluation reports on work in georgia, tanzania, rwanda, senegal, bosnia and herzegovina, lebanon, armenia, and albania. too little information is provided on the quality of the evaluations, the research methods used in the evaluation process or the reliability of the conclusions. for example, one evaluator, ashley goode, authors or co-authors six of the reports. did this fact affect the quality of the data set? the quality and credibility is apparently taken at face value. given mitchell’s recognition of the importance of credible, robust evidence of the contribution of fbos, it is essential for him to provide more information and critique of the data upon which he builds a substantial amount of his argument. the advantage of mitchell’s accessible writing is that non-academic professionals will read it. the downside is that critical academic readers may not appreciate the firm academic foundations from which his arguments emerge. mitchell describes a number of habits and practices that result in a more faithfully-based organization but he does not explicitly link them to any processes or models which embed the practices into the life of an organization. in the past 20 years, the academic discipline of practical theology has developed a number of rich and robust processes for theological reflection (see theological reflection methods, elaine graham, heather walton, francis ward, scm press, 2005). other writers who would have strengthened mitchell’s arguments include professor linda hogan from trinity college, dublin (keeping faith with human rights, 2015) and professor luke bretherton 102 pallant july 2017. christian journal for global health 4(2):100-102. from duke university (resurrecting democracy, 2015). this is a fast moving area of research and practice. interested readers can learn more about how secular and faith practitioners engaged in development work are learning together by visiting the partnership for religion and development (http://www.partner-religion-development.org) and the joint learning initiative on faith and local communities (jliflc.com). mitchell concludes with a discussion on the increasing demand for accountability in all areas of public life – including fbos and religious bodies. he argues that fbos should not resist these pressures but embrace accountability as an opportunity to increase faithfulness and transparency. a number of cross cutting themes are considered (disability, gender, environment, child protection). the book concludes with a call to all the actors (governors of fbos, churches interested in development, the development sector, governments, ngos, christian development practitioners) to think again about the contribution faith can make to solving the world’s greatest challenge – ensuring sustainable development for this and future generations. this book is primarily a pastoral, practical resource and should be essential reading material for all christians studying or working in the field of development. as bryant myers states in the foreword, “this is an important call for the leadership of faith-based agencies to recover their confidence in their own traditions in the aftermath of the corrosive effects of two hundred years or so of modernity and its secular faith commitments.” (pxii) competing interests: none declared. correspondence: major dean h pallant, the salvation army, united states of america. dean_pallant@salvationarmy.org cite this article as: pallant dh. faith-based development: how christian organizations can make a difference by bob mitchell, foreword by bryant l myers, orbis books, 2017. christian journal for global health. july 2017; 4(2):100-102. https://doi.org/10.15566/cjgh.v4i2.180 © pallant dh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.partner-religion-development.org/ https://jliflc.com/ mailto:dean_pallant@salvationarmy.org https://doi.org/10.15566/cjgh.v4i2.180 http://creativecommons.org/licenses/by/4.0/ original article the quantitative and qualitative contributions of faith-based organizations to healthcare: the kenya case alfredo l. fort a a md, phd, former senior monitoring and evaluation adviser with ima world health, currently with unfpa population and development branch abstract although faith based organizations (fbos) have had a long presence teaching health personnel and delivering health services to many rural and remote populations in the developing world, their poor visibility for this work can be due to several factors. fbos may keep a low profile, be confused with non-religious non-governmental organizations (ngos), or be excluded from surveys because respondents may not know the affiliation of the healthcare facility from which they last received services. it has been argued that their large networks, logistics agreements with governments, and mission-driven stance bring them closer to the communities they serve and that their services have been a higher quality than average. kenya has had a long history of established fbos but there has also been substantial recent health investment by the government. we aimed to find the quantitative and qualitative contributions of fbos by analyzing two recent data sources: the live webbased nationwide master health facility list and the 2010 nationwide service provision assessment (spa) survey. using this information, we found that fbos contribute to 11% of all health facilities’ presence in the country, doubling to 23% of all available beds, indicating their relative strength in owning mid-level hospitals around the country. we also constructed an index of “readiness” as a weighted average from services offered, good management practices, and availability of medicines and commodities for 17 items assessed during the spa survey. we found that fbos topped the list of managing authorities, with 69 percent of their health facilities achieving such readiness, followed closely by the government at 68 percent, ngos at 60 percent and lastly a distant private for-profit sector at 51 percent. these results seem to confirm that fbos continue to contribute to an important proportion of health care coverage in kenya and do so with a relatively high quality of care among all actors. it would be of interest to replicate this analysis with similar databases for other countries in the developing world. 61 fort nov 2017. christian journal for global health 4(3):60-71. key message: health facility-based government inventory list and nationwide survey in kenya reveal high hospital faith based organizations’ presence, wide range of service delivery, and better management practices and support mechanisms than public, ngo, and private sectors. introduction as part of a current trend and initiatives advocating for the strengthening of health systems in the developing world, there is increasing interest in assessing the contribution of non-governmental sectors such as the private sector in the provision of health care. 1,2 in this trend, several publications have tried to estimate the contribution of faith based organizations (fbos) to health service delivery in the developing world. for example, claims have surfaced in the last decade or so that “between 30% and 70% of the health infrastructure in africa is currently owned by faith-based organizations . . . ,” 3 up to 50% of the market share on beds and health facilities are related to fbos, 4 or they contribute to healthcare between 12% and 50% among ten assessed african christian health association member countries. 5 kagawa et al. conducted a systematic review of literature and meta-analysis of population-based surveys to arrive at some credible figures. 6 from an initial 3,645 sources, the authors could only utilize three studies plus nine references from personal contacts. an additional 47 dhs datasets were identified for meta-analysis. they found a range from 4.1 (angola) to 44 percent (rwanda) fbo contribution to healthcare with hospital shares being higher than other indicators. another indicator is hospitalizations, for which they found a 36 percent contribution by fbos in benin. a couple of recent publications make a lengthy review of the inaccuracies of and difficulties with different estimates (e.g., from inventories of facilities, published routine data on health information systems, household and facility surveys, or from international agencies’ reports) of the market share, facilities, beds, or simply “healthcare” of faithinspired institutions compared to the universe. 7,8 estimates of fbo contribution can be difficult due to the complexities of definitions, identification, politics, and modalities of healthcare beyond health infrastructure. they also find, through household surveys, that fbos may contribute lower market shares than often believed, but find higher user satisfaction levels than with public facilities. invariably, they note the large evidence gap and urge for the need to study further the quality, efficiency, and sustainability of their efforts. another study looked at the issue of relative contributions by using data on revenue and expenditure by different types of organizations through usaid’s annual report of voluntary agencies (volag). they found that between 1990 and 2013, fbos (96% of which were us-based) made up 26-33% of all 1,369 private voluntary organizations (pvos)/non-governmental organizations (ngos), and their spending for development assistance in health (dah) was, on average, 31% of all expenditure. the global fund has continuously increased its funding to fbos from 2003 to 2011, reaching $80.9 million or 17% of all its disbursements to ngos. for the gates foundation, this figure was a small but steady 1%. the study also found that the majority of the funds registered in the report were allocated for work in latin america, and the caribbean (lac), and in sub saharan africa (ssa). 9 although fbos have been recognized for making substantial contributions to local health systems in low income countries through teaching, setting up clinics, and distributing medicines in remote areas among the most vulnerable people, there are a number of reasons why estimating their unique contribution is challenging:  fbos are often lumped together with the “private” or non-governmental sector, making the distinction impossible.  measures of their contribution varies by whether the variable is infrastructure (health facilities, hospitals), hospital beds (or hospital62 fort nov 2017. christian journal for global health 4(3):60-71. ization), healthcare provided, community programs or initiatives, or training/education of health personnel. particularly, in this last category, there is no or little information about the education infrastructure (e.g., nursing schools) and numbers of health care students (e.g., nurses) trained by fbos.  population-based data using clients recalling services used for maternal (e.g., childbirth) or child care (e.g., diarrhea treatment) may underestimate values from clients not knowing the name of facilities or not being able to identify a facility as being faith-based. to these difficulties in assessing the quantitative contribution to health, one might add the even more daunting task of estimating the range and nature of services offered. it is said that fbos work in more rural and remote areas, often complementing services not provided by the public sector. 8 they engage in sometimes difficult public health topics, such as hiv/aids, neglected tropical diseases (ntds), gender-based violence, outbreaks such as ebola, 10 and other services such as reproductive health and family planning. 11 finally, there is ample speculation about its qualitative contribution. it is often stated that fbo staff are motivated by a mission, beliefs, and values that make them offer their services in a more holistic and humane way, hence increasing their quality, or that their services elicit an inherent trust by communities. they are also regarded as having increased capacity to purchase medicines at a discounted price and store and distribute them to remote locations. finally, it is thought that they have a flexibility to try new methods and strategies and are able to more effectively influence health behaviors. 8,12 these are claims even more difficult to confirm. kenya, a relatively large country in east africa, has had a long history of established fbos assisting the national government in providing health care in remote areas. however, with the advent of health reform, devolution, and decentralization in recent years, international donors and the kenyan government through its counties has reorganized and invested heavily in health, particularly on human resources and infrastructure, including remote and rural areas of the country. 13,14,15 these new investments by the government have brought renewed interest to the question of the current status of the fbo contribution to the country’s healthcare. the fact that the country has a combination of independently run surveys, in addition to relatively well established national information systems, allowed us to review these data sources to answer the questions of the quantitative and qualitative contribution of fbos in kenya. materials and methods in this analysis, we used two main sources of data. for the quantitative analysis, we reviewed the kenya master health facility list (kmhfl), a live inventory of nearly ten thousand registered health facilities throughout the country publicly available online. 16 for the qualitative portion, we used data from the kenya service provision assessment (kspa) surveys, part of the internationally recognized demographic and health surveys (dhs), a usaid-funded program. this nationwide facility survey conducted in 2010 looked into the availability of services and commodities and equipment at a range of facilities for the four main sectors or “managing authorities”: the government, the private for profit, the non-governmental organization (ngo), and the fbo sectors. 17 the kmhfl and kspa were used to estimate the total number and proportion of registered health facilities by ownership/managing authority in order to calculate the fraction belonging to fbos. the kspa was used to construct a composite variable representing the availability of services and their corresponding commodities and supplies, plus use of best practices for good management of facilities and human resources for health. we 63 fort nov 2017. christian journal for global health 4(3):60-71. constructed a weighted average of the percentage of facilities with readiness on 17 items (some comprised of weighted sub-items) assessed as whether the facilities offered certain common maternal, child, and infectious health services; whether they had the necessary equipment, medicines, diagnostic tests, or support for the services offered; and whether they employed common management practices such as good storage for commodities, equipment maintenance, and regular supervision of health workers. the specific breakdown of items assessed at each facility was whether it:  offered all basic services: antenatal care, family planning, child health, growth monitoring, immunization, and sexually transmitted infections  had minimum client comfort amenities: latrine or bathroom, protected waiting area, general cleanliness (floors swept, no dirt/waste; clean counters, tables, and chairs; no broken equipment, papers, boxes lying around in clutter/dirtiness)  had supportive management practices: external supervision at least once every 6 months; routine training (at least half of providers received structured training in last 12 months); and personal supervision  had a mechanism for obtaining community input on services (through community representation at management meetings or a system for eliciting and receiving client opinion)  carried out preventive maintenance for major equipment (e.g., generator, sterilizer, electric autoclave, x-ray machines, ultrasound equipment, ct scans)  had good storage conditions: items stored in a well ventilated and dry location, off the ground, and protected from water, sun, pests, and rodents; the weighted average of storage conditions were assessed separately for each of three types of commodities: contraceptive methods, medicines in general, and arvs  had equipment for quality sterilization or high-level disinfection (hld)  had all items for infection control in any assessed service delivery areas: soap and running water (or hand disinfectant), sharps box, disinfectant, and latex gloves  had first-line medicines for child health services: ors, antimalarials, plus at least one oral antibiotic  offered (provided, prescribed, or counseled clients on) any modern method of family planning: contraceptive pills (combined or progestin-only), injectables (combined or progestinonly), implants, intrauterine contraceptive devices (iucds), male condoms, and female condoms  offered antenatal care (anc), postnatal care (pnc), and tetanus toxoid (tt) vaccination  had capacity for conducting basic tests for pregnancy average for 5 tests: anemia (hemoglobinometer, calorimeter, centrifuge with capillary tubes, or filter paper methods); urine protein (dip sticks for urine protein or acetic acid for urine albumin and flame for heating acetic acid); urine glucose (dip sticks, benedict’s solution with stove for boiling the solution); blood grouping (anti-a, anti-b, anti-ab, and anti-d reagents, an incubator, coomb’s reagent, and glass slides); and syphilis (venereal disease research laboratoryvdrl, polymerase chain reaction-pcr with functioning rotator/shaker, or rapid plasma regainrpr)  had transportation support for maternity emergencies (an ambulance or provision of transportation to a referral site)  offered primary sexually transmitted infections (sti) services (counseling, testing, diagnosis, or treatment)  offered any tuberculosis (tb) diagnostic, treatment and/or follow-up services  had capacity to offer malaria diagnosis (blood smear) plus first-line medicines in the facility: average of the two  had an hiv testing system plus art and medical follow-up: average of the three 64 fort nov 2017. christian journal for global health 4(3):60-71. (see details of indicators and their values in annex 1) results quantitative contribution to health care the 2010 kspa report, table 2.1 (page 18) reported on the number of health facilities at the time and broke them down by ownership. in this table, faith-based facilities amount to 834 out of 6,691 facilities registered in the system, making up 12% of all facilities (replicated as table 1, below). this share is similarly reflected in the weighted number of facilities that the sample used for the survey, compared to the total. the number, 89, out of a total of 695 sampled, represents 12.8 percent of all facilities. table 1. health facilities in kenya by type and ownership type of service moh, public private for profit private not for profit faith-based total all hospitals 261 53 64 75 453 health centers (level 3) 473 21 88 139 721 nursing homes (level 3) 3 89 54 9 155 dispensaries (level 2) 2,393 74 380 509 3,356 clinics (level 2) 20 1,126 693 102 1,941 laboratory—stand-alone 52 2 54 dental clinics 10 1 11 total 3,150 1,425 1,282 834 6,691 percentage 47% 21% 19% 12% 100% source: ministry of medical services and ministry of public health and sanitation, 2010 a more direct way of determining the number of facilities and their characteristics is by using the kmfl accessed via internet. 16 the database provides an up-to-date number of facilities in the system registered in the country (in the first search of october 2016, 9,493 facilities). among faithbased providers, the category of “ownership” is sub-divided into “christian health association of kenya-chak,” “kenya episcopal conferencecatholic secretariat,” “supreme council for kenya muslims,” and “other faith based”. the database reported 924 health facilities categorized under these four sub-categories, representing 11% of all registered facilities. however, the proportions vary by type of facility; fbos are only 10% of all dispensaries but rise to 20% of all primary hospitals, signaling that this is the most common type established in the country. another category is “level” of care (i.e., level 2 being the lowest and level 6 the highest). fbo facilities comprise 10% of level 2 care, but rise to 13% at level 3 and 14% at level 4. at levels 5 and 6 the vast majority of facilities (82%) are of ministry of health (moh) or public, while fbos contribute only 5% of these facilities. again, one can see the relatively high distribution of hospitals with fbos, reflected in the participation of beds where fbos comprise nearly one-fourth (23%) of all beds in the list. see figure 1 for a full picture of these representations. 65 fort nov 2017. christian journal for global health 4(3):60-71. figure 1 relative size of fbos by institution and facility type – kenya 2016 master facility list notes: phc:primary health care; vct: voluntary counseling and testing for hiv. n = 9,493 facilities still using the kmfl, we broke down the facilities by their presence in urban and rural areas. it is interesting to note that fbos maintain the same proportion of their share of facilities (11%) in mostly urban counties as in rural ones. for this analysis, we have examined seven counties comprised of mostly urban populations (i.e., having at least 200,000 people): kiambu (ruiru-kikuyu), kisumu, mombasa, nairobi, nakuru, nyeri, and uasin gishu (eldoret). in urban areas, the private sector has the highest share of facilities (53%), which reduces to only 29% of all facilities in the rural area. the moh/public sector, has an inverse distribution, owning 29% of facilities in urban counties but over half (57%) of facilities among the rural counties (see table 2). in this sense, the public sector’s presence closely resembles the distribution of the urban population in the country, which is estimated by the world bank at 26%. 18 but, 23% of beds fbo compared to total 66 fort nov 2017. christian journal for global health 4(3):60-71. table 2. contribution of health facilities by main owner (managing authority), by main urban areas and all rural areas county/area kiambu (for ruiru / kikuyu) kisumu mombasa nairobi nakuru nyeri authority n % n % n % n % n % n % moh, public 100 24% 114 56% 44 17% 124 16% 128 36% 94 32% private for profit 248 59% 52 26% 179 71% 441 58% 162 46% 159 54% fbo 58 14% 17 8% 13 5% 79 10% 47 13% 29 10% ngo 8 2% 15 7% 9 4% 95 13% 14 4% 5 2% others 4 1% 4 2% 7 3% 19 3% 2 1% 9 3% total 418 100% 202 100% 252 100% 758 100% 353 100% 296 100% table 2. (continued) contribution of health facilities by main owner (managing authority), by main urban areas and all rural areas county/area uasin gishu (eldoret) total 6 urban areas urban over total rural grand total authority n % n % % n % n % moh, public 90 63% 694 29% 16% 3,591 57% 4,285 49% private for profit 35 24% 1,276 53% 41% 1,831 29% 3,107 36% fbo 17 12% 260 11% 28% 664 11% 924 11% ngo 2 1% 148 6% 53% 132 2% 280 3% others 0 0% 45 2% 59% 31 0% 76 1% total 144 100% 2,423 100% 28% 6,249 100% 8,672 100% source: kenya master health facility list. data accessed 17 april 2017 qualitative contribution to health care results with the composite variable showing the readiness of facilities from different institutions to offer key services are quite striking. the overall weighted average for fbos is 69 percent (of health facilities with all assessed services and practices) compared to 68 percent for the government, 60 percent for ngos and only 51 percent of the private for-profit sector. see figure 2. 67 fort nov 2017. christian journal for global health 4(3):60-71. figure 2. facilities’ readiness for quality health care services, by four main managing authorities (%) kenya spa 2010 note: superscripts refer to references detailed in annex 1. when we examine management specific practices (items 2 and 3-8), fbos have the highest weighted average at 72 percent compared to 69 percent for government (see annex 1 for data). the offer of services with medicines and tests (items 1 and 9-17) comes out at a slightly lower level of 67 82 80 79 78 41 76 55 72 73 96 74 22 55 97 55 64 50.5 68 72 67 78 65 33 70 24 49 58 89 61 17 64 90 49 60 67 60 28 89 34 22 57 89 62 70 47 84 26 36 36 87 17 53 30 51 54 83 82 50 43 82 80 84 92 44 69 50 60 100 57 90 55 69 0 20 40 60 80 100 120 offers basic services¹ client comfort² supportive mngmt practices³ comm input on services preventive maintenance for equipm good storage conditions⁴ equipment for sterilization infection control items⁵ 1st-line meds for ch⁶ modern fp methods offers anc, pnc, tt average capacity for pregn tests⁷ transport for matern emerg offering primary sti services tb dx, tx a/o fu services those w malaria services: meds + dx hiv test + art + fu services average fbo pfp ngo gov 68 fort nov 2017. christian journal for global health 4(3):60-71. percent for fbos, same to that of the government (see annex 1 for data). the private for-profit sector scores particularly low on offer of services, at only 44 percent. discussion although there have been several claims of a high contribution of faith based organizations to the amount of healthcare provided in a country, with some estimates up to 50 percent, our findings suggest that the fbo contribution is more conservative, at least for kenya. as reviewed, public investment by the government increasing steadily over time, especially in rural and remote areas that once were the predominant domain of fbos, may have reduced this influence in current periods. still, there is debate on whether some of this imprecision is due to peculiar situations occurring both at the supply and demand side of the equation. on the supply side, some assessments may incorrectly assign fbo facilities or services to a broader “private” sector. 8 it is also said that fbos may provide services that are not counted as “facilities” or not registered in the formal system of health care, such as with the free or subsidized distribution of medicines through community networks or remote warehouses. 7,8 the situation of the contribution of personnel by sector makes this task more complicated. known are the examples of religious personnel—either on voluntary basis or remunerated—working at public facilities or the community, as extension workers. conversely, through memoranda of understanding (mou) many state-funded staff are assigned to fbo institutions, and it is unclear in which sector their participation is counted. on the demand side, there are multiple opportunities where fbos may not be acknowledged, such as when mothers in a survey are asked for the name or characteristic of the facility or service they last attended and they are not able to identify or recognize it as a faith organization. additionally, fbos may be working on areas of demand generation, behavior change, or health education at the community level that may not be counted as healthcare participation. this may include advocacy for health care utilization by religious ministers at individual or mass opportunities (e.g., pulpit) and events. some of this extended reach versus its recognition has been addressed at a recent consultation between pepfar and fbos on the provision of hiv/aids services. 19 for kenya, analyses using the web-based kenya master facility listing (kmfl) and the 2010 kenya service provision assessment (kspa) nationwide facility survey indicate that fbos contribute between 11 and 12 percent of all facilities registered in the country. however, because fbos contribute relatively more with intermediate-level hospitals, their contribution rises to 23 percent of all available beds in the country. qualitatively, an index constructed from 17 separate items representing provision of maternal and child health services and good management practices reveals that, except for the provision of modern fp methods, the fbo sector consistently had similar or better capacity than the government or other sectors. overall, fbos contribute the highest levels of care, at 69 percent, closely followed by government facilities at 68 percent. what is surprising is to find that the private forprofit sector, except for physical characteristics such as having client amenities or equipment and its maintenance in facilities, scores low on management practices and does not offer a wide range of services. overall, they offer the lowest contribution to the index, with only 51 percent of their facilities fulfilling all requirements. these results seem to indicate that in kenya, fbos not only contribute to a sizable proportion of the total healthcare of the country, but their facilities operate at very high levels of capacity, comparable or higher to that of the national government, and certainly at much higher levels than that of the private sector. we believe this new finding adds to our knowledge base and opens up prospects for 69 fort nov 2017. christian journal for global health 4(3):60-71. additional research on the contribution of fbos to healthcare, especially in the developing world. it would be of great interest to ascertain whether these findings can be replicated in other countries in the world that possess similar databases. limitations there are a number of potential limitations to these analyses. the first one comes from the use of the kmfl. this is a government-hosted website that displays all health facilities registered in the country. among the categories of classification is “facility owner,” which breaks into 26 subcategories. we used sub-categories representing faith based organizations, comparing them to others representing different sectors. obviously, if there were misclassification (e.g., fbos registered as “public,” “private,” or “non-governmental organizations”) this could affect estimates. additionally, there may well be a number of fbo facilities, especially of smaller size or located in hard to reach areas that may not be registered in the list. being a “live” website, numbers can change depending on revisions, through updating or correcting entries. this is reflected in differing totals found when accessing the site at different times. for example, when accessed 10/17/2016, the site gave a total of 9,493 facilities, while when accessed six months later, on 4/17/2017, the site reported only 8,672 facilities, an inexplicable 9 percent drop. other limitations may arise from problems inherent to the conduct of a national survey, such as the quality and completeness of observations and registries on items used for the 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https://www.pepfar.gov/documents/organization/2476 13.pdf. peer reviewed competing interests: none declared. acknowledgments: the author wishes to acknowledge the support from senior management and officers at ima world health and for their encouragement to pursue this investigation. correspondence: dr. alfredo l. fort, unfpa, new york, usa fort@unfpa.org cite this article as: fort al. the quantitative and qualitative contributions of faith-based organizations to healthcare: the kenya case. christian journal for global health. nov 2017; 4(3):60-71. https://doi.org/10.15566/cjgh.v4i3.191 © fort al. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1016/s0140-6736(15)60251-3 https://doi.org/10.1016/s0140-6736(15)60251-3 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mailto:fort@unfpa.org https://doi.org/10.15566/cjgh.v4i3.191 http://creativecommons.org/licenses/by/4.0/ 71 fort nov 2017. christian journal for global health 4(3):60-71. annex 1 facilities’ readiness for quality health care services, by four main managing authorities (%) kenya spa 2010 # item assessed / institution government fbo ngo private for profit total 1 offers all basic services 1 82 54 72 28 59 2 has client comfort amenities 2 80 83 67 89 80 3 supportive management practices 3 79 82 78 34 68 4 community input on services 78 50 65 22 54 5 preventive maintenance for equipment 41 43 33 57 44 6 good storage conditions 4 (weighted average) 76 82 70 89 79 7 equipment for sterilization functioning 55 80 24 62 55 8 all infection control items 5 72 84 49 70 69 9 first-line medicines for children 6 73 92 58 47 68 10 modern family planning methods 96 44 89 84 78 11 offers antenatal care, postnatal care, tetanus toxoid 74 69 61 26 58 12 has average capacity for pregnancy tests 7 22 50 17 36 31 13 transportation for maternity emergencies 55 60 64 36 54 14 offers sexually transmitted infections (sti) services 97 100 90 87 94 15 offers tuberculosis diagnostic, treatment and/or follow-up services 55 57 49 17 45 16 malaria diagnosis and first-line medicines (average) 64 90 60 53 67 17 hiv testing system, art, medical follow-up (average) 51 55 67 30 51 total (overall average) 68 69 60 51 62 1 outpatient ch, sti, fp, anc, imm, gm 2 latrine, protected waiting area, cleanliness 3 external supervision at least every 6 months, routine training & personal supervision 4 dry location, off ground, protected from water, sun, rodents, well-ventilated (weighted average of percentages with good conditions assessed separately for each of three commodities: contraceptive methods, medicines and arvs) 5 soap & running water/hand disinfectant, sharps box, disinfectant, and latex gloves 6 oral rehydration solution (ors), an anti-malarial and at least one oral antibiotic 7 tests for anemia, proteinuria, glucosuria, blood group, and syphilis editorial may 2016. christian journal for global health, 3(1):3-10. theological foundations for an effective christian response to the global disease burden in resource-constrained regions daniel w. o’neill a a md, ma(ts), managing editor, cjgh; assistant professor of family medicine, university of connecticut school of medicine, usa introduction given the global spread of christianity, christians are in a critical position to effect radical change in individuals, communities, and systems for human flourishing and confront the global disease burden, injustice, and resource disparity that exists in the world. the increasing presence, activity, and faithfulness of christians among all peoples are necessary both for improved global health equity as well as the universal receiving of god’s healing message. as an expanding movement, the church has an increasing opportunity to define health, speak truth, provide care, make peace, cooperate, set priorities, and mobilize resources for maximum stewardship in low resource settings. theological correctives understanding the theological roots of our christian calling to be a healing community is vital to an effective and sustainable response to the current complexities of the global burden of disease in resource-constrained regions. serving god who is the healer, comforter, revealer, reconciler, sufferer, and redeemer, we ground our response in the very character and actions of god. his justice and mercy is revealed in his actions in history and reflected in his call to social justice and mercy among the poor and afflicted (ps 82:3; prov 31:9; jer 22:16; mat 10:8). his call to stewardship of limited resources and opposition to greed and partiality is corrective to the waste and favoritism found in many global health systems (lev 19:15; col 3:5). the high value of all human life, as made in the image of god, drives his people to protect and care for the most vulnerable populations of all races such as the underresourced, the unborn, the disabled, and the elderly at a time when materialist utilitarian ethics and eugenics are still persuasive forces in a world of exponential global population growth (gen 1:27). 1 jesus’ model of compassionate care-giving to individuals (sparrows) as well as populations (crowds) in matthew 9 affirms both curative care and public health interventions toward human health and well-being, in contrast to purely scientific and rational approaches driven by data. the concept of new covenant modeled in god’s character and laws counter an increasingly impersonal, technologically driven, and maldistributed $6.6 trillion global healthcare industry (2 cor 3:6). global inequalities and opportunities there is an estimated shortage of 4.3 million health professionals globally, and 57 of the poorest countries in the world have disproportionately severe shortages. one billion people have no access at all to a trained heath worker. subsaharan africa has the lowest ratio of trained health workers and the greatest burden of disease. there are also marked inequities within each country with rural areas having the least access, underlining a call for more innovative systembased education to meet the demands. 2 there is a similar maldistribution of church resources among the unreached and unengaged 4 o’neill may 2016. christian journal for global health, 3(1):3-10. peoples of the world. over 2 billion people are living in 4,841 people groups with very few, if any, christ-followers. 3 the value added to the health of communities when the church is planted is inestimable. as communities flourish, there is increased opportunity for the message of the saving grace of god to be heard. the ultimate divine goal and the end of history include every tribe, tongue, and nation in the manifest blessing of god’s presence (rev 7:9). the leaves of the currently inaccessible tree of life are for the healing of all nations without exception (rev 22:2); so neglect of a systemic, cooperative movement to proclaim this healing message and plant healing communities everywhere is off track with the purposes of god. this can be thought of as a pursuit of universal health coverage. as the church has expanded globally, and has increasing human and material resources in the global south, she has positioned herself as a potential influencer for health, particularly among the poor where christianity has “a breathtaking ability to transform weakness into strength.” 4 there are several ways in which the church can lead in the contemporary global health enterprise. each of these can be grounded in a robust theology informed by perspectives from the globalized church. defining health the biblical definition of health is more expansive than the broad generalization from the world health organization (who) and involves restored wholesome relationships with: 1. self — image, self-care, purpose, meaning 2. others — peace-making, intimacy, family integrity, care for neighbor, equality, forgiveness, just societies 3. nature — environmental harmony, clean water, nutrition, medicines, micro and macroorganisms 4. the creator — reconciliation, intimacy, and presence. health was the complete state described in genesis 2 and corrupted in genesis 3 and is the complete state to be gained in the consummation of a new heavens and earth (isaiah 66:22; rev 21:1). this state is best described with the hebrew word shalom and can be approximated and pursued earnestly between these two bookends of history. 5 worshiping communities seek to embody this principle of harmony, but have often fallen short in practice. when limited definitions of health are pursued, limited solutions are applied. technical and material solutions to moral and spiritual problems are insufficient — they are not sustainable. the extent to which christfollowers seek to flesh out the fullest definition of health in public conversations is the degree to which more effective and sustainable solutions will bring true lasting and widespread transformation to the nations. if human flourishing necessitates a coalesceence of well-being in these four areas, then global health promotion requires engagement with concepts of identity and purpose, ecological stewardship, environmental dominion, economic consciousness, justice in governmental and nongovernmental systems, and reconciliation with god. the hiv pandemic highlights the multifaceted effects of such a disease burden on whole communities and nations — affecting economic, social, physical, and emotional livelihood — “an evil that tears at the very heart of human life on god’s earth.” 6 this and the myriad of other diseases & infirmities globally are tangible expressions of the corruption of the planet, the often indiscriminate and far-reaching effects of sin, and the inter-relatedness of all aspects of life. the divine healing intent toward human well-being and the purpose of the gathered community as the “face of healing in the world” are manifestations of his grace. 7 the gospel provides a tangible expression of the only hope for complete healing, and the holistic mission of the church must include engagement with all four of 5 o’neill may 2016. christian journal for global health, 3(1):3-10. these areas to promote sustainable movements toward health and human flourishing. speaking truth as revealer, god not only reveals himself in the inspired word, but also in the magnificence of the created order and through his spirit. creating the material world as knowable, he calls us to apply science and observation in a rational and empirical way to address human problems. exploring the mysteries of causation and following evidence-based interventions is an exercise of dominion over the natural world. discerning solid realities from myths, while at the same time not denying spiritual truths, creates a full-orbed approach to human affliction. as he spoke the world into existence and the scriptures into writing, so he calls his people to speak the truth in love, to provoke one another toward love and good deeds, and to teach and admonish with all wisdom (eph 4:15; heb 10:24; col 1:24). this means that skills, best practices, and reflections must be shared — growing and learning together toward the goal of god-honoring improvements in global health. 8 as creator, god mandated the naming of every creature, (gen 2:19) and jesus named demons (mark 5:9), casting them out when necessary (mark 16:17). likewise, humans participate in identifying the cause of diseases, pursuing a cure or prevention when possible. these include more than pathogenic microorganisms or genetic mutations. increasingly, the diseases of excess, addiction, and meaninglessness are affecting low and middle-income countries (lmics) — the non-communicable diseases (ncds). three quarters of the 38 million deaths per year from ncds are in lmics. 9 with economic development and globalization have come unhealthy food access, sedentary lifestyles, urbanization, motor vehicle trauma, disordered mental health, and markets of addictive substances. biblical injunctions against gluttony, drunkenness, inordinate pleasures, abuse, violence, and laziness are truths that are increasingly recognized to have widespread health impact in communities. neglect of nurture and bonding in infants also has major effects on public health. 10 naming these causes of chronic illness and disability by looking at the evidence and addressing the systems which promote them are part of fulfilling this mandate. providing care a sincere longing for personal and family well-being is an innate drive of humans who retain the image of god and long for wholeness, but is often exploited by the healthcare industry or denied by oppressive social, governmental, or religious systems. 11,12 caution must be given not to allow the idolatry of physical health and safety (the diseases we fear) or the idolatry of trusting in technological healthcare systems or governments or organizations (the things we trust) to replace abiding trust in the living “god who heals.” (ex 15:26) 5 healthcare contextualized to the culture is of supreme importance, such as affirming african traditions of a dying process surrounded by family at home instead of a hospital. 13 the care rendered by jesus was exceptionally compassionate, personalized, indiscriminate, holistic, contextual, and self-sacrificial. he expects no less from his followers, who have unprecedented opportunity to retain and embody agape other-centeredness in contextualized care for the afflicted and work toward justice in all areas of life. after pentecost, the holy spirit as comforter empowers believers to comfort others with a care and concern that is unnatural and transformational (2 cor 1:4). a more robust theological understanding of god as healer will empower the church to follow in jesus’ footsteps in the power of the spirit as caregivers. making peace the church’s mandate to be a blessing to all nations, founded on the promise to abraham in genesis 12, is a means to counter the curse on the 6 o’neill may 2016. christian journal for global health, 3(1):3-10. earth and begin to restore shalom on the planet. peacemaking is a divine movement to work amid corruption to restore shalom within individuals, between people and nations, with the environment, and with our creator. as ministers of reconciliation, we participate in god’s work of reconciling the whole of creation to himself (2 cor 5:18-19). beyond proclaiming peace with god through jesus christ, this call to the church includes mental and physical health promotion and care, and extends to promote peace in areas of tribal, gender, class, and ethnic conflict. those who sow in peace reap a harvest of righteousness (justice) in communities impacted by their presence (james 3:18). this peace is not made with principalities and powers bent on destruction and the devaluation of human life such as pathogenic microorganisms and unjust oppressive systems. rather, peace is made with that which is redeemable: restored self-identity and the discipline of self-care; favorable pathogens in our microbiome and soil; the land’s crops and animal resources; geological and ecological balances; right relationships in our family and neighbors; witness in communities; affirmation of wholesome ethnic traditions and international harmony to reduce civil conflict. cooperating broadly though the church is designed to embody the fullness of truth, she does not have a monopoly on the truth. there was wisdom in the men of the east in solomon’s day (1 kings 4:30), the queen of sheba was thought able to judge the generation of jesus’ day (matt 12:42), and the cretan poets were true in their self-assessment of unhealthy practices in paul’s day (titus 1:12-13). if god can call nebuchadnezzar his servant (jer 25:9) and move the heart of cyrus (ezra 1:1), could he not also use governments and other global health actors to accomplish his purposes for the health of the nations? could the church consider greater levels of cooperation to help build health systems through ministries of health in lmics? 14 lancet published a series of articles in june 2015 that showed the important role the church plays in healthcare delivery, particularly in areas poorly served by governmental resources. they called for greater cooperation and mutual recognition between governmental organizations and faith-based organizations (fbos). 15 though jesus recognized that the people of this world are more shrewd than the people of the light (lk 16:8), he also called his disciples to be as shrewd as serpents and innocent as doves (mt 10:16). there are times when the wisdom of the world uninformed by god’s spirit and word will be foolishness (1 cor 1:20-25) and that powers designed to promote human flourishing may be corrupted and end up constraining it. however, the church must witness to those powers, working, in the words of n.t. wright, cheerfully “with the grain of good will” with people of all faiths or no faith in the art of “collaboration without compromise and of opposition without dualism.” 16 this requires deep trust in the sovereignty and immanence of god in all aspects of life, relying not on human wisdom alone but on god’s power to see true transformation and reconciliation (1 cor 2:5). interdenominational dialog and recognition of the charismatic nature of the global church in the majority world will be necessary for a unified approach to transformation. understanding that among the grassroots poor in asia, for example, christ is seen not as political liberator as in latin american liberation theology or among the elites, but as liberator from fear and fatalism caused by centuries of internalizing the law of karma, from fear of spirits, from demonic oppression (perceived or real), and through healing of diseases — especially when access to modern health care is limited or unattainable. 17 offering what samuel escobar called “transforming service” validates and confirms the truth and fullness of the gospel message. 18 7 o’neill may 2016. christian journal for global health, 3(1):3-10. setting priorities jesus modeled the priority of touch and the spoken word in healing the sick and integrated the redemption of the whole person — not resorting to its reductionist parts, nor to purely technical solutions. primary health care, embraced in the 1978 alma ata declaration through the influence of the christian medical commission, and reiterated in 2008 by the who, can be embraced and enhanced for greater global distribution. 19 christians can continue to influence goal-setting as they did with the millennium development goals (mdgs) and become more engaged to inform decisions for the next 15 years and beyond. `this year, the new sustainable development goals (sdgs) bring a new level of sophistication in seeking to be inclusive of many interrelated elements that contribute to human health, development, and also to planetary wellbeing. focusing on the complexities of systems, this goal-setting is explicitly calling for “transforming our world.” 20 to presume this can be accomplished without the transforming presence of christ and his followers is wishful thinking. while both the who definition of health and the sdgs seem utopian, there is value in setting goals for human flourishing and ecological stewardship as part of the cultural mandate of genesis 1:27-28. cooperating with all global health actors with similar goals, christians can participate in praying and acting toward these preferable futures. the third sdg is to “ensure healthy lives and promote well-being for all at all ages.” 21 this includes continuation of the mdgs for reduced maternal and child mortality, access to essential medications, and control or eradication of infectious diseases, but adds goals to reduce noncommunicable diseases, mental illness, tobacco and drug abuse, environmental hazards, and to enhance work-force and health systems along with global health threat preparation. resources, such as the disease control priorities (dcp-3), help countries improve health using evidence-based approaches in low-resource settings. 22 setting priorities based on jesus’ statement, “it is not the well who need a doctor but the sick” (luke 5:31) and paul’s ambition to make christ known where he is not (rom 15:20) will help us focus on the poorest, most vulnerable, and most infirm among global populations and the people-groups who have not yet experienced the presence of his people or his word in their own language and cultural context. this can be thought of as working toward global health equity. mobilizing resources for maximum stewardship in limited resources areas god has graciously provided a collective abundance of resources on the planet, but they are just not distributed equally or fully appropriated. just as material deprivation can lead to malnutrition, impaired immunity, crime, and disease; overabundance of resources can be harmful to body, mind, and spirit. this unequal distribution may be the results of oppression, corrupt systems, climate change, personal sin, etc., but it also may be part of the sovereign plan of god to call his people to exercise the grace of giving (2 cor 8:14-15) and to practice justice and mercy in the world as a sign of the kingdom (mat 11:5). would eradication of poverty undermine jesus’ statement that we will always have the poor with us (john 12:8)? are not the two extremes worth opposing (prov 30:8-9)? is not some degree of human deprivation beneficial: to feel the need for redemption, to seek interdependent relationships, to practice patience, and to respond to good news with gratitude and long for a better hope? after healing the crowds, jesus spoke of the blessings that reside with the poor and gave warnings to the rich that both may become a blessing to the nations (luke 6:17-26). as sustainer, god can mobilize unforeseen resources, but the injustice of an estimated 6% 8 o’neill may 2016. christian journal for global health, 3(1):3-10. fraud and embezzlement of global christian resources must be faced. 23 participating in training healthcare professionals for retained service in lmics helps meet the vast shortages and multiplies knowledge, as well as serving as an opportunity for mentoring. engaging in advocacy at the government level to create laws favorable to enhanced public health and justice is a calling to witness to the powers and cooperate with reforming systems for human flourishing. 24 embracing the public health movement to utilize community health workers to provide greater access to care can be a way to distribute christfollowers into suffering communities. as extensions to the reach of health knowledge, these empowered workers can move the locus of control from a minority of highly educated to the “strengthened hands of the poor” (ezek 16:49), and through approaches such as community health evangelism create greater witness to the truth of causes and cures of disease and the application of the gospel of peace. conclusion expanding christian communities throughout the world are indeed in a critical position to be faithful witnesses to the god who heals, to be salt and light to a health care industry that desperately needs to provide affordable, accessible, compassionate whole-person care to every population, and to influence policy and practice in global health toward equity and justice. the very character and nature of god and the call to those who follow him inform and inspire intelligent action, compassionate and comprehensive service, and effective results for human flourishing. though often unrecognized and underappreciated, the church needs to press on with increased confidence and vigor — standing in the gap to care and advocate for underserved populations, witnessing to corrupt systems for the greater good, extending god’s healing presence, and actively sending multipliers across cultures into all peoples until all things are made new. references 1. stern am. eugenic nation: faults and frontiers of better breeding in modern america, 2 nd ed. oakland: university of california press. 2016. 1-27. 2. crisp n, chen, l. global supply of health professionals. new england journal of medicine 2014; 370 (10): 950-956. http://dx.doi.org/10.1056/nejmra1111610 3. joshua project. global statistics [2015]. available from: http://joshuaproject.net/global_statistics. 4. jenkins p. the next christendom: the coming of global christianity, 3 rd ed. new york: oxford university press. 2011. 276. 5. myers bl, dufault-hunter e, voss ib, editors. health, healing and shalom: frontiers and challenges for christian health missions. pasadena, ca: wm carey library. 2015. 6. wright cjh. the mission of god: unlocking the bible’s grand narrative. downer’s grove, il: ivp press. 2006:168-9;437. 7. swartley wh. health, healing and the church’s mission: biblical perspectives and moral priorities. downer’s grove: ivp academic. 2012. 25-42. 8. larson he & o'neill d. collective wisdom and practical knowledge: the new christian journal for global health. christian journal for global health, 2014; 1(1) http://dx.doi.org/10.15566/cjgh.v1i1.26 9. world health organization. world fact sheet. noncommunicable diseases. [cited 2015, january] available from http://www.who.int/mediacentre/factsheets/fs355/en/ 10. world health organization, commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health. final report of the commission http://dx.doi.org/10.1056/nejmra1111610 http://joshuaproject.net/global_statistics http://dx.doi.org/10.15566/cjgh.v1i1.26 http://www.who.int/mediacentre/factsheets/fs355/en/ 9 o’neill may 2016. christian journal for global health, 3(1):3-10. on social determinants of health. geneva: world health organization. 2008, 50-9. 11. kotter-gruhn d, wiest m, zurek pp, scheibe s. what is it we are longing for? psychological and demographic factors influencing the contents of sehnssucht (life longings). journal of research in personality 43 (3), june 2009: 428-37. http://dx.doi.org/10.1016/j.jrp.2009.01.012 12. waitzkin h. the second sickness: contradictions of capitalist health care. (lanham, md: rowman & littlefield) 2000, 7. 13. bujo b. african theology in its social context. eugene, or: wipf & stock. 1992: 122-9. 14. pfeiffer j, johnson w, fort m, shakow a, hagopian a, gloyd s, et al. strengthening health systems in poor countries: a code of conduct for nongovernmental organizations. american journal of public health. dec 2008; 98 (12), 2134-40. http://dx.doi.org/10.2105/ajph.2007.125989 15. duff jf, buckingham ww. strengthening of partnerships between the public sector and faith-based groups. lancet 2015; 386(10005). http://dx.doi.org/10.1016/s0140-6736(15)60250-1 16. wright nt. surprised by hope. new york: harper one; 2008. p. 269. 17. chan s. grassroots asian theology: thinking the faith from the ground up. downers grove, il: ivp; 2014. p. 103. 18. escobar s. the new global mission: the gospel from everywhere to everyone. downers grove, il: ivp; 2003. p. 143-54. 19. litsios s. the christian medical commission and the development of the world health organization’s primary health care approach. american journal of public health 2004, nov 11; (11):1884-93. http://dx.doi.org/10.2105/ajph.94.11.1884 20. united nations. sustainable development knowledge platform. available from: https://sustainabledevelopment.un.org/post2015/transfo rmingourworld 21. united nations. goal three targets. sustainable development. available from: http://www.un.org/sustainabledevelopment/health/ 22. disease control priorities, 3 rd edition. (2015). department of global health, university of washington. world bank group publications. available from http://www.dcp-3.org/ 23. johnson t, zurlo g, hickman a. embezzlement in the global christian community. the review of faith and international affairs 13(2). june 2015. http://dx.doi.org/10.1080/15570274.2015.1039302 24. davis r. what about justice? toward an evangelical perspective on advocacy in development. transformation, 26(2), 2009. 89-103. http://dx.doi.org/10.1177/0265378809103385 peer reviewed competing interests: none declared. disclosures: the contents of this article were presented by the author at the international conference on christian response to global heath issues at the universitas pelita harapan on december 3, 2015 in jakarta, indonesia and published in the conference proceedings. correspondence: daniel o’neill, dwoneill@cjgh.org http://dx.doi.org/10.1016/j.jrp.2009.01.012 http://dx.doi.org/10.2105/ajph.2007.125989 http://dx.doi.org/10.1016/s0140-6736(15)60250-1 http://dx.doi.org/10.2105/ajph.94.11.1884 https://sustainabledevelopment.un.org/post2015/transformingourworld https://sustainabledevelopment.un.org/post2015/transformingourworld http://www.un.org/sustainabledevelopment/health/ http://www.dcp-3.org/ http://dx.doi.org/10.1080/15570274.2015.1039302 http://dx.doi.org/10.1177/0265378809103385 mailto:dwoneill@cjgh.org 10 o’neill may 2016. christian journal for global health, 3(1):3-10. cite this article as: o’neill dw. theological foundations for an effective christian response to the global disease burden in resource-constrained regions. christian journal for global health (may 2016), 3(1): 310. © o’neill dw this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://creativecommons.org/licenses/by/3.0/ editorial july 2018. christian journal for global health, 5(1):2-3. two cases of excluded middle? the november issue and this issue of the christian journal for global health each contain an article debating the two sides of whether and how christian organizations should support family planning in global health settings. wubbenhorst and wubbenhorst contend that use of modern, artificial contraception inevitably portends a transition to or a mentality of acceptance and promotion of abortion.1 they also question whether terms such as “unplanned pregnancy” and “unmet need” contain unexamined presuppositions. in this issue, professor henry mosley offers a vigorous response by providing evidence that modern contraceptive methods, in fact, prevent and reduce abortions.2 however, both sides of the argument contain areas that seem to us to be ripe for further comment. is it really the case, for example, that use of modern contraceptives inevitably leads to sympathy for abortion? there is no doubt that many secular organizations endorse abortion along with modern family planning methods, but this does not imply a necessary and logical progression. would a family intending to space its children also intend to do away with an untimely pregnancy? we find it difficult to accept this connection as inevitable. at the same time, there is good reason to believe that societywide changes in sexual mores have accompanied the introduction of modern contraceptives as pointed out recently by mary eberstadt.3 using historical, social, and legal reasoning, she concludes that, on a society wide basis, abortion and out-of-wedlock births have increased in parallel with increased use of modern contraceptives. she also argues that modern contraception makes pregnancy the sole responsibility of a woman, freeing men from an incentive to marry and an obligation to care for mother and child. professor mosley offers empirical evidence that introduction of modern family planning methods into societies where these had not been available resulted in reduced rates of abortion. could these be special cases and is it appropriate to compare these examples with society-wide developments in the west since the 1960s? is there not a subtle psychological shift implied in the term “unplanned pregnancy?” is it now expected that pregnancy be “planned” when formerly it was the natural outcome of a sexual relationship? it is since the introduction of modern contraception that use of the term “unexpected pregnancy” has developed currency. but how can pregnancy following sex be “unexpected?” throughout all of nature, sexual relations serve the purpose of reproduction. in human beings, have we tried to change this? is this natural? does not the term “unplanned pregnancy” reverse the normal logic of sex? whilst the wubbenhorsts tend to throw out modern contraception with the abortion bathwater, mosley reasons that it can play an important role in the health of families and in certain low income settings and that it may not necessarily promote abortion. but does professor mosley go too far in implying that the demographic transition leaves us only a choice between high birth rates along with high maternal, infant, and childhood mortality or employment of modern contraceptive methods with attendant decreased birth rates and improved survival of mother, infant, and child? is it true that without modern contraception, a reversion to developing world demographics is inevitable? in fact, birth rates declined substantially in western countries prior to the introduction of modern contraception.4,5 it appears that appropriately motivated families can reduce their family size 3 editors july 2018. christian journal for global health, 5(1):2-3. without a requirement for contraceptives. professor mosley’s reaffirmation of “population bomb” logic is challenged by contemporary commentary on this subject.6 there are good reasons why such predictions ought to be regarded as dubious.7 many variables are not scalar, functional relations between them are not known, they can be influenced by politics and fashion, and events are susceptible to being reflexive.7 but the main feature of such situations, as mcgurn points out, is that such logic neglects the greatest resource available to us which is humanity. humanity, especially when empowered by true religion, is capable of navigating successfully the ethics of family size without destroying innocent human life as well as the current challenge of demographic transition with its attendant consequences of elderly loneliness and abandonment. references 1. wubbenhorst mc, wubbenhorst, jk. should evangelical christian organizations support international family planning? christ j global heal. 2017;4(3):21-39. available from: https://doi.org/10.15566/cjgh.v4i3.184 2. mosley wh. why evangelical christians do support international family planning. christ j global heal. 2018;5(1) https://doi.org/10.15566/cjgh.v5i1.205 3. eberstadt m. the prophetic power of humanae vitae. first things. 2018; apr. available from: https://www.firstthings.com/article/2018/04/theprophetic-power-of-humanae-vitae 4. livingston g, cohn d. birth rates, 1920-2010 [internet]. in birth rate falls to a record low; decline is greatest among immigrants. pew research center social and demographic trends. 2012 nov 29. p. 3. available from: http://www.pewsocialtrends.org/2012/11/29/u-sbirth-rate-falls-to-a-record-low-decline-is-greatestamong-immigrants/ 5. roser m. children born per woman [internet]. in fertility rate. ourworldindata.org. 2018. available from: https://ourworldindata.org/fertility-rate 6. mcgurn w. the population bomb was a dud. wall street journal. 2018 apr 30. available from: https://www.wsj.com/articles/the-population-bombwas-a-dud-1525125341 7. medawar p. expectation and prediction. in pluto’s republic. oxford: oxford university press.1982. p. 302. www.cjgh.org https://doi.org/10.15566/cjgh.v4i3.184 https://doi.org/10.15566/cjgh.v5i1.205 https://www.firstthings.com/article/2018/04/the-prophetic-power-of-humanae-vitae https://www.firstthings.com/article/2018/04/the-prophetic-power-of-humanae-vitae http://www.pewsocialtrends.org/2012/11/29/u-s-birth-rate-falls-to-a-record-low-decline-is-greatest-among-immigrants/ http://www.pewsocialtrends.org/2012/11/29/u-s-birth-rate-falls-to-a-record-low-decline-is-greatest-among-immigrants/ http://www.pewsocialtrends.org/2012/11/29/u-s-birth-rate-falls-to-a-record-low-decline-is-greatest-among-immigrants/ https://ourworldindata.org/fertility-rate https://www.wsj.com/articles/the-population-bomb-was-a-dud-1525125341 https://www.wsj.com/articles/the-population-bomb-was-a-dud-1525125341 commentary nov 2014. christian journal for global health, 1(2):7-15. framing the role of the faith community in global health mark a. strand a and andrew m. cole b a phd, associate professor, pharmacy practice, master of public health program, college of pharmacy, nursing and allied sciences, north dakota state university, usa b mbbs, fafrm, conjoint associate professor, school of public health and community medicine, university of new south wales, australia abstract globalization has brought many people and organizations together. healthcare is one of the fields that has been the most prominent in global collaboration. healthcare professionals working from the framework of christian faith have been participants and leaders in global health for many years. the current challenges in global health call for the active involvement of all concerned players, christian healthcare professionals among them. in this paper, the authors suggest a unique framework for christians involved in global health to make contributions to research, scholarship, and practice innovation in this field. introduction the inauguration of the christian journal for global health is welcomed by people around the world who share a commitment to global health and the unique role that people of christian faith play in it. while the focus of the journal might seem implicit, in fact, the launching of this journal creates the opportunity for new paradigms to be explored. the purpose of this article is to propose a way of framing the role of christians in global health, and thereby invite others to work within and expand that framework. the approach of the paper is to define each of the terms, global, health and christian, and then propose a way in which the intersection of the three concepts may be understood. it is the authors’ contention that there is something distinctive about this intersection and that there is a paucity of current literature specifically describing the intersection. background in order for christians involved in global health to have impact that is distinctively christian and results in improved health for people around the world, it is important that careful consideration be given to how this might happen. ―christian‖ is here taken to mean centered on jesus christ and faithful to the bible. since early church times, christians have provided extensive health services at times when these did not exist on a public scale. 1 both before and after the reformation, catholics and protestants were deeply engaged in the establishment of healthcare and healing ministries across cultural and political boundaries. 2-4 and it can be argued that modern medicine was introduced to many regions of the world through the efforts of medical missionaries in the 19 th and 20 th centuries. 5 this rich tradition provides extensive resources from which to glean perspectives and models that might inform 8 strand and cole nov 2014. christian journal for global health, 1(2):7-15. current christian contributions in global health and could still be of relevance today. today’s global health stage is crowded with players, christians being only one group among many. 6 some, but not all, of the concerns of distinctively christian organizations and those working from a secular or another faith-based perspective may be held in common. there has been an increase in the number and influence of humanitarian global health organizations in recent decades relative to faith-based organizations. consequently, as the relative contribution of christians in global health has become less, it is imperative that christians expend additional effort to describe better their role and contributions in global health, in a way that is clear and winsome to people who may or may not share their christian faith. proposed framework the following framework for understanding a distinctive ―christian global health‖ identity and role has been constructed by the authors through selective review of the literature and extensive discussion, developing the three dimensions of christian global health. global in the third millennium of the christian era, the world has changed to become a more connected community. western nations alone are not able to direct global affairs through their selective influence or expect passive responses from other nations. the economic and technological rise of nations such as china and india is beyond dispute. new global alliances among emerging markets, such as the group of brics nations (brazil, russia, india, china, and south africa) challenge the assumption of unbroken western dominance. in healthcare, it has become even more difficult to identify which countries are sending medical assistance and which receive it. by 2009, china had helped build 30 hospitals and provided $143.9 million usd in foreign aid to help african governments treat malaria. 7, 8 therefore, any claim to be global must take seriously this reconfigured contextual reality. this currently complex age calls for carefully considered strategies and innovative leadership. medical missions now function in and deliver care through a multiplicity of agencies operating in international health — including ngos, government agencies and multilateral organizations — which has resulted in a perceived loss of the unique presence of christian medical missions in some settings. 9 it is time to create new strategies and approaches by which christian medical missions operations can establish even greater legitimacy and effectiveness. 10 this does not necessarily require multimillion-dollar investments or projects, but rather requires well-trained, well-placed individuals working together in highly effective teams for sufficiently long periods of time. it also includes partnership with the local church as appropriate. the healing mission of the church is expressed both through christian healthcare organisations and the ministry of the local church to its community, as the communities of the world determine their political and cultural context for themselves. in any given setting, a global health perspective is first informed by local health and faith movements, and then requires analyses of healthcare needs from within the local context and culture, finally being informed by models that have proven effective in other locations. clearly, this brings greater opportunity for global partners to speak for themselves and for their voice to be heard. 11, 12 global health focuses on shared challenges and problems, to which both rich and poor countries alike are vulnerable. these are best addressed by bringing global partners together to discuss solutions in settings of cooperative equality and mutual respect. 13 western nations have rapidly undergone an epidemiologic transition so they are now experiencing high rates of ageing and chronic diseases, such as diabetes and mental health disorders. 9 strand and cole nov 2014. christian journal for global health, 1(2):7-15. most regions of the world are at various stages of experiencing a similar transition, including subsaharan africa. 14, 15 transitioning a healthcare system from an acute to a chronic care model is challenging, but lessons learned in one place can be shared with another country. 16 conversely, middle income countries with highly organized healthcare systems, such as china and cuba, have had success with community-based chronic disease management models and have much to offer other countries. 17, 18 the local response to hivaids in africa has also informed both local healthcare delivery and national healthcare systems. a truly global perspective assumes that each country has something important to learn from every other country. 19 this global approach assumes the concept of ―sphere sovereignty,‖ first comprehensively formulated by the theologian and netherlands prime minister abraham kuyper. 20 sphere sovereignty posits that each area of life or societal community has its own sovereign authority, which must be objectively appraised in its own space, and no one sphere is sovereign over another, except for god’s sovereignty which is over all. therefore, critique of a given country or method must begin with an objective appraisal of that country or method in its own context, with secondary critique from an external perspective then being dependent on the antecedent objective and local understanding. the framework for global perspective being proposed is best built by the work of researchers and practitioners who are living longterm in the countries about which they write, whether as nationals or expatriates who have become culturally immersed in those countries. this assumes that one has first taken seriously what anthropologists call the emic (insider) perspective, with writing that reflects the full reality of someone who tries to understand complexity from an inside perspective. further, this approach should strive to avoid political or religious bias and must be factual and evidence-based. any bias that might influence the direction of analyses must be declared. the work should respectfully represent the corner of the globe to which it speaks. the global friends about whom the publication speaks should be aware of what is being written and participate in providing context and explanatory power. health health has been defined by the world health organization as ―a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.‖ 21 while not specifying spiritual health, this definition has space for christian concepts of whole health to be included. many christian organizations, including the world council of churches, have defined health in a way that incorporates the essentiality of the spiritual dimension of health. at the same time, it is important that evidence-based approaches are relied upon to substantiate any claims to efficacy of modern healthcare methods, the evidence having been generated by research and application. this proposed framework, therefore, assumes the use of a scientific approach to the evaluation of evidence, both qualitative and quantitative. in the pursuit of a global health perspective, evidence must be followed wherever it leads. 22 for example, the discovery of helicobacter as the agent responsible for gastric ulcers and the chinese herbal medicine qinghaosu (artemisinin) as an effective therapy for treating malaria, both required standing against intellectual inertia and prevailing wisdom. the possibility of medical breakthroughs may be uniquely open to those who are prepared to cross cultures and appreciate the special evidence then available to them. in order to increase the scholarly productivity of research partners in low and middle income countries, it will be necessary to invest more time, personnel, and resources in strengthening their research capacity. 23 this will require 10 strand and cole nov 2014. christian journal for global health, 1(2):7-15. more training in research methods and providing opportunities and resources to these global colleagues to help them engage in research. the highest standards for ethical research must be employed. global research has past egregious examples of unethical treatment of research subjects, 24, 25 so the approval of institutional review boards must be sought in all research situations. if such boards do not exist in a country, they should be created for the desired purpose of providing ethical oversight of high quality research and ethical care there, with locally appropriate informed consent from participants for any use of personal data. 26 healthcare services are expected to provide the most cost-effective care to the greatest number of people, with the subjects of research being the first to benefit from whatever is discovered as a result of their participation. therefore researchers and scholars will declare and avoid conflicts of interest with pharmaceutical companies, software designers or other financial interests that are driven by profit or control or that might compromise their commitment to bring the greatest benefit to those who need it most. christian just as healthcare information must be evidence-based, and one’s global perspective must be fair and impartial, so christian faith must adhere to historically and theologically sound criteria. as initially noted, for ―christian global health‖ to be truly christian, it must center on jesus christ, be faithful to the bible, and should reflect normative christian practices and ethics. additionally, the work of christians should be based on widely accepted best practices, and presented in a way that is discernible and reasonable to people who do not share their christian faith position, yet retaining theological integrity. a helpful concept here is that of ―middle level axioms,‖ as described by reinhold niebuhr. 27 middle level axioms are middle-ground words and concepts that are understood by multiple groups of people, even those who may not share the same theoretical perspective. for example, from a materialist perspective a principal focus in palliative or aged care may be control of the physical symptom of pain. but from a christian perspective, the hope of eternal life after death, living in god’s presence where there shall be no mourning, crying, or pain is also very real. therefore, for christians to describe research into the impact of the hope of eternal life after death, upon present pain, or coping with a painful terminal condition, would require the use of middle level axioms to describe ―the hope of eternal life,‖ in a way that a reader who adheres to a materialist perspective would understand and could then value. this might mean balancing increasing use of pain medication with a person’s desire to be able to derive comfort from personal contemplation of future life. in this case, the middle level axiom is describing increased individual pain tolerance in a terminal patient, in terms of greater ability to endure pain at the moment because of the promise or hope of a future life that goes on forever, perfectly, and without pain. christians working in global health and having long-term residence in a foreign country have a unique opportunity to contribute with deep understanding of the history, language, and culture of that country. many medical missionaries themselves are what william easterly would call searchers. 28 these are people who are on the ground, attentive to what is happening, encouraging local initiatives, and providing close accountability. 29 inasmuch as social transformation occurs at a community level, religious bodies are there, in the community, serving as a force for good, even if at times they might be perceived as being sectarian or isolationist. religious communities frequently have high levels of credibility in their local community. taylor-ide and taylor identify three main players in community change: government, professionals and the community. 30 faith-based organizations (fbos) often function as an intimate 11 strand and cole nov 2014. christian journal for global health, 1(2):7-15. participant at both the professional and community level, so they are in the ideal position to be catalysts for good work that is appropriate for that community, uniquely validating the work done by christians involved in global health. even secular agencies like unaids have identified the essential role of fbos in delivering healthcare services to aids patients. 31 one feature of the christian ethic is respect for the dignity of persons. this is shown both in the way in which one’s work is done and the way in which it is portrayed. for example, the use of images of patients or people in the community, or their medical information, should be done with individual permission and adhere to normal standards of information privacy protection. 32 the faith community thus has the opportunity to impact the direction of global health in a way that more truly reflects the needs, concerns, and hopes of communities most in need around the world. one thinks of the impact of medical missionaries through their work in the christian medical commission (cmc) that came about as a result of the tubingen consultations, established because of concerns over the operation of church health services. 33 the cmc ultimately gained the hearing of the world health organization, driving the establishment of the concept of primary health care for all, first made explicit with the alma ata declaration in 1979. 34-36 this serves as a reminder that christians can have an impact that extends well beyond their own faith community, and people who do not share their christian faith can still embrace their work, because it represents quality work and progressive ideas that uniquely address pressing needs. research and scholarship gaps the three concepts of christian, global, and health can be conceptualized by an interdependent relationship, as shown in figure 1. we suggest that much scholarship has been done in each of the three disciplines individually, represented by each individual circle. however, scholarly contributions from the areas of intersection between any two circles, and the central region where all three overlap, is far less frequent. figure 1. a model for relating the concepts of christian global health the desire is to develop innovation and scholarship at the interface of evidence-based healthcare practice and contextualized global perspectives, with that interface being fully informed by christian thinking. this clearly requires the engagement of healthcare professionals everywhere with interest in global health issues, who also have an ability to analyze the interface from a uniquely christian perspective. at the same time, the work should be inspiring to people of faith and testify to the veracity of their faith. 37 there are many ways that global health done by christians can testify to the gospel, for example, by communicating and embodying the larger vision of human origin, nature and destiny. this involves upholding belief in the dignity of each person as created in god’s image, while at the same time acknowledging the brokenness of humanity and the consequences on human experience. people who don’t believe the christian faith might not share this perspective, but christians who illuminate these issues, and behave consistently, can set forth a clear and just vision for all to see and understand. christian global health also impacts society in a normative way by establishing a whole range of social, legal, and political norms that reflect 12 strand and cole nov 2014. christian journal for global health, 1(2):7-15. the values of the kingdom of god. the recent publication of robert woodbury’s work on the social impact of what he calls ―conversionary protestant‖ christian missionaries around the world has brought this to light in a convincing manner. 38 this process calls on christians to build trusting relationships and to demonstrate honesty in one’s work in a way that is winsome and transparent. finally, christian global health testifies to the world in a truly holistic way by proclaiming the saving gospel of jesus christ to those in one’s sphere of influence. secular readers do not share this view, but it is a testimony from which sincere christians will not shrink. table 1 presents a list of research areas and examples of research questions that lie within the intersection of the circles of healthcare and global need. while not exhaustive, this list represents areas where further research into a distinctively christian approach may bring the intersection of the third christian circle into clear focus. for instance, the first example in the table, ―geriatric and restorative care in an ageing world,‖ could result in researching current clinical models in low and middle income countries, with a view to evaluating their preparedness for expanded numbers of geriatric and chronic disease patients. each of the examples in table 1, and many others that are not listed, could likewise be developed. the process of conducting this work could unfold in many ways. for example, a group of concerned persons could come together for a collaborative discussion, applying their expertise to identify existing knowledge gaps, which could then lead to identifying research needing to be done, for example in relation to developing practicable models of care. incremental research contributions would over time build a body of evidence that would be compelling. the contributions of christian healthcare workers to improved global health have been consistently reported. 39-42 however, there is much more that could be done to explore and explain the unique nature of medical care provided by christians. as evidence is generated, analyses could be done to demonstrate the distinctive aspects of the faith perspective that predict improved outcomes in patients. 43, 44 furthermore, this process could increase documentation of important work that has previously gone unrecorded. table 1. research areas to pursue and examples of gaps to be filled. research area examples special populations geriatric and restorative care in an ageing world. sustainable care for people with mental illness. end of life care in different contexts. demonstrating the efficacy of cheaper drugs compared to more expensive new drugs. health services planning, delivery and evaluation impact of providing free services or free medications. models of chronic disease management and supportive care. design of instruments to measure spiritual impact or outcomes. evidence for the effectiveness of distinctively christian global health initiatives. framework for prioritizing disease interventions using criteria reflective of the christian ethic. healthcare leadership and workforce understanding the global mental health services shortage. mental health status and risk factors for cross-cultural medical professionals. servant leadership approaches in healthcare. professionalism in healthcare rooted in christian ethical values. social and behavioral sciences human decision-making processes in the face of health crises. social, psychological and spiritual factors in holistic healthcare. causes and solutions to global human trafficking. variable distribution and causes of diseases in different populations. 13 strand and cole nov 2014. christian journal for global health, 1(2):7-15. conclusion the intersection of the circles called christian, global, and health is a rich place awaiting further exploration. at the same time, this includes the challenge to conduct this work in a way that is appropriate to the core content of each of the three domains, without violating any of the three individually. exploring the intersection of these three circles is sure to generate critical practical knowledge, which will result in expanding the evidence-base for all global health. this will ultimately improve the health of populations around the globe in a way that reflects the integrity of the christian faith. references 1. stark r. 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arch facial plastic surg. 2012;14(3):215-7. http://dx.doi.org/10.1001/archfacial. 2011.1643 27. niebuhr r. christian realism and political problems. eugene, oregon: wipf & stock; 1953. 28. easterly w. the white man’s burden: how the west’s efforts to aid the rest have done so much ill and so little good. ny: penguin books; 2006. 29. hunter jd. to change the world: the irony, tragedy and possibility of christianity in the late modern world. new york: oxford university press; 2010. 30. taylor-ide d, taylor ce. just and lasting change: when communities own their futures. baltimore: johns hopkins university press; 2002. 31. sweat m. a framework for classifying hiv prevention interventions: report to the joint united nations programme on hiv/aids (unaids). baltimore, md: the johns hopkins university bloomberg school of public health, 2008. 32. holt gr. ethical conduct in humanitarian medical missions. ii. use of photographic images. arch facial plastic surg. 2012;14(4):295-6. http://dx.doi.org 10.1001/archfacial.2011.1646 33. jansen g. christian ministry of healing on its way to the year 2000: an archaeology of medical missions. missiology: an international review. 1995;23(3):295307. http://dx.doi.org/10.1177/009182969502300304 34. cueto m. the origins of primary health care and selective primary health care. am j public health. 2004;94(11):1864-74. http://dx.doi.org/10.2105/ajph.94.11.1864 35. socrates l. the christian medical commission and the development of the world health organization's primary health care approach. am j public health. 94(11):1884-93. 36. karpf t. faith and health: past and present of relations between faith communities and the world health organization. christian journal for global health. 2014;1(1):16-25. http://dx.doi.org/10.15566/cjgh.v1i1.21 37. simons rg. competing gospels: public theology and economic theory. united states: morehouse publisher; 1995. 38. woodbury rd. the missionary roots of liberal democracy. am polit sci rev.2012;106(2):244-74. http://dx.doi.org/10.1017/s0003055412000093 39. dehaven m, hunter i, wilder l, walton j, berry j. health programs in faith-based organizations: are they effective? am j public health. 2004;94(6):1030– 6. http://dx.doi.org/10.2105/ajph.94.6.1030 40. grundmann c. the contribution of medical missions to medical education overseas. mission studies. 1992;9(17):79-99. http://dx.doi.org/10.1163/157338392x00072 41. green e. faith-based organizations: contributions to hiv prevention. harvard center for population and development studies: usaid, 2003. 42. madrid a. healthcare missions: proclaiming jesus and saving lives. leaven. 2013;21(1):4. 43. ebaugh hr, pipes pf, chafetz js, daniels m. where’s the religion? distinguishing faith-based from secular social service agencies. j sci stud relig. 2003;4(3):411–26. http://dx.doi.org/10.1111/14685906.00191 http://dx.doi.org/10.1001/jama.291.21.2639 http://dx.doi.org/10.1590/s0042-96862004001000012 http://dx.doi.org/10.1590/s0042-96862004001000012 http://dx.doi.org/10.3402/gha.v7.23569 http://dx.doi.org/10.1001/archfacial http://dx.doi.org/10.1001/archfacial.2011.1643 http://dx.doi.org/10.1177/009182969502300304 http://dx.doi.org/10.2105/ajph.94.11.1864 http://dx.doi.org/10.15566/cjgh.v1i1.21 http://dx.doi.org/10.1017/s0003055412000093 http://dx.doi.org/10.2105/ajph.94.6.1030 http://dx.doi.org/10.1163/157338392x00072 http://dx.doi.org/10.1111/1468-5906.00191 http://dx.doi.org/10.1111/1468-5906.00191 15 strand and cole nov 2014. christian journal for global health, 1(2):7-15. 44. campbell mk, hudson ma, resnicow k, blakeney n, paxton a, baskin m. churchbased health promotion interventions: evidence and lessons learned. annu rev public health. 2007;28:213–34. http://dx.doi.org/10.1146/annurev.publhealth.28.02140 6.144016 peer reviewed competing interests: none declared. correspondence: mark a strand, phd, college of pharmacy, nursing and allied sciences, north dakota state university, 118l sudro hall, fargo, nd, 58101. fax: 701-231-7606. mark.strand@ndsu.edu cite this article as: strand, ma and andrew m cole. framing the role of the faith community in global health. christian journal for global health (november 2014), 1(2):7-15. http://dx.doi.org/10.15566/cjgh.v1i2.19 © strand, m.a. and a.m. cole. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.1146/annurev.publhealth.28.021406.144016 http://dx.doi.org/10.1146/annurev.publhealth.28.021406.144016 mailto:mark.strand@ndsu.edu http://dx.doi.org/10.15566/cjgh.v1i2.19 http://creativecommons.org/licenses/by/3.0/ case study nov 2018. christian journal for global health 5(3):29-34. solving ethical dilemmas in international healthcare professional education: a case study using a revised ethical model in east africa kate thomasa, james smithb, j dwight phillipsc, shari falkenheimerd a md, united states of america b md, professor emeritus, oregon health and science university, oregon, usa c md, professor of pediatrics, department of pediatric and adolescent medicine, mayo clinic, minnesota, usa d md, phd, mph, ma, academy of fellows, center for bioethics and human dignity, trinity international university, deerfield, illinois, usa abstract ethical issues frequently arise during the practice of clinical medicine and when providing medical education. these issues become particularly challenging when practicing and teaching medicine cross-culturally. in this case study in a family medicine residency program in east africa, a structured approach to managing ethical challenges effectively was found to assist in overcoming a conflict about potentially removing a seemingly incompetent medical trainee from a residency program. the step-wise approach includes identifying relevant stakeholders; agreeing on actual background facts; understanding the various goals and values involved in the situation; reviewing locally applicable ethical, professional and legal standards; acknowledging limitations in various options to resolve the issues; and analyzing risks and benefits of the various courses of action. key words: ethics, medical education, intercultural dilemmas, east africa introduction when facing ethical dilemmas in an international healthcare professional educational setting, it is helpful to have some guidelines to make ethical decisions. dr. anji e. wall’s book “ethics for international medicine” outlines a helpful method for evaluating ethical situations and provides a template to aid in making these difficult decisions.1 for the 2017 global missions health conference’s pre-conference workshop on “professional moral and ethical dilemmas in international health care education,” we modified the method she presented to cover educational as well as clinical dilemmas. dr. wall’s method is a modification of dr. jonsen and colleagues’ approach to identify, analyze, and resolve ethical issues in clinical medicine.2 wall’s approach uses a critical analysis of the case looking at five areas: 1) who are the stakeholders in this situation? 2) what are the medical or educational (as modified for this workshop) facts involved? 3) what are the goals and values involved in this situation? 4) what are the ethical, professional and legal norms in this setting? 5) what are the limitations encountered in this situation? 30 thomas, smith, phillips & falkenheimer nov 2018. christian journal for global health 5(3):29-34. once these steps have been discussed, one must analyze options being considered as to whether they are feasible. then the stakeholders must go through a process of evaluation for each option and decide which option is the most justified. at the conclusion of the process it is hoped one option will be more justifiable than the others. finally, the decision makers should be comfortable sharing their decision-making process with the community with which they are working but also with peers and colleagues in their home practice-setting. method an ethical dilemma in resident education teaching and remediating a resident who is struggling academically can be challenging in any culture. when the resident belongs to one culture and the faculty to another, the obstacles multiply. dr. s., a second-year family medicine resident in this east african country was in his third probationary period and not meeting requirements. each probation period’s structured remediation program attempted to correct these deficiencies: multiple exam failures, recurrent failures to complete patient care duties (arriving late for call, forgetting to give patient hand-over reports, not performing physical exams, not completing documentation), “misleading” faculty (as to his activities, falsifying patient records), and poor judgement in patient care (poor differential diagnoses, wrong treatments, wrong medication doses, not precepting cases). each time the faculty placed him on probation, he corrected his deficiencies briefly, but then the same problems reemerged. the faculty worried about the growing and blatant disregard for feedback and correction in all forms. as he was finishing his third probationary period, he attempted to perform a cesarean section independently and without authorization, resulting in a poor surgical outcome. in the past, the faculty met repeatedly with the resident to discuss his remediation. after the unauthorized cesarean section incident, the faculty retained no hope for rehabilitation. they feared the problem involved insufficient motivation to be a competent physician and possibly a character flaw as exhibited by recurrent indifference for patient safety. after lengthy deliberation, the faculty unanimously decided to have the resident leave the program. however, the following day, dr. y., the medical school dean who oversaw the residency program, informed the program director that this resident could not be removed from the program, but he would speak with dr. s. about his behaviors. applying wall’s framework when first faced with a moral dilemma, the emotional response often initially clouds the mental ability to problem-solve effectively. in this situation, the faculty, after failing to effectively remediate a struggling resident despite their best attempts, learned from dr. y. that they were obligated to keep the resident within the training program. wall provides a framework to deliberately and succinctly work through difficult ethical questions, which can be effectively applied to moral dilemmas in international medical education. who are the stakeholders? at first glance, this case involves the resident, the family medicine faculty, and the medical school dean. a closer look reveals the other stakeholders: the patients and their families for whom the resident provides care; the resident’s family who expect the resident to bring them honor and a paycheck; the other residents requiring attention, supervision, and teaching from the faculty; the community expecting the university to graduate competent physicians; the other university officials who want to produce an adequate number of physicians for the country and to retain qualified expatriate teachers (medical and nonmedical); and the faculty’s organization which has a long term relationship with dr. y. and the other university officials. 31 thomas, smith, phillips & falkenheimer nov 2018. christian journal for global health 5(3):29-34. what are the facts? the resident consistently performed at a substandard level despite multiple remediation and probationary periods. this led directly to significant and recurrent compromises in patient care and safety. the resident’s actions dismissed multiple foundational values to which the training program formally ascribed and of which all trainees were fully informed; the values included patients first, integrity, respect, life-long learning, and excellence. the resident’s family held power and influence in the community and was distantly related to dr. y. all the faculty members came from the same culture but lived in a foreign country. the resident and all other stakeholders belonged to this country, and they held a significantly different worldview than the faculty members. the faculty members worked for the university as volunteers, but they were part of a larger humanitarian organization. this organization, which had other non-medical personnel volunteering within the university, enjoyed a long and deep relationship with the university officials and the dean. what are the goals and values of each stakeholder? what does each person or group want? what is important to each of them? for simplicity, this discussion includes only the resident, the patients, their families, the dean (who represents the university officials), and the faculty as the major stakeholders. the resident wanted to graduate and enjoy the status as a specialist physician within the community. he valued upholding his family’s honor, which included the dean, and knew his family’s status in the community helped him maintain his position within the residency program. the patients and their families wanted the patient’s health to improve. they desired healing. in the situation involving the woman who needed a cesarean section, the family wanted a live and healthy mother and baby. the patients and families valued physician competency and patient safety. dependent upon physician availability (or lack thereof), they only held the power to accept the care offered or to refuse it. dr. y. wanted to see the residency program succeed in the cultural context by graduating competent family medicine doctors who served their communities. as a physician and community leader, he desired to see improved health status and outcomes for his fellow community members and countrymen. he wanted to avoid a permanent breach in his relationship with the resident’s immediate family, the faculty, and the community. he valued his relationship with the resident and the faculty, and viewed himself as the mediator between the two parties directly involved in the conflict. he also valued his position as a spokesperson for and a member of the community and university leadership. in addition to the goals and values held by the dean, university officials also enjoyed a good working relationship with the faculty’s humanitarian organization. while they valued and depended on the faculty’s expertise to administer the residency program, the program belonged to the university. although long-term partners, the faculty remained expatriate guests within the university system. the faculty wanted to graduate competent family medicine physicians able to achieve high objective standards in patient care and professionalism. while the other residents watched to see if the program’s educational standards were upheld, the faculty knew residents’ future performance would diminish if substandard performance was accepted without remediation. they valued whole person care and growth for patients and residents. they upheld honesty and integrity in both themselves and in their learners, the residents. they valued christ and his glory, and desired their words and deeds to reflect jesus messiah to those around them, especially as no other christian witness existed within the region. 32 thomas, smith, phillips & falkenheimer nov 2018. christian journal for global health 5(3):29-34. what are the ethical, professional, and legal norms in this setting? in this situation, the familiar biomedicine ethical considerations applied, including autonomy, beneficence, non-maleficence, and justice. professional standards included patient safety and competent care. legal norms defining confidentiality, patient’s rights, and malpractice varied drastically between the two cultures. as often encountered in international health educational settings, different cultures and their contrasting approaches to resolve conflicts played a major role in this ethical dilemma. the local culture upheld honor and avoided shame to such a high degree that it affected every relationship, even in ways that were incomprehensible to the faculty. in this culture, relationships held more importance than truth. conflict resolution occurred indirectly, between third parties, to restore honor and minimize the shame attributed to the individuals directly involved in the conflict. what are the limitations? the stakeholders belonged to two different cultures and embraced different worldviews. the faculty maintained the responsibility to teach and train but held limited authority to make employment decisions. dr. y.’s relationships with the faculty, their organization, the community, the resident and his family varied in depth and significance, and influenced his role as a decision-maker. faculty members perceived limitations in time and personnel to teach all the residents effectively and thoroughly. the faculty also admitted to personal limitations in their waning goodwill towards the resident. moving towards resolution: identify possible options to solve this dilemma, what solutions were available? were there only two options – keep the resident or have him leave the program? was a compromise achievable? other possible responses included refusing to train and supervise the resident, allowing the resident to graduate and practice medicine despite his inability to meet the qualifying standards, quietly negotiating with the dean and resident’s family to find another honorable position/employment, requiring the resident to repeat a year of residency training with increased supervision from local physicians, and improving the faculty’s ability to provide culturally appropriate feedback, assessment, and evaluation. moving towards resolution: analysis and justification of options during the analysis and justification of options, major stakeholders need to agree on a solution that effectively reaches the desired goal. while evaluating each option, it is best to consider if the benefits outweigh the risk or infringe on the values and norms of each stakeholder. is infringement even necessary? how can the infringements be minimized? can each stakeholder communicate his/her decision-making process or rationale with the other stakeholders? final resolution in this real-life scenario, dr. y., as the university’s representative, held decision-making power. like the faculty, he valued graduating competent physicians; however, cultural norms dictated removing a resident from the program was an inconceivable and impossible option because the resultant shame would cover everyone involved – the resident, his family, the university, the faculty, and the community. the faculty refused to advance dr. s. to his third year and recommended he repeat his entire second year since he could not be removed from the program. after deliberation, dr. y. agreed to require the resident to repeat his second year. to a lesser degree, this option also brought shame upon dr. s. but allowed him to remain as a member within the family medicine residency program. this option also incorporated the dean and faculty’s value and aim to graduate competent physicians. during a private meeting with dr. s., dr. y. realized dr. s.’s 33 thomas, smith, phillips & falkenheimer nov 2018. christian journal for global health 5(3):29-34. inability to immediately restart his second year: dr. s. needed a reprieve from the constant pressure under academic scrutiny. dr. y. demanded dr. s. take a one-year leave from the residency program to contemplate if he really wanted to be a family medicine physician. for the year, dr. y. found employment for dr. s. where he could serve in a remote community with no modern healthcare access. after a year, dr. s. could elect to return to the residency program and repeat the second training year or seek employment elsewhere. the resident, his family, and the faculty agreed to this solution. the remote community accepted the resident gratefully because dr. s. possessed more skills and competency than any other practitioner available. after a daunting yet growth-provoking year, dr. s. returned home and rejoined the training program motivated and eager to learn. two years later, he graduated as a family medicine physician, fulfilling all the program’s training and competency requirements. discussion in this scenario, the successful remediation for this physician far exceeded the faculty’s expectations. on his return, dr. s. displayed humility by willingly receiving corrective criticisms and consistently requesting feedback. when reviewing the entire process, the faculty identified several factors which they believed contributed to the successful outcome and could be instituted in other international medical education settings to curb ethical cross-cultural quandaries before they arise. as previously mentioned, the faculty valued their witness of jesus in a society that rejected him. working within a community that knew of their claim to be followers of jesus messiah, the faculty realized their response to the resident and this ethical dilemma had to mirror their beliefs. upon review, the faculty identified the most important factor leading to a favorable outcome — prayer. from the start, when the faculty first contemplated the terms of the initial probation, praying had also begun. the faculty requested their non-medical colleagues from the same organization join them in prayer for dr. s., themselves, and the difficult situation. together, they offered praise to god for his sovereignty even in trying circumstances and requested wisdom, love, forgiveness, integrity, and peace. during the resident’s year away, the prayers continued on his behalf. another contributing factor to this successful story involved establishing a strong educational foundation for the residency program before problems presented themselves. since its creation, the residency program stood rooted within a valuesbased education system. the faculty discussed these values often with the residents and frequently applied them to clinical cases. the program kept easily accessible written expectations for the residents and reviewed them at the beginning of each academic year and each rotation. the residents received routine oral and written evaluations and feedback. the main sections within the written evaluations were derived directly from the program’s values. over time, the residents learned how their performance as physicians reflected these values. all patient safety and disciplinary incidences received a documented review at the time they occured. the faculty enumerated these educational factors as contributing to a successful outcome in this ethical scenario: the dean, the faculty, and the resident clearly understood the expectations and the resident’s delinquencies. another institutional factor, the disciplinary advisory board, also contributed to this success. the dean and other university leaders served as board members and retained final decision-making authority. although the faculty recommended removing the resident from the program, the board, fully versed in their own cultural norms, decided to retain the resident within the program to avoid unacceptable shame. the faculty also identified providing the resident with a knowledgeable advocate (in this case, the chief resident) which led to a successful remediation. finally, as christ’s image-bearers, the faculty recognized their need to constantly remember: love 34 thomas, smith, phillips & falkenheimer nov 2018. christian journal for global health 5(3):29-34. is patient, kind, does not dishonor, keeps no record of wrongs, always protects, always trusts, always hopes, always perseveres.3 this persistent determination to allow love to motivate actions enabled the faculty to receive the resident after the year’s leave and see him fully remediated, growing into a competent family medicine physician. conclusion wall’s approach to ethical and moral dilemmas may work well when applied to other medical education problems, even in an international setting involving different cultures and divergent worldviews. in our experience, following this method leads to improved clarity when attempting to address challenging educational situations. establishing a values-based educational system assists in identifying and defining problems early in the process. once an ethical dilemma emerges, praying for wisdom and permitting love to motivate actions enables one to maintain a god-glorifying witness even in difficult circumstances. references 1. wall ae. ethics for international medicine: a practical guide for aid workers in developing countries. hanover, nh: dartmouth college press; 2012. 2. jonsen ar, siegler m, winsdale wj. clinical ethics: a practical approach to ethical decisions in clinical medicine. new york: mcgraw-hill medical; 2010. 3. i corinthians 13:4-7. holy bible. new international version peer reviewed: submitted 10 july 2018, accepted 8 sept 2018, published 9 nov 2018 competing interests: none declared. correspondence: kate thomas, gmhc, united states of america. drkthomas18@gmail.com cite this article as: thomas k, smith j, phillips jd, falkenheimer s. solving ethical dilemmas in international healthcare professional education: a case study using a revised ethical model. christian journal for global health. nov 2018; 5(3):29-34. https://doi.org/10.15566/cjgh.v5i3.233 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:drkthomas18@gmail.com https://doi.org/10.15566/cjgh.v5i3.233 http://creativecommons.org/licenses/by/4.0/ editorial nov 2018. christian journal for global health 5(3):1-2. following christ in global health service the call for papers for this third issue of 2018 was “following christ in global health service.” the editors hoped for submissions that illustrated how jesus’ life and ministry inspired, guided, and empowered specific efforts in global health. professor christopher grundmann provides a scholarly and thoughtful review in christ as physician of how efforts for physical healing were intrinsic to jesus’ ministry. that is, he became known as a physician as early as the second century of the common era. practicing medicine, especially in countries receiving missionary outreach in more modern times, was in the imitation of christ and helped to reinforce the corporeality of salvation. this is relevant to our own day in light of our prevalent cultural gnosticism and reductionism. part of following christ’s character is to practice the highest ethics. two contributions in this issue have to do with teaching and implementing ethical decision making in the training of young physicians cross-culturally. eric mclaughlin and alyssa pfister have developed a case-based approach to ethical decision making that is relevant to a rural african context in burundi. the approach combines the principles of beneficence, non-maleficence, autonomy, and justice with the uniquely christian principles of sanctity of life, stewardship of creation, the fall, suffering and death, miracles, the sovereignty of god, grace and mercy, compassion, and hope. the paper gives examples of the cases used, a framework for case discussions, and examples of several themes that, with experience, help facilitate learning. kate thomas and her colleagues describe a challenging case report dealing with an apparently incompetent and unethical medical resident in a training program in east africa. the challenge involved maintaining integrity in the training program while dealing with the restraints imposed by the local culture and professional relationships. meeting this challenge, they show how an established stepwise approach helped to manage the various conflicts. jesus integrated a spiritual world view into everyday life amid social, physical, and political challenges of his day. an original article by jason paltzer describes the results of a survey of christian public health training programs to determine the extent to which a christian world view can be incorporated into such trainings. thematic analysis of the results demonstrated significant success in integrating biblical values into some areas of understanding, but challenges in doing so in other areas, calling for further research. jesus demonstrated love for one’s neighbor as the fulfilment of the law, and this included the foreigner. two submissions reference judith lasker’s 2016 book, hoping to help: the promises and pitfalls of global health volunteering. professor laura montgomery provides an evaluative review of the book, commenting on both its strengths and weaknesses. rebecca houweling and barbara astle provide a case study of an effort to apply the principles suggested by lasker to an ongoing, multiyear short-term mission effort in nepal. robert mitchell describes research being conducted by the church agencies network disaster operations (can do) to provide a theological basis for disaster risk management in the south pacific. the incarnation speaks of the sacredness of human life in the body, and the atonement speaks of the sacrifice and unity which is borne out in the body. in her poem, god in a cup, martha carlough reflects on the two disparate worlds of a missionary http://journal.cjgh.org/index.php/cjgh/article/view/236 http://journal.cjgh.org/index.php/cjgh/article/view/236 http://journal.cjgh.org/index.php/cjgh/article/view/229 http://journal.cjgh.org/index.php/cjgh/article/view/229 http://journal.cjgh.org/index.php/cjgh/article/view/233 http://journal.cjgh.org/index.php/cjgh/article/view/228 http://journal.cjgh.org/index.php/cjgh/article/view/228 http://journal.cjgh.org/index.php/cjgh/article/view/246 http://journal.cjgh.org/index.php/cjgh/article/view/235 http://journal.cjgh.org/index.php/cjgh/article/view/238 http://journal.cjgh.org/index.php/cjgh/article/view/238 http://journal.cjgh.org/index.php/cjgh/article/view/234 2 editorial nov 2018. christian journal for global health 5(3):1-2. – life back home and in the context of nepal – brought together by the common experience of the sacrament of communion. poet sarah larkin offers what is the cry of my heart? a collective reflection from the 7th triennial micah global consultation on integral mission and resilient communities in philippines in september.1 following christ is a widespread and diverse phenomenon as the gospel is contextualized in various global cultures. this is demonstrated in a conference report about the xvith world congress of the international christian medical and dental associations where two of our journal editors presented a session on research and publishing in august.2 the challenge for christ-followers going forward will be to identify and retain their distinctives, to share those distinctives clearly in a pluralistic world, to retain the best practices of quality service based on biblical and scientific evidence, to hold to the highest virtue and deontological ethics, and to extol the supremacy of christ for the health of nations. this will be vital especially as the global conference on primary health care was held in october in astana, kazakstan, 40 years after the christian medical commission-influenced alma-atta conference.3 caring and access is more important than ever before in this world of disparities, climate change, disasters, displacement, epidemics and conflict. caring among the nations with compassion, engagement, integrity, resilience, wisdom and hope is following the way of the messiah. references 1. micah global [internet]. micah 7th triennial consultation. 10-14 september 2018. tagaytay city, cavite, philippines. available from: http://micahgc2018.org 2. international christian medical and dental associations [internet]. xvi world congress. 21-26 august 2018. hyderabad, india. available from: http://icmda2018.org 3. world health organization. global conference in primary health care. astana, kazakhstan. 25-26 october 2018. [internet]. available from: www.who.int/primary-health/conference-phc http://journal.cjgh.org/index.php/cjgh/article/view/257 http://micahgc2018.org/ http://icmda2018.org/ http://www.who.int/primary-health/conference-phc commentary nov 2016. christian journal for global health, 3(2): 107-112. an educational model for preparing christian nurses and church congregations to offer local whole-person health programmes helen anne wordsworth a a dmin, mth, rn, founder and ceo of parish nursing ministries and associate fellow at university of durham department of theology, uk abstract the implications of the tübingen declarations for congregational involvement in health provide the setting for this commentary. using an example from the united kingdom, where government health provision has become economically challenging and largely disease focused, the author demonstrates how it is possible to introduce the kind of education for nurses and congregations that will lead to them becoming important sources of whole-person health promotion. in this way, parish nurses and church congregations may make a distinctive contribution that will complement state and private health provision. this model has relevance across all christian denominations. it is already being followed in 28 different countries, and with appropriate respect to culture, language and health policy, could be globally transferable. introduction the article by professor flessa in the may 2016 edition of the christian journal for global health reviews the declarations of tübingen in the 1960s, in the light of the subsequent development of contemporary global health provision. 1 flessa suggests that even in the christian hospitals and clinics, care has moved away from the whole person approach advocated by the tübingen papers, and focuses largely on the cure or prevention of specific physical or mental conditions. moreover, in low and middle income countries, the rise of good private and government provision, often much less expensive for the patient, has left the christian health clinics and hospitals unable to compete economically. flessa challenges the churches to review their role in global health; to decide “what criteria make them special,” and to consider, “how they can find their place in the health care market.” he suggests that if christian influence in health and healing is to survive, the church must have something distinctive to offer. 2 what then is that distinctive? the theological concept of personhood and life in the old and new testaments implies an understanding of health that is more than purely the absence of specific physical or mental ailments. 3 it encompasses community wellbeing, peace, justice, forgiveness, service with god and others, 108 wordsworth nov 2016. christian journal for global health, 3(2): 107-112. purpose, identity, the ability to give as well as receive, to use one’s gifts, to be able to pray and to worship god, to choose good and to resist evil, to care for the environment, and enjoy god’s creation. this is whole-person health, or “wholistic health” (the w differentiates it from the new age concept of holism), and should underlie and direct the christian approach to health provision. the tübingen documents of 1964 and 1968 appear to present this concept of health. they state that: the christian church has a specific task in the field of healing arising from its understanding of its place in the whole christian belief about god’s plan of salvation for mankind. the same documents then go on to suggest that the christian ministry of healing belongs primarily to the congregation as a whole and only in that context to those who are already trained. 2 in 2014, a further consultation in germany resulted in the publication of tübingen iii. it affirms that the christian church continues to have a unique, relevant and specific role to play in health. 4 this commentary concerns one way in which the local congregation may enter in to this role, led by a specially trained and experienced community nurse. 5 it will describe how christian nurses who have no opportunity to offer wholeperson care in a secular environment can be educated to combine their nursing experience with christian spiritual care and to work with the church, encouraging the congregation to reach out to the community in health promotional ways. background westberg, a lutheran hospital chaplain and pioneer in the field of whole person health, saw the potential for nurses to use their skills with congregations in the 1970s. 6 in 1986, westberg pioneered the way, attaching nurses to the ministry teams of six churches in the chicago region of the united states. parish nursing, also known as faith community nursing, is now practiced by christian churches and organisations in 28 countries throughout the world. it was adopted first in canada, then australia, new zealand, south africa, the uk, and now south asia, sub-saharan africa, the middle east, and south america. it combines a judaeo-christian understanding of health with nursing skills and a congregational involvement in health promotion. parish nurses work by invitation with people of all ages, all faiths or no faith. they encourage healthy living, help people regain independence after surgery or acute illness, support selfmanagement of chronic conditions, and offer nonspecialist end of life care. 7 they do not do invasive treatments or prescribe medications. in this way, they complement rather than compete with government and private provision. education for this specialty has developed over the last twenty years and the core curriculum is now available to be translated and appropriately adjusted for different cultures and languages. 8 before the introduction of the national health service in the uk in1948 churches had been actively engaged in practical health and healing ministries. as government provision became more established, they tended to withdraw from this aspect of their ministry. this was evidenced in the changing role of deaconesses, who were the forerunners of contemporary parish nurses; they moved from being churchbased nurses in the community to being accredited ministers in the church, and so congregations no longer played such an active role in health. 9 since then, like many “global north” and “global south” countries, health provision in the uk through both government and private providers has focused largely on the relief and cure of specific physical disease. but universal government provision has become economically difficult. an ageing population and the availability of new but expensive treatments for these diseases means that the time and resources 109 wordsworth nov 2016. christian journal for global health, 3(2): 107-112. left for public health programmes, mental health conditions, and spiritual care are limited. although a patient in hospital may ask for a visit from a chaplain, and a few notable gp surgeries provide a chaplaincy service, this does not meet all of the whole person health ideals set out by the tübingen declarations. during the nineteen seventies, hospitals also began to lose the act of daily prayer that had been part of ward life in the nineteen fifties and sixties. nurses now employed in the government sector are not permitted to talk about faith or pray with patients unless the patient specifically requests that and the nurse manager agrees that it may be appropriate. there have been some legal cases around this, and the result is that christian nurses have tended to separate their nursing employment from their faith life. they are not therefore used to praying with patients. and whilst spiritual care is acknowledged as important, it is poorly understood, and there is little nursing time to focus on anything but urgent physical need. this is evidenced in nursing literature, most recently by selby, d. et al. they studied 21 health care practitioners in an acute setting, including seven nurses, and found that: despite spirituality being highlighted as important to care, few hcps (health care professionals) felt able to provide this, raising questions around how such care can be encouraged and developed in busy acute care settings. 10 this faces the church with the following challenge: if christian nurses are to work with congregations and communities in promoting whole person health, how may they be educated and given permission to rediscover the ministry of prayer in appropriate ways with patients? how should they learn how to work with volunteers? and if congregations are to be more active in whole person health ministry, how are church leadership teams to be persuaded that wholeperson health demands their attention? in the uk, these questions have given rise to the progressive development of learning support for both nurses and congregations over the last twelve years, which has so far resulted in more than 85 churches of all denominations currently active in health ministry through parish nursing. 11 educating nurses the westberg institute for faith community nursing, (formerly the international parish nurse resource centre) has developed some post registration/licensure education for this nursing specialty. 12 for a fee, medical institutions and universities may become “educational affiliates” and then offer the curriculum in an appropriate way for their own countries. parish nursing ministries uk became an international affiliate of this programme in 2005 and were given permission to adapt the curriculum to the educational needs of nurses working in the uk context. the latest revision provides 35 hours of interactive content and is divided into the following sections:  spiritual care: includes understanding of your own and other faiths, and prayer.  professional issues: includes legal issues, ethics, record-keeping, and team-working.  whole-person health: includes health education, family violence, and mental health.  community development: includes volunteer recruitment, training, and coordination several institutions have devised web-based versions of the curriculum. but the context in the uk demands that it should be done with interactive small group teaching. some nurses come to the course fearful of acknowledging that they are christians in our multicultural state provision. they have very little understanding of the theological rationale for whole person care or of how to make connections between their faith and the nursing profession. therefore, more content around the hebraic concept of wholism has been added. the new testament emphasis on the integration of spiritual healing with physical healing, spiritual care assessment, and appropriate 110 wordsworth nov 2016. christian journal for global health, 3(2): 107-112. ways of discovering whether or not a patient would like to have prayer is taught. there is also now a module on leadership. this version of the core curriculum is called the “preparation for practice course,” and is run over five days, four of which are residential. in addition, a two-day course for health care assistants is soon to be offered for those without current nursing registration, but who wish to work from their church under the leadership of a registered parish nurse. 13 evaluation forms are collected at the end of the four-day residential, and these have been consistently positive. a portfolio of practice in the first year is also requested, which leads to the award of a badge and certificate. the portfolio includes a 1000 word summary of how the nurse sees the practice of parish nursing; a case study showing the way in which integrated care has been delivered; a theological and professional reflective piece; notes on a mentoring meeting; evidence of congregational involvement; and future plans for the ministry. this helps to evaluate the effectiveness of the course teaching, ensuring that theory turns into practice. a refresher course over two days for those who have been in practice for three years is soon to be offered. educating churches if the challenge faced in educating the nurses for this ministry is demanding, that of educating the congregation is perhaps even more difficult. the notable exception is that older members of the congregation may have grandparents that may have told of the parish nurse who went about the community working with the poor and the sick, and their approval may be more forthcoming. the leadership team, many of whom have other work pressures, face many expectations, including church management, building maintenance, legal issues, theological and pastoral concerns. they are left with little time for local mission work or community outreach, let alone health. for too long these leadership teams have seen health as the task of the state, and they may view any attempt by the church to engage with it as politically unhelpful, potentially relieving the state of its responsibilities. but the theological and missional rationale becomes apparent when seen in the light of missio dei — the mission of god in the world. it becomes compelling when viewed in the context of the biblical principles of disciples of christ being called to reach out to their neighbours in wholistic healing activities and of integration of the spiritual and physical aspects of life. these themes should be developed in theological colleges, in leadership seminars, and in ministers’ conferences. a doctoral thesis on health as a mission of the church has now been published, and a practical guide for clergy is about to become available. 14, 15 for a church to re-engage with health ministry requires professional support and so a not for profit organisation has been set up in the uk. promotional and training aspects of health ministry are provided by this organization. regional coordinators meet with the nurse and church leadership and offer a set of quality standards. when these are in place, the church’s parish nursing service receives accreditation reviewed annually. the task of educating the congregation happens at both a formal and informal level. global developments this example from the uk is just one small part of a much larger movement. the westberg institute for faith community nursing not only provides educational resources for thousands of churches and nurses across america and canada, but also a world forum in which international affiliates share learning and experience. this forum is divided into regions; there is one for asia, africa, australasia, south america, and europe. there are now parish nurses or faith 111 wordsworth nov 2016. christian journal for global health, 3(2): 107-112. community nurses in each of the continents. education for these nurses has been provided using the same basic curriculum in a contextualised way, so that, for example, in kenya where hiv and malaria are major challenges, there are additional modules on those topics. the core curriculum is now available to be purchased and translated by applying to the westberg institute for faith community nursing. 16 in europe, finland still has the lutheran “diakonie” in its original form, with nurses attached to each church and a formal method of training that includes a theology component. elsewhere, the “diakonie” has become more focused on institutional care for the elderly and vulnerable. in germany, a new and growing movement called “vis-a-vis” has been started by a nurse who came to the uk to train as a parish nurse, and in the ukraine, a missionary nurse teaches the core curriculum to nurses from a variety of denominations across the country. 17 the first european conference on parish nursing is to be held in germany in 2016. conclusion churches can offer a distinctive contribution to local community health by appointing or employing registered nurses to develop health promotional programmes that include a spiritual care component. in order to do this pioneering work, they will need educational input and professional support. the curriculum that has been developed in the us is inexpensive, and as demonstrated in this commentary is both adaptable and transferable. its potential for use across many contexts should not be underestimated. it refocuses the church’s mission on public health with the added dimension of care of the spirit. global support and professional networking are available. references 1. flessa s. christian milestones in global health: the declarations of tübingen. christ j glob heal, may 2016;3(1):11-24. http://dx.doi.org/10.15566/cjgh.v3i1.96 2. mcgilvray jc. the quest for health and wholeness. tübingen: german institute for medical missions; 1981. 3. wilkinson j. the bible and healing; a medical and theological commentary. edinburgh: handsel press; 1998. 4. german institute for medical missions. symposium proceedings, christian responses to health and development. a call to health and healing — declaration tübingen iii.2014. available from: https://www.oikoumene.org/en/resources/documen ts/other-meetings/a-call-to-health-and-healingdeclaration-tubingen-iii 5. patterson d. the essential parish nurse. cleveland, ohio: pilgrim press, 2003. 6. westberg ge. the parish nurse: providing a minister of health for your congregation. westberg mcnamara j, editor. minneapolis: augsburg fortress, 1990. 7. wordsworth h, moore r, woodhouse d. parish nursing: a unique resource for community and district nurses. brit j community nurs. 2016 feb 1;21(2). http://dx.doi.org/10.12968/bjcn.2016.21.2.66 8. westberg institute for faith community nursing. foundations of faith community nursing curriculum. [2014 revision] 9. wordsworth h. rediscovering a ministry of health; parish nursing as a mission of the local church. oregon: wipf and stock, 2015. 10. selby d, seccaraccia d, huth j, kurrpa k, fitch,m.. a qualitative analysis of a healthcare professional's understanding and approach to management of spiritual distress in an acute care setting. j palliat med. oct 2016. [ahead of print] http://dx.doi.org/10.1089/jpm.2016.0135 11. parish nursing ministries uk. available from: www.parishnursing.org.uk 12. the westberg institute for faith community nursing, church health centre, memphis, tn. available from: www.churchhealthcenter.org/westberg-institute http://dx.doi.org/10.15566/cjgh.v3i1.96 https://www.oikoumene.org/en/resources/documents/other-meetings/a-call-to-health-and-healing-declaration-tubingen-iii https://www.oikoumene.org/en/resources/documents/other-meetings/a-call-to-health-and-healing-declaration-tubingen-iii https://www.oikoumene.org/en/resources/documents/other-meetings/a-call-to-health-and-healing-declaration-tubingen-iii http://dx.doi.org/10.12968/bjcn.2016.21.2.66 http://dx.doi.org/10.1089/jpm.2016.0135 file:///c:/users/user/appdata/local/temp/www.parishnursing.org.uk file:///c:/users/user/appdata/local/temp/www.churchhealthcenter.org/westberg-institute 112 wordsworth nov 2016. christian journal for global health, 3(2): 107-112. 13. parish nursing ministries uk and the westberg institute for faith community nursing. preparation for practice workbook. 2016. 14. wordsworth h. rediscovering a ministry of health; parish nursing as a mission of the local church. oregon: wipf and stock, . 15. wordsworth h. nursing and the mission of the church. oxford: grovebooks, 2016. 16. the westberg institute for faith community nursing, church health centre, memphis, tn. available from: www.churchhealthcenter.org/westberg-institute 17. wordsworth h. health ministry through local faith communities: a european perspective. community practitioner. 2014 jan 1;87(1):24-8. available from: http://www.ncbi.nlm.nih.gov/pubmed/24597058 peer reviewed competing interests: none declared. correspondence: rev. dr. helen anne wordsworth, parish nursing ministries uk. rev.h@rhwordsworth.plus.com cite this article as: wordsworth ha. an educational model for preparing christian nurses and church congregations to offer local whole-person health programmes. christian journal for global health (nov 2016), 3(2):107-112. © wordsworth ha. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org file:///c:/users/user/appdata/local/temp/www.churchhealthcenter.org/westberg-institute http://www.ncbi.nlm.nih.gov/pubmed/24597058 mailto:rev.h@rhwordsworth.plus.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ sept 2018. christian journal for global health, 5(2):37-42. field report living the gospel through the feet of a refugee: sharing abraham’s hope in kindness and humility dale roemer agnera a md, clarkson family medicine residency-nebraska medicine, usa the hope and humility of the gospel took on new meaning for me one night in a central european free-clinic for refugees. with a syrian refugee translator, we treated fellow sons and daughters of abraham from syria, iraq, and additional refugees from throughout areas of asia. many years prior, our young family lived for two years in asia minor, better known as modern-day western turkey. we studied and traveled the biblical lands of the seven churches, israel, galatia, cappadocia, and many of the coastlands in greece and turkey along paul’s missionary journeys. this current migration is along these areas.1 i even visited areas near haran and antioch, bordering syria. haran is where abraham briefly sojourned.2 antioch is where early believers demonstrated god’s grace and were the first to be called christians.3 it is easy to study and travel; it is difficult to truly practice humility as a daily way of life. a special grace and insight took place that evening upon, figuratively, washing and clothing the worn feet of a refugee. the kindness and honor practically demonstrated moved our translator to honestly inquire about the light and hope of abraham, as abraham’s hope is briefly recounted below: by faith abraham obeyed . . . and he went out, not knowing where he was going . . . living in tents with isaac and jacob, heirs with him of the same promise. for he was looking forward to the city that has foundations, whose designer and builder is god . . . and having acknowledged that they were strangers and exiles on the earth . . . but as it is, they desire a better country, that is, a heavenly one. therefore, god is not ashamed to be called their god . . . and all these, though commended through their faith, did not receive what was promised, since god had provided something better for us, that apart from us they should not be made perfect (hebrews 11:8-10, 13, 16, 39-40). 4 so'journer, n. a temporary resident; a stranger or traveler who dwells in a place for a time. for we are strangers before you and sojourners, as all our fathers were. our days on the earth are like a shadow, and there is no abiding (1 chronicles 29:15). 5 . . . his {abraham’s] faith was "counted to him as righteousness." but the words "it was counted to him" were not written for his sake alone, but for ours also. it will be counted to us who believe in him who raised from the dead jesus our lord . . . (romans 4:22-24). for i consider that the sufferings of this present time are not worth comparing with the glory that is to be revealed to us. for the creation waits with eager longing for the revealing of the sons of god. for the creation was subjected to futility, not willingly, but because of him who subjected it, in hope that the creation itself 38 agner sept 2018. christian journal for global health, 5(2):37-42. will be set free from its bondage to corruption and obtain the freedom of the glory of the children of god (romans 8:1821). thousands of abraham’s descendants from syria and iraq with those from afghanistan and additional locations throughout central and southeastern asia are making an arduous, and often treacherous, journey to western europe. most have been traveling through turkey, on to greece, and from there traversing central europe for western europe.1 the reason for this modern-day exodus is manifold and caught in a whirl-wind of terminology that often defines political hearts or fears.6 many feared for their lives due to ongoing war, conflicts, and persecutions in their homeland, often facing insecurities of food, safety, and justice. some ascribe mostly economic motives to the migration.7 escaping to lands largely free from hunger and violent political upheaval is likely much more prevalent a reason for migration than singularly partaking in the european union’s economic “four freedoms”8 of free movement of goods, services, capital, and labour.9 perhaps, many may not be much different than naomi, who sojourned during a famine with her husband and sons in moab (jordan),10 returning only with ruth, a moabitess and the future great-grandmother of king david.11 yet most refugees are unaware of the hope and freedom promised to abraham and his descendants of promise. that evening, middle-aged men and women, families, teens, children, and a few unaccompanied young men often wore expressions of muted anxiety while awaiting their next leg of travel; worried for the family left behind and looking for family and a hope laying ahead of them. biblically speaking, they were (are) on a sojourn for a new hope, even if their journey is more or less like jacob’s escape to haran as a single man, fleeing a brother intent on his death.12 the lands of turkey and the mediterranean coastlands of paul’s journeys have remained in my heart, which often stirs when i have seen news reports of this current migration navigating on land and sea where we once visited. now many years after our family’s two-year employment in izmir (smyrna), turkey, we now made plans to visit our daughter studying abroad in central europe. she learned of the free-clinic for refugees and that i might be welcomed to assist upon our visit. i jumped at the opportunity to briefly serve the ongoing migration funneling through this central european train station. providentially, i work in a u.s. midwestern medical practice with a palestinian follower of jesus. upon learning of my plan to visit the free-clinic in europe, my palestinian friend gave me several gospels of john written in arabic. i prayed for an opportunity to honor my palestinian friend by putting these accounts of jesus’ life to good use. i found a small group of dedicated local medical professionals volunteering their time in a make-do, field-style clinic for the refugees. the clinic director eagerly accepted my offer to assist them. she paired me with a single 20-something year-old syrian gentlemen to translate for me. he happened to be a refugee himself that knew arabic, english, and likely several other languages and dialects. he had stopped for several days along his trek to assist others at this way-point clinic and aid station. this way-point featured not only shelter, food, and clothing, but also wi-fi access to try and communicate with relatives. he wished to help fellow sojourners on their trek while also hoping to hear or connect with family and friends spread across two continents. together we sat on clinic cots providing advanced medical triage. this was triage with a stethoscope, blood pressure cuff, pulse oximeter, urine dip-stick, and years of history and physical exam assessments in much more austere environments. we listened to the stories of these refugees, these sons and daughters of abraham. we determined who could be treated at the clinic with over-the-counter medicines and medical supplies purchased from a drug store shelf and who needed to be referred on for immediate or definitive medical 39 agner sept 2018. christian journal for global health, 5(2):37-42. attention at the local hospital. commonly, we gave reassurance to a mother or father that their child only had a cold and did not have pneumonia. we dispensed many antacids and laxatives for worried bellies or stomachs stopped up or stressed. many regions through which they traveled had not been as kind nor did not have as many resources to assist the refugees. several refugees had a serious illness needing immediate transport to an emergency or casualty department. whether the illness be major, minor, or mundane i strove to remember the “father of mercies and god of all comfort, who comforts us in all our affliction, so that we may be able to comfort those who are in any affliction, with the comfort with which we ourselves are comforted by god.”13 toward the end of the evening, a young man came seeking medical care for his feet. he had traveled a great distance, likely more than a thousand miles. this traveler had no socks and, much of the time, he told us, he had traveled without any shoes at all. his feet had obvious sores, and his clothes had not been washed for many days or weeks. the shoes he had were threadbare canvas, thin-soled, and carried a thick smell of poverty. i carefully lifted one foot at a time for inspection and to see how he could best care for each foot. he had likely worn out many shoes during his travels. currently, the left ankle had an abrasion created by the ill-fitting, sockless, heavily-worn canvas shoe. the right large toe had a small abscess on top; again, likely from not wearing socks. after cleaning the foot, i carefully lanced the abscess with a needle, liberating a large amount of purulence. careful examination found no deeper, nor more serious, infection. while bandaging the feet, i asked how the wounds had happened. the translator passed on to me that the traveler did not know for sure, as he had often been barefoot and often times could not feel his feet. the translator then observed something that he had never experienced before. the aid station had shoes to give to the refugees but had run out of the size that the traveler needed. our traveler wore the same size shoe as i. even though my trekking shoes had many miles under them, they also were built to last with warm, strong, breathable fabric and a good sole. i removed my shoes and asked through the translator to give my shoes to our traveler. the translator tried to intervene, saying he, a fellow refugee with more means than the traveler should be the one to donate his shoes. i gently persisted in giving the traveler my shoes. the translator enlisted the nurse running the clinic, who agreed that i need not donate my shoes. again, i gently stood firm, reminding them that although the clinic had socks to give the traveler, they had no shoes that fit our young man. "what will you wear back to your place?" asked my syrian friend. i replied, "his shoes." i finished dressing the traveler’s wounds and passed on bandages i brought for myself. this included a small foot-care kit purchased earlier that day. i then placed my shoes on the grateful traveler’s feet to ensure that they indeed did fit. the translator had never observed such an act before. shoes carry much more significance in the land of abraham. a presumably respected physician had not only donated his shoes but was going to wear the traveler’s pungent, worn shoes home. in many cultures, this would be a disgrace.14,15,16 later that night, after the patients had all been seen, my syrian translator friend and i talked over a cup of coffee. he was surprised to learn that i had once visited close to his home, haran and antakya (antioch), knew many of the words he spoke, and had also traveled and visited many of the coastlands and turkish cities he had also walked. i asked of his family. he then shared his story, a story of broken relationships and a broken home now scattered across many lands. his father and his father’s new wife had successfully traveled recently from syria to a destination european country. his birth mother still lived back in a war-torn syrian city; he hoped to be able to send for her once he arrived in western europe. the translator wished to know more about how i had come to the clinic and the kindness that had 40 agner sept 2018. christian journal for global health, 5(2):37-42. been shown. i spoke of hope, especially the hope of abraham. i shared that the great religions of christianity and islam share a common lineage that traces to abraham. i pointed out to my syrian friend that his home-town is near one of abraham’s homes (haran) where abraham had briefly sojourned. the translator spoke of knowing that abraham was the father of many prophets. i then shared of the one, isa, which is jesus in arabic, who makes himself known to those who seek him. the translator asked if i had read the book of his prophet. i affirmed that indeed i had read an english version of the koran. i then explained that the prophet born of the promise of abraham would make himself known to him, the translator, if he sought him.17,18 this provided opportunity to share the account of john, jesus’ most intimate friend on this earth, to whom jesus referred, “the disciple with whom he loved.”19 just as the shoes had been tangibly received by the traveler, our syrian friend gratefully accepted the arabic version of the gospel of john. the act of kindness and humility of exchanging shoes had opened his heart to learn of isa. we bid our farewells that included a late-night selfie outside the train station clinic. i then laced-up the traveler’s well-used, odiferous shoes on my feet and took a local train back to the hotel room. i hoped the others on the sparsely populated train could not detect from where the pungent smell emanated. sometime after midnight i reached my train stop and slipped the odiferous shoes into a waste-bin outside the hotel. yet, the smell reminded me that i had been willing to materially assist another sojourner. verses of hebrews, matthew, john, and others came vividly to life. i dimly understood many aspects of the gospel in a new way. how jesus' humbling of himself when he washed the feet of the disciples took on new meaning; " . . . but [he] emptied himself, taking the form of a bond-servant, and being made in the likeness of men."20 the translator had been willing to listen to the hope of abraham and isa after he had observed a "person of stature" humbling himself to help clothe and wash another,21 as jesus had washed the disciples’ feet,22 then (literally) walk in his shoes. i also better understood the humbling of the woman who had washed jesus' feet with her hair in front of others.23,24 her hair was her dignity and washing jesus' feet was her sacrifice to him. again, the kindness had opened a door to speak to my syrian friend of the hope available to all that would call upon him isa, jesus.17,18 additional thoughts flooded my mind, including a story from a missionary friend that had assisted refugees migrating between istanbul, turkey, and vienna, austria in the 1990s. our friend shared the story of one december night, when she spoke to refugees in central/eastern europe about the christmas story, wondering if they could relate to such a story for which they had not heard before or have a cultural context. when she came to the part of mary and joseph having to flee to egypt to escape the authorities seeking jesus’ life25 and being afraid to live in their homeland upon return from egypt,26 our friend realized that these refugees with whom she ministered understood the christmas story in a much deeper way than she had expected. the christmas story spoke to them in their current modern-day experiences of fleeing and fearing for their lives and the life of their child. jesus and his parents had also been refugees. the current migrations give us a real-world opportunity to move from fear to faith. if we cannot welcome refugees, then we will not recognize when jesus is in our midst.21 the act of giving my shoes is only a fleeting moment in my walk by faith, and i do not wish to give the impression that this type of grace has been common. yet, to live by faith means taking off the old self and clothing ourselves in a humility that comes from being transformed by jesus’ grace;27 and by so doing, we become a fellow sojourner and learn what it means to be like abraham, “friend of god.”28 41 agner sept 2018. christian journal for global health, 5(2):37-42. but you . . . the offspring of abraham, my friend; you whom i took from the ends of the earth, and called from its farthest corners, saying to you, . . . i have chosen you and not cast you off”; fear not, for i am with you . . . (isaiah 48:810). references 1. looking for a home special report on migration. economist. may 26, 2016 available from: http://www.economist.com/sites/default/files/20 160528_sr_migration.pdf. 2. genesis 11:31-12:4. 3. acts 11:17-26. 4. holy bible english standard version. wheaton, illinois: crossway bibles; 2001; all verses quoted are from the english standard version, and accessible online at https://www.biblegateway.com/. 5. kjv dictionary definition: sojourn [internet]. king james dictionary definition online. 2018. available from: https://av1611.com/kjbp/kjvdictionary/sojourn.html. 6. terminological exactitudes; special report on migration. economist. 26th may 2016. available from: http://www.economist.com/sites/default/files/20 160528_sr_migration.pdf. 7. how many migrants to europe are refugees? economist; 8th sep 2015. available from: https://www.economist.com/the-economistexplains/2015/09/07/how-many-migrants-toeurope-are-refugees. 8. [internet]. euabc.com. 2018. available from: http://en.euabc.com/word/506. 9. the four freedoms on which the european union is based are under threat. economist. 9th feb 2006. available from: https://www.economist.com/node/5494628. 10. ruth 1:1,22. 11. ruth 4:13-17. 12. genesis 27:41-45. 13. 2 corinthians 1:3-4. 14. the telegraph. arab culture: the insult of the shoe. [internet]. 2008. available from: https://www.telegraph.co.uk/news/worldnews/ middleeast/iraq/3776970/arab-culture-theinsult-of-the-shoe.html. 15. georges j. honor and shame societies: 9 keys to working with muslims [internet]. zwemer center for muslim studies. 2018. available from: http://www.zwemercenter.com/guide/honorand-shame-9-keys/. 16. nacht j. the symbolism of the shoe with special reference to jewish sources. the jewish quarterly review. 1915;6(1):1-22. available from: http://www.jstor.org/stable/1451461. 17. matthew 7:7-12. 18. john 11:25-26. 19. john 19:26; 20:2; 21:7,20. 20. philippians 2:7. 21. matthew 25:31-40. 22. john 13:13-17. 23. luke 7:37-50. 24. john 12:3-8. 25. matthew 2:7-17. 26. matthew 2:18-23 27. colossians 3:8-13 28. isaiah 41:8 . peer reviewed: submitted 21 may 2018, accepted 23 june 2018, published 22 sept 2018. competing interests: none declared. http://www.economist.com/sites/default/files/20160528_sr_migration.pdf http://www.economist.com/sites/default/files/20160528_sr_migration.pdf https://www.biblegateway.com/ https://av1611.com/kjbp/kjv-dictionary/sojourn.html https://av1611.com/kjbp/kjv-dictionary/sojourn.html http://www.economist.com/sites/default/files/20160528_sr_migration.pdf http://www.economist.com/sites/default/files/20160528_sr_migration.pdf https://www.economist.com/the-economist-explains/2015/09/07/how-many-migrants-to-europe-are-refugees https://www.economist.com/the-economist-explains/2015/09/07/how-many-migrants-to-europe-are-refugees https://www.economist.com/the-economist-explains/2015/09/07/how-many-migrants-to-europe-are-refugees https://www.economist.com/node/5494628 https://www.telegraph.co.uk/news/worldnews/middleeast/iraq/3776970/arab-culture-the-insult-of-the-shoe.html https://www.telegraph.co.uk/news/worldnews/middleeast/iraq/3776970/arab-culture-the-insult-of-the-shoe.html https://www.telegraph.co.uk/news/worldnews/middleeast/iraq/3776970/arab-culture-the-insult-of-the-shoe.html http://www.zwemercenter.com/guide/honor-and-shame-9-keys/ http://www.zwemercenter.com/guide/honor-and-shame-9-keys/ http://www.jstor.org/stable/1451461 42 agner sept 2018. christian journal for global health, 5(2):37-42. correspondence: dale agner, clarkson family medicine residency-nebraska medicine, dale.agner@gmail.com cite this article as: agner d. living the gospel through the feet of a refugee: sharing abraham’s hope in kindness and humility. christian journal for global health. sept 2018, 5(2):37-42. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:dale.agner@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ book review july 2018. christian journal for global health 5(1):44-46. vulnerability and care: christian reflections on the philosophy of medicine by andrew sloane bloomsbury 2016 benjamin r doolittlea a md, m div, faap, facp, associate professor, yale university school of medicine; program director, combined internal medicine & pediatrics residency program; medical director, yale medicine-pediatrics practice, united states of america healthcare is in crisis. countries spend trillions without concomitant gains in health outcomes. in 2016, the u.s. alone spent $3.3 trillion, nearly 18% of the gdp.1 disparities between the rich and poor are more pronounced than ever. recent bow-shots from the current political administration threaten even the most sacrosanct of healthcare programs. amidst the maelstrom, a thoughtful voice is needed to recalibrate our values, to ground healthcare in core principles that inform our increasingly complex healthcare debate. andrew sloane is such a worthy voice. in his vulnerability and care: christian reflections on the philosophy of medicine, he provides a refreshing perspective — one of christian theology and philosophy. he is quick to point out that his project is not bioethics. tongue in cheek, he writes, “i’m not sure the world needs another book on bioethics: along with studies on the theology of paul or the historical jesus... bioethics has generated a volume of literature that itself justified ecclesiastes’ weary words; ‘of making many books there is no end, much study is a weariness of the flesh’ (eccl 12:12, esv).” (p. 5) and yet, there are few projects that explicitly inject a christian perspective into modern medical ethics, to dare and invoke a christian image: his is the voice crying out in the wilderness. there are elements of medicine that rank of sordid priorities. big pharma makes billions at the expense of those who cannot pay. research priorities emphasize highly remunerative diseases (think erectile dysfunction and me-too antidepressants) while millions die of preventable diseases. health care companies eye the bottom line at the expense of the communities they serve. sloan’s work comes at an opportune time. his perspective is much needed in a world that has become increasingly post-religious and postchristian. medical ethics often defaults to utilitarianism — the most good for the most people — with an emphasis on patient autonomy. there is inherent tension here. in the same breath, i might want the latest subspecialist opinions and the most advanced testing, while recognizing that not all people have access to these same resources. in conventional bioethics, the standard domains of beneficence, nonmaleficence, justice, and autonomy strain to capture what comes so naturally to christian theology. autonomy is not human dignity. mercy is not justice. does bioethics attempt to capture christian virtue using a secular system of thought? sloane provides an alternative viewpoint from traditional bioethics that is familiar to the christian and accessible to the secular. 45 doolittle july 2018. christian journal for global health 5(1):44-46. his central thesis is this: medicine’s goal is to care for the vulnerable, “so as to demonstrate our solidarity with them as suffering persons and seek to enable them to return to a reasonable level of functioning in relationships.” (p. 4-5) medicine, he claims, often focuses on the alleviation of suffering and the removal of disease, which are largely mechanistic projects. medicine needs to be something more. he highlights the challenge of the 2014 ebola outbreak in west africa. in particular, he highlights the stories of kent brantly and sheik umar khan, both physicians who became infected with ebola while treating patients. dr. brantly was affiliated with a western ngo. he was flown to an american hospital where he received state-of-the-art care, including an experimental treatment for ebola. he survived. dr. khan was a locally-trained physician. upon contracting the disease, he received care in a local ebola treatment center. sloane is careful not to pass judgment about the ethical implications. the experimental treatment was available to dr. khan, but it was decided he would not receive it. rather, sloane highlights the tragedy — the disparity between those who have and those who have not. dr. khan perished. dr. brantly survived only through excessive expenditure that few can access. what of this? sloane’s work grapples with this question. sloane’s method is unique as we grapple with ethical and philosophical quandaries in modern medicine. he uses the bible’s narrative. for the christian, this is not a radical viewpoint. but for the rationalist, evidence-based, medical community, to use the bible to inform complicated medical decisions is new territory indeed. further, i believe his thoughts inform the secular community as well. caring for the vulnerable and affirming human dignity are central tenants for any serious christian. to the secularist, sloane suggests a narrative vision that upholds secular medicine’s core values. sloane affirms for the secularist and the christian alike that the central project of medicine is care for those who need care the most. this is not a rational proof. this is a story that speaks to the hearts and minds of the suffering and those who care for them. for a skeptical world, perhaps the most obvious question is, “why?” why should i care for the vulnerable and affirm human dignity? as if in response, he writes, “god created human beings in the image and likeness of god, in a particular pattern of relationship with god, each other and the world. from the beginning, then, humans are social beings, and embodied beings who inhabit god’s world as god’s people.” (p. 128) what follows then is the concept of the human as sacred and worthy, not merely as an organism with disease. for example, in his argument about euthanasia, sloane writes, “life is god’s gift, and it is god’s prerogative to determine its end; for us to take a human being’s life, even out of (misguided) compassion, is to despise the giver of the gift and fail to respect human dignity.” (p. 40) this sounds very familiar to a christian. but to the healthcare community, i believe it is an important perspective that articulates the intuitive sentiments of many. there are some aspects of vulnerability and care upon which not all would agree. first is his central claim that medicine should care for the most vulnerable. he is quick to point out that medicine can be about healing and alleviation of suffering, but these projects are secondary. i wonder if this difference is one of degree rather than category. do not the vulnerable also suffer? might the vulnerable also require healing? curing disease and the more holistic notion of healing can be seen as noble, sacred endeavors. i wonder if parsing the differences in these terms detracts from his powerful witness: medicine should focus on the care of the patient, not only the patient’s treatment, study or investigation. i think this is sloane’s point: the human being should be central to medicine’s mission. 46 doolittle july 2018. christian journal for global health 5(1):44-46. second, there is another aspect that perhaps merits a more balanced attention: the science of medicine. medicine, at its scientific best, pursues truth in the cause of healing. what occurs in the lab is randomized controlled trials, and in crunching big data, has philosophical, even theological, implications. these endeavors pursue truth. does not philosophy pursue the same? the findings in a lab can reveal god’s glory too. would not the christian agree? medicine connects pure science with human healing, the bench to the bedside. what occurs in a test tube relates to what happens in a human being, which in turn, affects a population. this is unique among the sciences and does not negate medicine’s mission to care for the vulnerable. for all its faults, medicine tries to do it all. sloane’s use of the christian narrative could be applied to the research aspects of medicine. he could add humanity and dignity to the scientific endeavor. perhaps he might take the “bench to bedside” rubric and add, “from the bench to the bedside to the soul.” this would be a helpful contribution to the field during a moment when science and faith seem so disparate. there is a third important question: while his project is accessible to the non-christian, is it enough? is this message relevant to a hospital executive trying to meet budget requirements, a cash-only physician in a well-healed neighborhood or an emotionally scarred nurse in an innercity emergency room? i heard one hospital executive say, “if there is no margin, there is no mission.” how does one care for the vulnerable when hospitals are strapped for cash and physicians are sapped of their emotional strength? sloane’s message is very comfortable for the christian, but is it compelling enough to the non-christian? in some ways, yes! sloane offers hope and restores humanity to medicine. in other ways, no! avarice and self-interest often begets more of the same. sloane takes on a big project. but is it too big? when the next ebola outbreak occurs, the wealthy westerner may once again get evacuated to the tertiary care hospital, and the local physician may die in the plague tent. there is a forlorn sadness to modern medicine. is the system so hopelessly broken? who will save medicine? andrew sloane offers us a hopeful, compelling answer: jesus. references 1. centers for medicaid and medicare services [internet}. baltimore (md): department of health and human services (us); 2018. available from: https://www.coms.gov/research-statistics-dataand-systems/statistics-trends-andreports/nationalhealthexpenddata/ nationalhealthaccounts historical.html competing interests: none declared. correspondence: benjamin r doolittle, yale university school of medicine, united states of america. benjamin.doolittle@yale.edu cite this article as: doolittle b r. vulnerability and care: christian reflections on the philosophy of medicine by andrew sloane – bloomsbury 2016. christian journal for global health. july 2018; 5(1):45-47. https://doi.org/10.15566/cjgh.v5i1.206 https://www.coms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/%20nationalhealthaccounts%20historical%20.html https://www.coms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/%20nationalhealthaccounts%20historical%20.html https://www.coms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/%20nationalhealthaccounts%20historical%20.html https://www.coms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/%20nationalhealthaccounts%20historical%20.html mailto:benjamin.doolittle@yale.edu https://doi.org/10.15566/cjgh.v5i1.206 case study nov 2017. christian journal for global health 4(3):53-59 death in a mission hospital james v ritchiea a md, emergency medicine, lecturer, kabarak university, kenya abstract medical missionaries may struggle with the proper understanding of their roles in the death of their patients. to better grasp a biblical concept of death, medical missionaries should understand god’s plan for death and also understand both god’s sovereignty and their own free will. missionaries should prepare patients and their families for impending death while observing cultural sensitivity. cultural objections to discussing impending death may be addressed by emphasizing the christian understanding of earthly death and eternal life, and by honoring the passing of the believing patient. a new work we had started a good work. we had taught advanced cardiac resuscitation to our new residents and interns, and placed our newly-donated defibrillator on our shiny donated code cart in the ward. this was a new capability for pcea chogoria mission hospital in central kenya, and we were very excited. within hours of starting the program, the defibrillator was used, and the patient was saved! hallelujah! more cardiac arrests occurred during the next week, and the code responses rapidly became more coordinated. most codes ended in death, of course, but we could finally do something about the death of our patients instead of simply pulling the curtains with embarrassment and putting the body quietly in a side hallway. now, even the failed codes were a victory of sorts. but one morning, one of our outstanding family medicine residents spoke quietly to me during rounds. “you know, daktari1, the nurses are calling us for every single death, even deaths that are anticipated. last night, we coded the 95-year-old man who had a large stroke at home three weeks ago and was brought to us completely comatose and covered with bedsores. this does not seem right.” the resident was correct. we had introduced a powerful new tool but had not taught the concept of do not attempt resuscitation (dnar). as a result, we were engaged in a futile attempt to revive people who should have been allowed to die in dignity. furthermore, we were using supplies needlessly and assaulting our patients with electricity and rib-fracturing chest compressions. chagrined, i thought, “at least this is easily remedied and hasn’t gone on for too long. we will speak to the nurses and doctors, and introduce the concepts of dnar and advance directives.” i began immediately speaking with our charge nurse about those ideas and asking her advice on how to teach the ward staff. but i was surprised by her response. “daktari, we cannot do that. we cannot do everything for some patients and do nothing for others. that would be very disrespectful and would make us seem uncaring or appear to choose who should die. also, it is not welcome to speak with 54 ritchie nov 2017. christian journal for global health 4(3):53-59 the family about death before it occurs. doing so would make us seem to be wishing for the death.” i was stuck. i had no idea of how to deal with these cultural objections. but i knew that in our mission hospital, we were not “doing death” well. “am i a bad missionary?” months beforehand, a colleague had come to lunch in a distraught condition. she was an outstanding obstetrician-gynecologist and was also new to the mission field. we asked her what was wrong. “you have to understand. in the us, i was in private practice for nine years, and i never lost a single patient. not one. but in the last 24 hours, i have lost four—in the or, in delivery, and in the ward. i don’t know what to do. am i a bad doctor? am i a bad missionary? is god trying to tell me something? i am afraid to touch another patient. who will die next?” after learning the details of the cases, we tried to comfort her, assuring her that she was a fine physician and had treated her patients very well. but we also realized that in the minds and expectations of our doctors, we were not “doing death” well. paul and questions the apostle paul expressed his ideas about his own death very clearly. in his letter to the philippians, he wrote, for to me, to live is christ and to die is gain. but if i am to live on in the flesh, this will mean fruitful labor for me; and i do not know which to choose. but i am hardpressed from both directions, having the desire to depart and be with christ, for that is very much better; yet to remain on in the flesh is more necessary for your sake. (phil 1:21-24, nasu, emphasis added) paul was mentally whole, but was glad to look forward to his own death. he even preferred death and seemed disappointed that he had to continue to live on a while longer. in our mission hospital, with regard to the problems on the ward and the expectations of our colleague, our concept of death did not match very well with paul’s concept of death. we realized that we needed to return to the word to re-orient our ideas of death. we decided to ask some questions about death and answer them from the bible. question 1: who is the author of life? the answer to this question should be obvious to us. in genesis god said, let the waters teem with swarms of living creatures, and let birds fly above the earth in the open expanse of the heavens.” god created the great sea monsters and every living creature that moves… (gen 1:20-21 nasu) god, therefore, is definitively the author of life. question 2: who is the author of death? the answer to this question took more study. it seemed logical that the devil would be the author of death. but god, in the book of genesis, told us otherwise. the lord god commanded the man, saying, “from any tree of the garden you may eat freely; but from the tree of the knowledge of good and evil you shall not eat, for in the day that you eat from it you will surely die.” (gen 2:16-17 nasu, emphasis added) by the sweat of your face you will eat bread, till you return to the ground, because from it you were taken; for you are dust, and to dust you shall return. 2 (gen 3:19 nasu, emphasis added) the first mention of death was made by god in the bible. it was his idea. when adam and eve ate of the fruit, god decreed death. death is a prescription and a curse. death (or, put another way, an end to this earthly life) is god’s decree. 55 ritchie nov 2017. christian journal for global health 4(3):53-59 we realized that we had been thinking of ourselves, as doctors, as the enemies of death. perhaps we had been thinking of paul’s words in 1st corinthians, “the last enemy that will be abolished is death.” (1 cor 15:26 nasu) but on further study, this verse did not really apply to our current situation. it was a description of the end of christ’s millennial reign on earth. it referred to the end of god’s prescription/ curse/decree, because all had been judged and set right. perhaps the death referred to in this verse was the second death described in the book of revelation. we realized that we were still under god’s prescription/curse/decree of death. so if we thought of ourselves as the enemies of death, we were setting ourselves up as the opponents of the lord god of heaven and earth. it was singularly unwise to try to be god’s opponent, especially when we had promised to serve him. one might ask, “didn’t jesus heal and resurrect? don’t those actions identify death as the enemy?” it is true that jesus did heal and resurrect! but we would be wise to remember what happened to every person whom jesus healed and resurrected. ultimately, they died. jesus showed that he was compassionate and had power over life and death. but god’s decree was fulfilled in the end. so, for a christian, earthly death, the first death, is not our enemy. it is not a failure, not a lost battle in which the devil won, not the catastrophe that non-believing eyes might perceive. the end of earthly life is guaranteed, decreed by god. the timing of death but this raised the question of timing. what about an untimely death? what about the death of a child or the unexpected death of a person in his/her prime? after all, we generally acknowledge that a very elderly person with advanced alzheimer’s disease might “appropriately” die. but what about a young person full of life? from the medical perspective, we might ask the question this way: question 3: when my patient suffers an unexpected death, who is accountable—god or me? in western medicine, we are steeped in responsibility for our patients and have built a culture of blame for “untoward outcomes”. so, it was no surprise at all when our ob/gyn colleague felt great guilt when four of her patients died. but isn’t god sovereign? which is it? is god sovereign or are the actions of our free will responsible for the unexpected deaths of our patients? we returned to the scriptures and the answer was both clear and mysterious. somehow god is sovereign, and we have free will for which we are accountable. god is sovereign see now that i, i am he, and there is no god besides me; it is i who put to death and give life. i have wounded and it is i who heal, and there is no one who can deliver from my hand.” (deut 32:39 nasu, emphasis added) in him also we have obtained an inheritance, having been predestined according to his purpose who works all things after the counsel of his will.” (eph 1:10-12 nasu, emphasis added) we have free will i call heaven and earth to witness against you today, that i have set before you life and death, the blessing and the curse. so choose life in order that you may live, you and your descendants. (deut 30:19 nasu, emphasis added) the spirit and the bride say, “come.” and let the one who hears say, “come.” and let the one who is thirsty come; let the one who wishes take the water of life without cost. (rev 22:17 nasu, emphasis added) we could not find verses that specifically spoke of a doctor’s responsibility toward his or her patients, but we did find many examples of verses in which a person was accountable (positively and 56 ritchie nov 2017. christian journal for global health 4(3):53-59 negatively) for his or her actions that affected another person. 3 therefore, somehow god is sovereign, and we have free will. somehow, god is sovereign over the lives and deaths of people, and somehow we doctors have a responsibility for the way in which our actions change the lives of our patients. this seems to be contradictory, but is better understood as a mystery. we cannot understand it, but god’s word clearly conveys both situations as true. looking at it from another point of view, god gives our patients life. but their parents have an important responsibility in starting that life, too. god gives our patients an end to their earthly lives. but they also share responsibility in the end regarding the choices they made in life (diet, exercise, smoking, driving habits, risks, etc.), and we, as their doctors, are responsible, too. god’s sovereignty and our free will are both fully engaged—a mystery, but a truth. in western medicine, we place the burden of life and death on ourselves as doctors; but that gives no room for god’s sovereignty and is a flawed mindset for a christian doctor. furthermore, placing the full burden on ourselves suggests that we are ultimately capable of saving every patient’s life. such a mindset is not just unrealistic; it is frankly delusional. though we as doctors do not bear the entire burden for the death of our patients, we must not become fatalistic. we should attempt resuscitation in appropriate patients. one day, during rounds, we witnessed a cardiac arrest in one of our patients. we successfully defibrillated and resuscitated him. later, when he awakened, we told him that he had died, but that god had given him a few more days. we asked him whether he needed to reconcile with god or with anyone else. he was very glad for the opportunity to do both. both situations are true: god is sovereign and we have a role in our patients’ lives. our actions matter. we must act with compassion and competence. question 4: do we respect the cultural taboo which shuns speaking about expected death? when we introduced the idea of advance directives to our charge nurse, she recoiled. she contended that speaking about death would violate cultural norms and might even cause the families to think that we were promoting death or bringing it about. we were stymied. we wanted to be culturally respectful to those in our care. but we realized that death is taboo in virtually every culture.4–8 it is always a difficult subject. in the us, we tend to avoid conversations about death. it is the same everywhere. so we are not dealing with a specific cultural taboo, but a general human condition. we do not like to talk about death. though death is uncomfortable to discuss, the necessity of addressing it has become more widely accepted and even encouraged in kenyan society. 8–12 surveys have suggested that kenyans want to know if their lives will end soon and want their families to be involved in the discussion.13 patients of many cultures consider spirituality to be important by the end of their lives,4,5,14–16 and palliative-care patients who consider themselves to be more spiritually-oriented also tend to report less spiritual pain, depression, and anxiety.17, 18 therefore, we should overcome our perceived awkwardness in approaching the subject of death and provide the spiritual balm our patients need. furthermore, the bible teaches us not to fear earthly death. as mentioned before, paul saw earthly death as something to be anticipated. he saw death as a means “to depart and be with christ,” which is “very much better.” (phil 1:23 nasu) we, as christians, should have no fear of death. if we do treat death as a fearful event, we are not thinking like christians; we are thinking like pagans. if we avoid speaking of death, we are tacitly honoring a pagan understanding of death and failing to teach one of the chief joys of christian life. paul reveals this to us. but we do not want you to be uninformed, brethren, about those who are asleep, so that you will not grieve as do the rest who have no hope. for if we believe that jesus 57 ritchie nov 2017. christian journal for global health 4(3):53-59 died and rose again, even so god will bring with him those who have fallen asleep in jesus. (1 thes 4:13-15 nasu) speaking with patients about their upcoming death also gives them an opportunity to reconcile with god, reconcile with important people in their lives, prepare financially, and plan for the ceremony. rob moll records the thoughts of gerontologist john dunlop: you ask anybody how they want to die today and they say “make it quick,” he says. instead of fearing the slow decline, dunlop, who has cared for hundreds of elderly patients, says, “i hope i die slowly.” a slow death offers opportunities to spend time with family, say good-bye and slowly orient a person toward life with god, he says. “i think most people who have thought it through will say there are more advantages to my family with my dying slow. it’s kind of selfish to want to die fast.”19 if we hide the news of upcoming death from our patients and their families, we deprive them of these opportunities for reconciliation and planning. and, of course, we as christian doctors must ensure that our patients have had the opportunity to respond to the gospel. people who are aware of their own impending death are often far more sensitive to spiritual issues. we simply must help them to understand their situation spiritually. to do otherwise should be anathema to a christian doctor. but when we are able to inform our terminal patients about their impending death, and help them and their families understand their heavenly future and the futility of highly invasive medical intervention, they are often quite amenable to considering the concept of a peaceful death. our chaplains helped us to understand that news of impending death should not be delivered abruptly, even if the news is delivered in a compassionate way. the news may be best brought through another family member and brought gradually. in addition, we found that most patients and families were not ready to think about choosing to limit heroic lifesaving medical efforts immediately after receiving the news of impending death, but were often ready after a day or two. question 5: how should we encounter the actual event of death? not so long ago in our hospital, before we began using the defibrillator and “running a code,” the usual medical response for a dying patient was to pull the curtain and perhaps try a few interventions without much expectation of success. then, when the patient truly died, the body was quietly moved to a side hallway behind another curtain, awaiting movement to the morgue. families were not invited to attend the body in the ward, but only in the morgue. the entire “ceremony” was imbued with a sense of failure, embarrassment, and loss. i could not help but contrast this ceremony of death with the ramp ceremony which was held for the repatriation of soldiers who fell in afghanistan.20 the ceremony usually occurred very early in the morning, often 2 a.m., when there were absolutely no distractions. the aircraft that would carry the body was parked front-and-center of the flight line. hundreds of troops would come to the ceremony and would stand at attention in disciplined lines, honoring their fallen comrade. the soldier’s body, carefully prepared in a flagdraped casket, was carried with full honors into the aircraft for the journey home. it was a profound time—a time of loss, certainly, but also of great honor. why couldn’t we have a ramp ceremony for our patients at our mission hospital? would not such a ceremony be appropriate for a christian hospital? if we were to institute a ramp ceremony, when the nurses were to notice that the patient was nearing the end, they would notify the team. the doctor would come. the other nurses would come. the family (if present) would come. the chaplain would come. the other patients would even be invited to attend if interested and able. any symptoms that appeared to distress the visiting patients would be attended to by the team. the team would pray, sing, and honor their brother or sister into the kingdom. wouldn’t that be a more 58 ritchie nov 2017. christian journal for global health 4(3):53-59 faithful response to the end of the earthly life and beginning of heavenly life of a believer? in consultation with our nurses and chaplains, we began to approach some patients’ families with the idea. this ceremony was a new idea for most families, and we proposed it carefully, inviting acceptance. the explanation of this ceremony provided a wonderful opportunity to present the good news to all who could hear. some families did not accept the idea and asked for medical resuscitation. we followed their wishes. but some families did accept the idea of foregoing medical futility and celebrating the transition of life. when we have had the opportunity to use this ceremony, the entire mood around the deathbed had changed. of course, there was mourning for the person who would be missed until reunion. but there was also celebration and honor. we realized that this ceremony need not be restricted to expected deaths; it could also take place after an unsuccessful resuscitation effort. also, sometimes the timing was awkward. sometimes the team was called because the patient was at the point of death, but death was slow in coming. we learned to talk about this beforehand. if the honoring team needed to disband and reassemble later, that was no problem. more worship and honor were better. the situation was also uncomfortable when the patient was known not to be a believer, and we, therefore, could not be confident of a joyful spiritual outcome. but we were determined to show kindness to all our patients and their families, and, of course, we purposed to share the gospel with all. when the patient was known to be a believer, the ceremony of life transition could be joyful. the ceremony also provided an answer to the problem of “doing nothing.” when we had originally proposed withholding “heroic measures” for patients with terminal illnesses, our charge nurse objected. she said that it would be inappropriate to “do everything” for some patients and “do nothing” for others. but a ceremony of life transition was hardly “doing nothing.” instead, it was a far more fitting and faith-filled way to honor a life. patients’ families were glad for a way to honor god and his sovereignty at the same time that we honored their loved ones. conclusion “precious in the sight of the lord is the death of his godly ones.” (ps 116:15 nasu) death, the end of this earthly life and transition to eternal life, is one of the most important events in any life. if god considers death to be precious, it is appropriate that we do likewise. of course, when a medical resuscitation seems appropriate, we should attempt it. but when a medical resuscitation seems futile or dishonorable, and when we have the acceptance of patients and families, we can honor god and his sovereignty in death even as we celebrate the life transition of one of his children. such a homegoing would be “doing death” very well indeed. references 1. swahili word meaning “doctor.” 2. god is speaking, and is using poetry form for this curse. 3. for instance: then moses set apart six cities across the jordan to the east and west, that a manslayer might flee there, who unintentionally slew his neighbor without having enmity toward him in time past; and by fleeing to one of these cities he might live: (deut 4:41-43 nasu) any verse that pertains to consequences of actions against others, such as murder or theft or injury, is only meaningful in the context of free will. 4. steinberg sm. cultural and religious aspects of palliative care. int j crit illn inj sci. 2011;1(2):154– 6. https://doi.org/10.4103/2229-5151.84804 5. koenig hg. the role of religion and spirituality at the end of life. the gerontologist. 2002 oct 1;42(suppl_3):20–3. 6. voltz r, akabayashi a, reese c, ohi g, sass hm. end-of-life decisions and advance directives in palliative care: a cross-cultural survey of patients and health-care professionals. j pain symptom manag 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https://doi.org/10.1186/1472684x-13-4 14. harding r, selman l, powell ra, namisango e, downing j, merriman a, et al. research into palliative care in sub-saharan africa. lancet oncol [internet]. 2013;14. https://doi.org/10.1016/s14702045(12)70396-0 15. karches ke, chung gs, arora v, meltzer do, curlin fa. religiosity, spirituality, and end-of-life planning: a single-site survey of medical inpatients. j pain symptom manage. 2012 dec;44(6):843–51. https://doi.org/10.1016/j.jpainsymman.2011.12.277 16. steinhauser ke, christakis na, clipp ec, mcneilly m, mcintyre l, tulsky ja. factors considered important at the end of life by patients, family, physicians, and other care providers. jama. 2000 nov 15;284(19):2476–82. https://doi.org/10.1001/jama.284.19.2476 17. bernard m, strasser f, gamondi c, braunschweig g, forster m, kaspers-elekes k, et al. relationship between spirituality, meaning in life, psychological distress, wish for hastened death, and their influence on quality of life in palliative care patients. j pain symptom manage [internet]. https://doi.org/10.1016/j.jpainsymman.2017.07.019 18. delgado-guay mo, hui d, parsons ha, govan k, de la cruz m, thorney s, et al. spirituality, religiosity, and spiritual pain in advanced cancer patients. j pain symptom manage. 41(6):986–94. https://doi.org/10.1016/j.jpainsymman.2010.09.017 19. moll r. the art of dying: living fully into the life to come. downers grove, ill: ivp books; 2010. p. 29 20. i had the profound privilege of serving with the us marine corps and uk royal army at bastion hospital in afghanistan during the "surge" in 20092010. peer reviewed competing interests: none declared. correspondence: dr james v ritchie, kabarak university, kenya. ritchiejim263@gmail.com cite this article as: ritchie jv. death in a mission hospital. christian journal for global health. nov 2017; 4(3): 53-59. https://doi.org/10.15566/cjgh.v4i3.189 © ritchie jv. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://theconversation.com/what-kenya-needs-to-do-to-end-the-taboo-of-talking-about-end-of-life-care-76868 http://theconversation.com/what-kenya-needs-to-do-to-end-the-taboo-of-talking-about-end-of-life-care-76868 http://theconversation.com/what-kenya-needs-to-do-to-end-the-taboo-of-talking-about-end-of-life-care-76868 https://doi.org/10.1016/j.resuscitation.2008.09.019 https://doi.org/10.1186/s12904-017-0186-z http://kehpca.org/advance-care-planning-in-kenya-starting-the-conversation/ http://kehpca.org/advance-care-planning-in-kenya-starting-the-conversation/ https://www.msh.org/sites/msh.org/files/national_guidelines_for_cancer_management_-_kenya_.pdf https://www.msh.org/sites/msh.org/files/national_guidelines_for_cancer_management_-_kenya_.pdf https://doi.org/10.1186/1472-684x-13-4 https://doi.org/10.1186/1472-684x-13-4 https://doi.org/10.1016/s1470-2045(12)70396-0 https://doi.org/10.1016/s1470-2045(12)70396-0 https://doi.org/10.1016/j.jpainsymman.2011.12.277 https://doi.org/10.1001/jama.284.19.2476 https://doi.org/10.1016/j.jpainsymman.2017.07.019 https://doi.org/10.1016/j.jpainsymman.2010.09.017 mailto:ritchiejim263@gmail.com https://doi.org/10.15566/cjgh.v4i3.189 http://creativecommons.org/licenses/by/4.0/ commentary nov 2018. christian journal for global health 5(3):47-53. the case for a theology of disaster risk management robert bradley mitchella a phd, ceo, anglican overseas aid, australia abstract pacific island communities are among the most disaster prone on earth. the churches in these communities have a pervasive social role and a wide geographic footprint, and it therefore makes good sense to engage them in better preparing their communities for disasters. that said, there are a variety of pre-existing religious beliefs about disasters, some of which are antithetical to proactive disaster risk management. important theological research is being undertaken to map existing beliefs. this research will then help inform an indigenous and systematic theology of disaster risk management. the goal is to reduce death and destruction from foreseeable events, giving the research a special relevancy. key words: theology, disaster risk management, pacific communities, climate change, church, social engagement. can theological research save lives? my suspicion is that most people think of theological research as being dry, academic, and fairly abstract, leading them to answer that question in the negative. the purpose of this article is to provide information about a unique piece of theological research that has life-saving implications to better prepare pacific communities for natural disasters, reducing the death toll and other damage that can be associated with these events. can do consortium the church agencies network disaster operations (can do) is an ecumenical collaboration of eight australian churchaffiliated aid and development organisations and their respective partner churches across the pacific.1 these organisations have come together for the important humanitarian purpose of responding more effectively to natural disasters. this consortium has a strong emphasis on disaster risk reduction, that is, to engage with communities to proactively mitigate the impact of foreseeable disasters through careful planning and training. the establishment of the can do consortium was reported in volume 4 of this journal as an initiative of major ecumenical significance.2 the work of the consortium is largely funded by the department of foreign affairs and trade of the australian government through its humanitarian partnerships program. pacific focus the geographic focus of the consortium is the south pacific covering the countries of solomon islands, vanuatu, fiji, and papua new guinea (png). this is significant for several reasons. firstly, the christian churches play a central role in the culture of these island nations.3 they overwhelmingly identify as christian in terms of their religious affiliation and are devout in the way that their faith is expressed. there are high rates of weekly church attendance,4 and the churches exercise a powerful and persuasive voice on matters of social policy.5 the churches have a wide geographic reach and have an 48 mitchell nov 2018. christian journal for global health 5(3):47-53. unrivalled footprint in terms of infrastructure and influence across island archipelagos. in many places, the church is the dominant institution within civil society. secondly, these nations are amongst the most disaster prone nations on earth. they rank from 1st (vanuatu), 6th (solomon islands), 11th (png), to 15th (fiji) in terms of disaster risk on the world risk index (out of 171 nations).6 recent examples of disasters to which can do agencies have responded include: • tropical cyclone pam in vanuatu (2015), volcanic eruption on ambae island (2018), • floods (2012, 2014), earthquake (2013), tsunami (2013), and cyclone (2015) in the solomon islands, • floods (2012, 2014), drought (2015, 2015), and cyclones (2012, 2016) in fiji, and • el niño drought (2015) and earthquake (2018) in png. in terms of climate-related disasters, the seasonal warming of the vast waters of the pacific gives birth to many typhoons and cyclones, which these nations will be the first to experience due to their geographic proximity. there is growing evidence, however, that climate change is having an increasingly major impact in the pacific and this is reflected in the number, intensity, and spatial reach of these events.2 these factors — the reach and influence of the church, and the extremely high disaster risk profile of these countries — support and underpin the work of the can do consortium in the pacific. respect for the local voices in 2017, the world humanitarian summit endorsed a commitment to localisation in the design and implementation of humanitarian programming. this is a very important shift, recognising the importance of building the capacity of local actors and respecting their voice and agency in times of emergency. the commitment of can do to work through local church partners is entirely consistent with this global agenda. at a very practical level, churches are uniquely positioned grassroot organisations that are present before, during, and after disasters. they are often the first responders in time of humanitarian crises. the deeply embedded nature of the church in the pacific “means that the theology and doctrine of the church is very influential in shaping beliefs and actions.”7 it is perhaps surprising, therefore, that the belief systems of the churches have rarely been engaged by governments or ngos as part of their development programs. one advantage offered by churches is that the language and idiom of their communication resonates more easily within local frames of reference. this is in sharp contrast to the language of the secular development discourse which may seem distancing and alien.8 it has been reported that, “one reason for the failure of external interventions for climate-change adaptation in pacific island communities is the wholly secular nature of their messages. among spiritually engaged communities, these secular messages can be met with indifference or even hostility if they clash with the community’s spiritual agenda.”9 against this background, working through the churches to better prepare communities for disasters seems like an obvious strategy. that said, it cannot be assumed that local theological convictions will always be consonant with a program of disaster preparedness. religious explanations for disaster religious explanations for disasters are highly important in non-western contexts, including the pacific. the can do consortium has posited that greater impact will be achieved through partner churches in its disaster risk management work if prevailing beliefs are understood in a more systematic way. this will enable theologically-informed counter narratives to be developed where they are needed. this approach may seem strange to western 49 mitchell nov 2018. christian journal for global health 5(3):47-53. sensibilities, where theological readings of natural disasters have been largely discounted since the 18th century.10 in contrast, in the pacific there is strong anecdotal evidence, and some published research findings, which suggests a wide range of theologically-informed views at community level about natural disasters, many of which are antithetical to taking preventative action. one reported theme is to understand disasters as a form of personal punishment.7 the recent cyclone pam (vanuatu) was interpreted by some as god’s judgement. evangelical christians regarded cyclone winston (fiji) “as an act of chastisement from god,”10 with some pastors making the explicit link between personal sinfulness and this type of event. one account from fiji notes, “it is forbidden to be a lesbian in my church and the pastor preaches against it. after tropical cyclone winston, the church pastor said that winston was caused by our sin, and i felt bad. it is not us who they should blame.”11 consistently, cox’s research notes that the biblical story of the destruction of sodom and gomorrah has provided some fijian christians with an analogue linking homosexual practice with judgment by way of natural disaster. there are also reports linking disaster with sabbath observance and the excess of drinking alcohol. these are more localised and may reflect intervillage suspicions and rivalries rather than providing a general narrative.10 conversely, an explicit link has been made between personal piety and the avoidance of calamity. in vanuatu, it has been reported, “we survived because of how hard we prayed” (following tropical cyclone pam).7 similarly, in fiji, a community representative noted, “we, in suva, prayed harder than those in the north,” resulting in tropical cyclone winston diverting away from suva at the last minute and impacting elsewhere.12 professor nunn reports attending a church where, “the preacher told his congregation that... because they were pious, they had been spared the cyclone’s wrath.”9 a more sophisticated theological narrative has been essayed by cox. this proposes the restoration of the true and paradisiacal fijian national identity by the pursuit of faithfulness and piety. under this thesis, indigenous fijians, especially those from methodist traditions, see themselves in a unique salvific relationship to god as a kind of “chosen people” or exemplar akin to ancient israel. on this view, natural disasters are used by god to remind fijians and their political leaders of their particular covenantal responsibility. a key text attached to this view is 2 chronicles 7:14 (niv), “if my people who are called by my name will humble themselves, pray, seek my face, and turn away from their wicked ways, then i will hear from heaven and will forgive their sin and heal their land.” a corollary to this line of thought is that rebuilding efforts following disasters are largely pointless unless accompanied by a genuine and widespread repentance. where the disaster in question is inundation by rising sea levels, another possible response is confusion. in the book of genesis, god promised that “never again will there be a flood to destroy the earth.”13 for communities living in low-lying atolls, inundation by rising sea levels represents an ongoing existential threat. some communities are now facing the prospect of climate-related transmigration. for them, their world is ending by flood. another potential response to natural disasters, which is by no means unique to the pacific, is to take refuge in divine inscrutability. a community may state, “if this [disaster] is god’s will there is nothing we can do about it either way.”12 the risk with this kind of viewpoint is a kind of incipient fatalism which may preclude preventative actions. there are also more positive views about disasters that stress compassion as well as personal and community responsibility as an aspect of christian discipleship. this line of thought teaches that god made humans both as stewards or caretakers of the environment, and as mutually inter-dependent and caring. this thread 50 mitchell nov 2018. christian journal for global health 5(3):47-53. provides a stronger foundation to pursue programs designed to proactively mitigate the impacts of disaster. towards a systematic theology of disaster risk management these brief reflections reveal a variety of views about why disasters happen. at times, these views are unhelpful in terms of the disaster risk reduction work of the can do consortium. the response of the consortium has been to affirm its basic approach of working through local churches while developing a comprehensive theology of disaster risk management which is more facilitative of its work. this theological work will focus on environmental stewardship, climate justice, and disaster preparedness. implicit in this theological work “is the assumption that biblical/theological beliefs underpin peoples’ responses to natural disasters,” and “that these beliefs can either hinder or motivate action.”7 one aspect will be mapping and countering less helpful views by presenting alternative theological narratives. important in this regard will be a renewed appreciation that disasters are not caused by a person’s individual conduct. it is proposed that this theological engagement will be ecumenical in its nature. this means that the materials and resources developed through this effort can be used by all church partners involved with the consortium ensuring a very broad coverage. the key messages will be reinforced not only among co-religionists but by the community more generally, which will be exposed to common materials through their respective denominations. the support of ecumenical bodies in each country will be sought. they are the png council of churches, the fiji council of churches, the solomon island christian association, and the vanuatu christian council (including the seventh day adventist church as an observer). theologians from church partners in the pacific have been engaged to review and produce materials. their involvement is critical to ensure that local culture, traditions, and frames of reference are included. a major mistake is made when development programs are projected on to a community from the outside. when genuine participation is sacrificed, motivation and engagement may be quickly lost.13 locallyproduced resources will not only be more sensitive to local culture but will imbue a greater sense of community ownership. introducing counter narratives without being pre-emptive about the proposed research, there are a range of biblical narratives that concern disasters. critically, disasters are not always associated with divine punishment and may be seen as a part of the ordinary course of life. there are verses that suggest that jesus is seeking to break the causal link between sinfulness and weather conditions. for example, in matthew 5:45 we are reminded that god “causes his sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous.” in luke 13, jesus refers to the tower of siloam that fell down and killed 18 people. jesus comments that the victims of this tragedy were no worse than anyone else.14 in the old testament too, there are clear examples of people taking steps to avoid the effect of disaster, even when that disaster was god-induced. for example, noah was instructed to take preventative measures to preserve his family. later in genesis 41, joseph is enlisted to interpret pharaoh’s dream. joseph advised that it referred to an imminent period of seven years of abundant crops to be immediately followed by seven years of famine. pharaoh was counselled to store up crops to prepare his nation for the future food shortage. the book of proverbs also urges prudent action in the present as a bulwark against the future.15 at a more general level, there is ample biblical material to inform an approach to disaster risk management. compassionate and 51 mitchell nov 2018. christian journal for global health 5(3):47-53. neighbourly action is commended by jesus, and interdependence and strong communitarian values are clearly reflected in the earliest faith communities.16 jesus gives us his example of speaking and acting prophetically in response to issues of justice. we are frequently reminded about our obligations to the vulnerable and are challenged to be more inclusive. there are broad biblical motifs about good stewardship and care for the environment.17 in short, there are many dimensions that could be explored, but how that material is best used should be left to local theologians. outline of research project the initial step was to administer a comprehensive baseline survey. the survey instrument was designed to test local beliefs in relation to disasters and existing levels of disaster preparedness in communities across the four countries. it also gathered data about the ways in which women, children, and people with disabilities were included in disaster response. at the date of this writing, the survey results are yet to be analysed. the analysis of the survey results will inform the work of pacific theological specialists tasked with preparing resources on disaster preparedness for use in local partner churches. these resources will draw on bible teachings and theological motifs that are contextually and culturally appropriate. these resources will then be socialised through national ecumenical bodies. in the first year, high level support and participation of church leaders across denominations will be a priority. this will secure official buy-in at the highest levels and allow time for any further contextualisation to take place. in years 2-4, a program of training local clergy/pastors will be undertaken and materials will be disseminated for use at a grassroot level. resources will start with a theological framework and bible studies, and may include other materials such as sermon outlines and workshops. the premise is that a change in theological understanding about disaster risk management at the local level will result in increased community engagement and behaviour change. a final step, in year 4, will be an end line survey to test attitudinal shifts.7 implications this particular piece of theological research has the potential to be lifesaving as communities reflect more deeply on their social responsibility in times of natural disaster. this reflection may involve positive elements such as exercising compassion, inclusion, and good stewardship but may also require the revisiting of existing beliefs that may be problematic. this type of research program also puts into sharp relief the difference between eisegesis and exegesis. there is an obvious risk in taking scripture and using it in an uncritical way to serve a particular social goal. no matter how worthy that goal might be, the focus should always be to draw out from scripture its proper meaning within its own context, and not read other agendas into it. that said, there are a range of hermeneutical techniques to help bring scripture to life, and alternative readings and meanings that can be established through critical engagement. one example of this type of approach is world vision’s channels of hope program. this development program is directed at communities with strongly christian religious underpinnings. it aims to use alternative interpretations of scripture to produce more inclusive and developmentally-friendly approach to gender relationships, and also for people living with hiv. this program has received strong community support and qualitative feedback. the theology of disaster risk management program takes this same kind of approach but in a very different scenario. one added feature of the present research is its strong emphasis on indigenised and contextual resources designed to enhance a sense of community ownership. 52 mitchell nov 2018. christian journal for global health 5(3):47-53. a final point worthy of specific commendation is the wisdom of the australian government in committing funds to this kind of developmentally-orientated theological research. while the australian government has a secular ethos, that outlook has not prevented it from supporting a well-designed program involving theological research, where conducive, to more effective outcomes. this kind of enlightened secularism is an example for other governments and multilateral funders to consider.18 references 1. the agencies are: act for peace, anglican board of mission, anglican overseas aid, adventist development and relief agency, baptist world aid, caritas, australian lutheran world service, unitingworld. more information is available at: http://www.churchagenciesnetwork.org.au/can-doconsortium/ 2. mitchell b and grills n. an historic humanitarian collaboration in the pacific context. christian journal for global health. 2017;4(2):87-94. https://doi.org/10.15566/cjgh.v4i2.160 3. robbins j. pacific islands religious communities. in juergensmeyer m (ed.) the oxford handbook of global religions oxford. oxford: oxford university press; 2006. https://doi.org/10.1093/oxfordhb/9780195137989. 003.0057 4. clarke m. christianity and the shaping of vanuatu’s social and political developments. journal for the academic study of religion. 2015;28(1). https://doi.org/10.1558/jasr.v28i1.25723 5. laking r. state performance and capacity in the pacific. manila: asian development bank; 2010. 6. world risk report 2107. [cited 2018 august 6]. available from: https://reliefweb.int/sites/reliefweb.int/files/resour ces/wrr_2017_e2.pdf. 7. can do consortium, theology of disaster risk management, program sub-design, 2018, page 6 8. clarke g, and jennings m. development, civil society and faith-based organizations: bridging the sacred and the secular. bassingstoke: macmillan 2008. https://doi.org/10.1057/9780230371262 9. nunn pd. sidelining god: why secular climate projects in the pacific islands are failing. australian centre for pacific island research reported in the conversation, may 17, 2017. [cited 2018 august 6]. available from: https://theconversation.com/sidelining-god-whysecular-climate-projects-in-the-pacific-islands-arefailing-77623. 10. cox j, finau g, kant r, tarai j, titifanue j. disaster, divine judgement, and original sin: christian interpretations of tropical cyclone winston and climate change in fiji. the contemporary pacific. 2018;30(2):380-410. https://doi.org/10.1353/cp.2018.0032 11. oxfam australia, down by the river report. february 2018, page 8. [cited 2018 aug 8]. available from: https://www.edgeeffect.org/wpcontent/uploads/2018/02/down-by-theriver_web.pdf. 12. conversation in the field with anglican overseas aid, disaster response and resilience coordinator, 2018 13. tyndale w. key issues for development. world faiths development dialogue, occasional paper. nov 1998;1:13. 14. luke 13:4-5 15. for example, proverbs 30:25 16. acts 2:42-47 17. romans 8:22–24, psalm 24:1, deuteronomy 10:14, genesis 2:15. 18. mitchell b. faith-based development. new york: orbis books; 2017 at pp. 124-26. peer reviewed: submitted 18 aug 2018, accepted 25 oct 2018, published 8 nov 2018 competing interests: none declared. correspondence: robert bradley mitchell, anglican overseas aid, australia. bmitchell@anglicanoverseasaid.org.au http://www.churchagenciesnetwork.org.au/can-do-consortium/ http://www.churchagenciesnetwork.org.au/can-do-consortium/ https://doi.org/10.15566/cjgh.v4i2.160 https://doi.org/10.1093/oxfordhb/9780195137989.003.0057 https://doi.org/10.1093/oxfordhb/9780195137989.003.0057 https://doi.org/10.1558/jasr.v28i1.25723 https://reliefweb.int/sites/reliefweb.int/files/resources/wrr_2017_e2.pdf https://reliefweb.int/sites/reliefweb.int/files/resources/wrr_2017_e2.pdf https://doi.org/10.1057/9780230371262 https://theconversation.com/sidelining-god-why-secular-climate-projects-in-the-pacific-islands-are-failing-77623 https://theconversation.com/sidelining-god-why-secular-climate-projects-in-the-pacific-islands-are-failing-77623 https://theconversation.com/sidelining-god-why-secular-climate-projects-in-the-pacific-islands-are-failing-77623 https://doi.org/10.1353/cp.2018.0032 https://www.edgeeffect.org/wp-content/uploads/2018/02/down-by-the-river_web.pdf. https://www.edgeeffect.org/wp-content/uploads/2018/02/down-by-the-river_web.pdf. https://www.edgeeffect.org/wp-content/uploads/2018/02/down-by-the-river_web.pdf. mailto:bmitchell@anglicanoverseasaid.org.au 53 mitchell nov 2018. christian journal for global health 5(3):47-53. cite this article as: mitchell r b. the case for a theology of disaster risk management. christian journal for global health. nov 2018;5(3):47-53. https://doi.org/10.15566/cjgh.v5i3.238 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.15566/cjgh.v5i3.238 http://creativecommons.org/licenses/by/4.0/ family planning practice among christian health service providers in ghana: a case study 80 | christian journal for global health 4(2) www.cjgh.org case study christian journal for global health | family planning practice among christian health service providers in ghana: a case study james duaha and peter yeboahb a md, mph, emba, deputy executive director, christian health association of ghana (chag) b m.sc. mph/ichd, bsc, executive director, christian health association of ghana (chag) abstract introduction: the interphase of faith and practicing health professionally often presents a challenge. to navigate between the two requires tact, experience, and professionalism. such is the case of the christian health association of ghana (chag). objective: this case report presents an overview of how the christian health association has provided family planning services for marginalized communities in ghana by church denominations some of whose doctrines forbid them from practicing certain forms of family planning. background: chag is a network of 300 health facilities and health training institutions owned by 25 different christian church denominations. chag provides health care to the vulnerable, deprived, and marginalized population groups in all 10 regions of ghana. as an implementing partner of the ministry of health, chag is mandated to implement key policies to achieve national health outcomes, including family planning. some members do not accept artificial family planning on the account of religious faith. this often presents a challenge in addressing the need to provide family planning services as required. this challenge is further complicated by the fact that the chag secretariat charged with protecting the interests of member institutions as well as those of the ministry. strategy: chag tailors the provision of family planning interventions to denominational, socio-cultural, and religious acceptability, and client needs. results: over a period of three years, the proportion of family planning acceptors who are adolescents (10-19 years) increased from 13.7 percent to 17.0 percent, total family planning acceptors increased from 67,312 to 73,648 and total couple years of protection increased from 71,296 to 92,852. male sterilization also increased, contrary to cultural beliefs. importantly, chag as an implementing partner is able to satisfy its obligation of providing service to achieve national health goals. conclusion: protecting the interests of christian health institutions and those of government may conflict at some point. being tactful and allowing work within the confines of faith and obligations helps in achieving desired results. http://www.cjgh.org www.cjgh.org july 2017 | 81 introduction family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods. family planning services are therefore services designed to help couples and individuals of reproductive age (15-49 years) to space their children, prevent unwanted pregnancies, and improve reproductive health. there is evidence to show that family planning improves health, reduces poverty, and empowers women.1 in developing countries such as ghana, there are many impediments to family planning including limited access to services, products, and information; lack of spousal consent; and, in particular, issues of faith and religion. christian health organizations take interest in faith and practice. the interface between faith and practicing health professionally often presents a challenge. to navigate between the two requires tact, experience, and professionalism. such is the case of the christian health association of ghana (chag). this case report presents an overview of how 25 denominations (the association) have institutionalized the provision of family planning services, some of whose doctrines prohibit the use of certain forms of family planning. according to the 2014 ghana demographic and health survey, knowledge of contraception is universal in ghana.2 twenty-seven percent of currently married women use contraception; 22 percent use a modern method. the three most popular modern methods used by married women are injectables (8 percent), implants (5 percent), and pills (5 percent). use of modern methods has more than quadrupled in the past 25 years, rising from 5 percent in 1988 to 22 percent in 2014. the government sector remains the major source of contraceptives in ghana, providing them for 64 percent of current users, an increase from 39 percent in 2008. overall, one in four contraceptive users discontinues using a method within 12 months of starting its use. six percent of episodes of discontinuation occur because of side effects or health concerns. thirty percent of currently married women have an unmet need for family planning services, meaning they are fertile and desire to either stop or postpone childbearing but are not currently using a contraceptive method,3 with 17 percent having an unmet need for spacing and 13 percent having an unmet need for limiting.2 the government of ghana believes that ghana’s population dynamics can be turned into a valuable demographic dividend only if investments are made in family planning and reproductive health programmes to promote a lower fertility rate and more balanced age structure, as well as investments in multi-sectoral social and development programs that enable economic growth and quality-of-life improvements.4 consequently, the objectives of ghana’s family planning policy, called ghana family planning costed implementation plan (gfpcip), for 2016-2020 fiscal year are: 1) increase the modern contraceptive prevalence rate (cpr) amongst currently married women by 33 percent by 2020 (base cpr in 2014 was 22.2 percent) and 2) increase the modern cpr amongst unmarried, sexually active women from 31.7 percent in 2014 to 40 percent by 2020. the key areas being addressed in the gfpcip include demand creation, service delivery, contraceptive security, policy and enabling environment, financing, stewardship, management, and accountability. these national objectives and priority areas are to be implemented by all agencies of the ministry of health (moh), both public and private, including chag. as a network of 300 health facilities and training institutions, chag is composed of 25 different church denominations and provides health care to the most vulnerable, deprived, marginalized, and underprivileged population groups in all 10 regions of ghana, particularly in the most remote areas. these denominations include catholic (44 percent), presbyterian (18 percent), adventist (11 percent), methodist (8 percent), anglican (3.5 percent), pentecostal (3.2 percent), and other (12.3 percent). serving in 177 districts, chag provides curative, duah and yeboah christian journal for global health | http://www.cjgh.org 82 | christian journal for global health 4(2) www.cjgh.org preventive, and rehabilitative care to about 6 million ghanaians every year. as an implementing partner of the moh, chag is mandated to implement key policies to achieve national health outcomes. such policies include family planning, maternal, and child health services. the challenge there are two situations that conflict in administering family planning services within the chag network. first, one of the core functions of chag is to protect and promote the interest of its member institutions. second, as an implementing partner and an agency of the moh, chag is required to provide all services approved by the ministry including family planning. the catholics, who form about 44 percent of the chag membership, do not accept artificial family planning, which is one of the main forms of family planning. the remaining 56 percent of members, including pentecostals, do not have doctrines against the utilization and provision of family planning services. the challenge is thus to provide a service required by the moh and at the same time to protect the interest of the members. until 2013, the catholics formed more than 70 percent of the chag network and, given their majority status and doctrine, family planning did not feature prominently in chag’s list of priorities. after 2013, about 111 new members were added, the majority of whom were not catholic institutions and who had no doctrinal challenges with providing artificial family planning services. objective 5 of ghana’s 2014-2017 health sector medium term development plan (hsmtdp) sought to enhance national capacity for the attainment of health-related millennium development goals (mdgs).5 through this objective, ghana’s health sector working group (a group of representatives of the moh implementing agencies and development partners in health) agreed that all agencies implementing the mdg accelerated framework should train service providers in artificial family planning methods, particularly implant insertion. consequently, family planning was prioritized by all agencies, including chag, such that about 115 midwives and community health nurses were trained in family planning methods within chag. how chag resolves conflicts in administering family planning of the various forms of family planning, the artificial forms, including oral contraceptives, barrier methods, injectables, and implants, have proven to be highly effective and easy to use. the government of ghana’s commitment to reach more women, youth, and adolescents and make services affordable, accessible, and equitable for all population groups involves promoting the artificial methods. however, not all the populations served by chag accept the artificial methods even when highly promoted. specifically the catholics do not subscribe to the artificial and modern forms of conception due to doctrinal concerns. the presbyterians, adventists, methodists, anglicans, and the other minor groups who form 18 percent, 11 percent, 8 percent, and 19 percent respectively do not have any doctrinal inhibitions to family planning utilization and service provision. all the denominations accept single marriages, and so marriage does not usually pose restrictions to family planning within the network. aside from the doctrinal barriers for the catholics, there are also cultural barriers to providing modern family planning services in certain communities where chag operates, specifically beliefs that women might become unfaithful if they accept family planning services. to deal with these situations while protecting and promoting the interest of its members, chag’s strategies for family planning services are tailored, ensuring that interventions within specific denominations are socio-culturally and religiously acceptable by both the denomination and the community for whom they are intended. for example, since the catholics do not accept artificial family planning, training programs on implant insertion exclude catholic health institutions. likewise, artificial family planning supplies like oral contraceptives, implants, and condoms are given only to facilities duah and yeboah christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 83 that accept these methods. the regional health administration offices of the ghana health service, through their district health management administration (dmha), provides family planning supplies every month to all health facilities in their catchment districts, including chag facilities. these supplies are supported by donor partners including united nations populations fund (unfpa). facilities that believe only in natural family planning would only be given education on natural family planning and supplies like cyclebeads®, which are used to plan or prevent pregnancy by tracking the start dates of a woman’s period based on the standard days method (sdm). chag member institutions that do not accept artificial family planning methods have agreed to refer clients requiring artificial family planning to the nearest facility that offers those services (a government-, chag-, or marie stopes-accredited facility). cultural barriers are dealt with differently by different church denominations. for example, communities that do not accept injectables are not forced to have them. voluntary acceptance is encouraged. often, innovative ways of dealing with such cultural barriers have been explored by members. for the most part, counseling for both members of a couple is conducted together, particularly in northern ghana where decisions are primarily made by men. chag, through its various denominations, uses quarterly community durbars—when education on pertinent health issues, including the need for family planning, is conducted—to address cultural barriers, along with conversations with traditional and opinion leaders. chag implements both artificial and natural family planning methods. the natural methods that are provided include rhythm, cyclebeads® (sdm), lactation amenorrhoea (lam), etc. natural family planning is considered one of the oldest methods women have used to control their fertility, and addresses the concerns of a diverse population of ghanaians with varying religious and ethical needs. modern family planning services include injectables and voluntary surgical interventions (sterilizations) for both men and women. a majority of people view these modern methods as more effective than natural methods. consequently, there is the tendency for practitioners (doctors, midwives, and community health nurses) to promote modern methods, particularly injectables. a common injectable used is medroxyprogesterone (depo-provera) and often midwives tend to promote it particularly among the youth. this is evident in the kind of advertisements and family planning educational programs that are run on national television channels. rarely would one find natural family planning being promoted. the excessive focus on artificial family planning creates pressure to utilize these methods, which are often not accepted by certain cultures and certain religious views. this leads to resistance and low acceptance. prior to 2012, chag did not have any significant data on family planning but the need to track the effectiveness of their approach was needed.. methods data for this study was taken from routine service data collected from member institutions by the health management information systems (hmis) unit of chag. this is part of quarterly data that member institutions submit to the hmis for policy, planning, and decision-making. the same data is submitted to the district health information management systems 2 (dhims2) software of the ghana health service. data collected include outpatient and inpatient service utilization, morbidity and mortality for all age groups, and family planning service (various methods) utilization, and is submitted using the moh service reporting formats. other data that is routinely collected by the hmis unit include antenatal and postnatal care utilization data, supervised and non-supervised deliveries, immunizations, outreach services, diseases of public health concern, and human resources. the data is excel-based and is stored on a server at the chag secretariat’s hmis unit. for this study, data on family planning from the various institutions were collated from 2013–2015 and were based on 93 percent response rate. data duah and yeboah christian journal for global health | http://www.cjgh.org 84 | christian journal for global health 4(2) www.cjgh.org was analyzed using excel for computations of averages, percentages, and total numbers. analyzed data was compared with data reported in the dhims to ensure reliability and, where necessary, facilities were called for clarification. results from the analysis were reported in tabular forms based on which interpretations were made. other information used in this study was taken from chag’s 2013-2015 annual reports. results broadly, all the interventions that chag implements are within the national priority areas, thus satisfying the requirements for the health sector for which chag is mandated. secondly, implementing strategies that are within the confines of the beliefs and faith satisfies chag’s stewardship mandate. largely, because this approach is socio-culturally and religiously acceptable, patronage and prevalence of contraception is appreciable. in 2015, a total of 15,101 people accepted natural family planning, which formed about 20.5 percent of total family planning acceptors. the number that accepted natural family planning in 2015 was 4,757 (46 percent) more than 2014. of the acceptors of natural family planning for 2015, a total of 13,881 (91.9 percent) used lam whilst 1,220 (8.1 percent) used sdm. though the proportion of persons using natural family planning is small, chag is assured that all populations, no matter how small, are offered care. importantly, chag has observed a significant increase in the proportion of family planning acceptors who are adolescents, an indication of the fact that cultural barriers to adolescents using family planning are being reduced. over a period of three years (2013-2015), the proportion of family planning acceptors who were adolescents (10-19 years old) increased from 13.7 percent to 17.0 percent, the total number of family planning acceptors increased from 67,312 to 73,648 (a 9.4 percent increase) and total couple years of protection rose from 71,296 to 92,852 (a 30.2 percent increase).6 table 1 shows the trend of family planning acceptors in chag facilities and couple years of protection from 20132015. male sterilization also increased, contrary to cultural beliefs. in 2013, there was no vasectomy performed in any of the numerous chag facilities. in 2014 and 2015, the number of vasectomies recorded were 4 and 14, respectively, whilst female sterilization increased from 455 in 2014 to 807 (a 77.4 percent increase) in 2015, as seen in table 2.6 the increased female sterilization is in tandem with growing trends of caesarean section (c/s) rates observed within the chag network. between 2012 and 2016, the c/s rate has increased by 43 percent and this may partly account for the rising female sterilization.7 generally, family planning utilization increases as the number of children increases.8 when women have more than three deliveries by c/s, they are often counseled on medical grounds to undergo sterilization. intensive education on family planning table 1. family planning acceptors and couple years of protection, 2013-2015 description 2013 2014 2015 percentage postnatal registrants accepting family planning 16.7 14.6 14.8 proportion of fp acceptors who were adolescents (10-19) 13.7 15.0 17.0 proportion of fp acceptors who were older adolescents (15-19) 12.3 14.2 16.0 total family planning continuing acceptors 44,668 45,526 50,293 total family planning new acceptors 22,644 21,969 23,355 total drop-outs 21,786 17,202 total family planning acceptors 67,312 67,495 73,648 total couple years protection 71,296 69,701 92,852 duah and yeboah christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 85 is another factor that may have played a key role in the increased trends observed in both male and female sterilizations. in 2015, 73,648 postnatal women (14.8 percent) accepted various forms of family planning.6 this represents an increase from 67,312 in 2013 to 73,648 (9.4 percent) in 2015 as shown in table 1. table 2 gives a trend of the various family planning methods from 2013 to 2015. consistent with findings from research conducted by amu and nyarko,9 it is to be noted that the short-term injectable (depot medroxyprogesterone acetate) is the most accepted contraceptive within the chag network. discussion faith and cultural beliefs must be linked to the knowledge of family planning in order to increase family planning uptake. implementing interventions that are socially, culturally, and religiously acceptable are likely to yield appreciable outcomes. there is an increasing trend of using family planning methods within the chag network, and this may be related to the chag’s program and observed national trends. at the national level, the last ghana demographic and health survey indicated that from 2008 to 2014, the use of any method of contraception increased from 24 percent to 27 percent and modern methods had increased from 17 percent to 22 percent. use of family planning increases with the prevalence of outreach campaigns.8 thus, education on family planning, increased advertisements, and stakeholder engagements on family planning contributed to the increasing trends of family planning acceptance. the increased proportion of adolescents using family planning may be an indication of the fact that cultural barriers to adolescents using family planning are being reduced. chag data also shows that 13,881 family planning acceptors (18.9 percent) use lam.6 this contrasts with national findings where only 0.2 percent of married women use lam.8 but this situation draws attention to the need for complementary services between governments and faith-based health systems in achieving national health outcomes. where each has a deficiency, the other can fill in the gap, as in the case of lam in ghana. being religious, cultural, and client sensitive may lead to increased lam acceptors and proportions of adolescents who use family planning methods. additionally, male and female sterilization could increase when family planning practitioners are culturally sensitive. over the years, implementation of interventions and policies has typically been a top-down approach where agencies are expected to accept and implement policies as they are. by taking a bottom-up approach that responds to faith and culture, contraceptive use is increased. a top-down approach often presents a challenge. though implementation may table 2. trend of family planning by type, 2013-2015 description 2013 2014 2015 natural family planning 10,821 10,344 15,101 male sterilization (vasectomy) 0 4 14 female sterilization 463 455 807 condom (male) 3,748 4,591 8,192 condom (female) 81 162 108 oral contraceptives (the pill) 10,542 11,592 10,810 implant 2,956 3,308 4,336 short term injectable (depot medroxyprogesterone acetate) 36,870 32,799 33,947 intra-uterine contraceptive device (iucd) 119 134 202 all other artificial methods 64 93 131 duah and yeboah christian journal for global health | http://www.cjgh.org 86 | christian journal for global health 4(2) www.cjgh.org be done, it may not yield the impact it should since it may not be socio-culturally acceptable. denominations may not accept certain forms of family planning but can easily refer clients who require those services to facilities that do provide them. this allows faith-based organizations to satisfy clients’ needs and policy requirements for service provision whilst remaining true to their doctrinal beliefs. the limitations of this study are that it may not be generalizable, and for that matter one cannot be sure how this would work in another context. chag’s approach correlated with improved family planning acceptance, but this does not mean it caused it. there was no comparison group; indeed a comparison study may not be feasible. like any other case report study, the findings in this study may be over-interpreted, and readers may be distracted when focusing on the unusual. more research is required with other christian health service organizations with similar socio-cultural contexts. conclusions the interests of christian health facilities and those of the government may conflict at some point. being tactful and allowing work within the confines of faith and obligations helps in achieving desired outcomes. references 1 bongaarts j, cleland j, townsend wj, bertrand tj gupta dm. family planning programs for the 21st century: rationale and design. new york: population council; 2012 2 ghana statistical service. ghana demographic and health survey 2014. rockville, maryland, usa. april 29, 2016 3 measure evaluation project [internet]. unmet need for family planning. [updated june 4, 2016] available at: https://www.measureevaluation.org/prh/rh_indicators/ specific/fp/unmet-need-for-family-planning 4 government of ghana. ghana family planning costed implementation plan. washington d.c., ghana: futures group, health policy project. april 26, 2015 5 ministry of health. (2014). the health sector medium term development plan. accra: powerhaus media concepts. 6 chag. (2013-2015). reports from minimum data set. accra: chag 7 christian health association of ghana. annual report 2016. accra, ghana. may 31, 2017 8 ghana statistical service. (2014). ghana demographic and health survey. accra: ghana health service 9 amu h, nyarko sh. trends in contraceptive practices among women in reproductive age at a health facility in ghana: 2011–2013. contraception and reproductive medicine. 2016; 1:2;1-5. https://doi.org/10.1186/s40834016-0010-9 peer reviewed competing interests: none declared. correspondence: james duah, james.duah@chag.org.gh; peter yeboah, peter.yeboah@chag.org.gh cite this article as: duah j and yeboah p. family planning practice among christian health service providers in ghana: a case study. christian journal for global health. july 2017; 4(2):80-86; https://doi.org/10.15566/cjgh.v4i2.175. © duah j. and yeboah p. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ duah and yeboah christian journal for global health | http://www.cjgh.org https://www.measureevaluation.org/prh/rh_indicators/specific/fp/unmet-need-for-family-planning https://www.measureevaluation.org/prh/rh_indicators/specific/fp/unmet-need-for-family-planning https://doi.org/10.1186/s40834-016-0010-9 https://doi.org/10.1186/s40834-016-0010-9 mailto:james.duah@chag.org.gh mailto:peter.yeboah@chag.org.gh https://doi.org/10.15566/cjgh.v4i2.175 http://creativecommons.org/licenses/by/4.0/ commentary june 2014. christian journal for global health, 1(1):60-63. beyond “teach a man to fish”: communal meta-cognition as the key to sustainable professional development ken foster a a md, assistant professor of surgery, northern ontario school of medicine, canada abstract improvement in the quality of aid and development in a community requires a feedback loop within the community, known as “communal meta-cognition.” this is relevant to medical education in resource-poor countries and is illustrated with the author’s own surgical experience. the usual source of truth is unquestioned allegiance to established wisdom rather than the dynamic state that comes through the feedback loop of asking questions, most importantly of one’s self. some elements of what this might look like in a medical education context are illustrated. introduction in 2010, the lancet charted a path into the 21st century with its commissioned report “medical education for the 21st century” put together by recognized leaders in the field. 1 as a manifesto outlining where medicine should go, it represents the top of the game. so why, for me, should it be such a frustrating read? the lancet report’s executive summary states, “professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates.” 1 if the leadership of the medical profession continues to focus on fixing curricula and equipping graduates, then i am afraid that for another generation, especially in the countries where the need is greatest, professional education will continue to lag behind. knowledge content, including skills in that category, like natural resources in the economic sphere, can often end up doing more harm than good because of the tendency to promote inequity, corruption, and the use of force. to the extent that medical education can be shifted away from maximizing the capacities of individual doctors and towards the promotion of a culture of learning as a community, then change begins to come from within. one can easily argue that developing curricula and providing resources to increase the capacities of individual practitioners is a good way to exacerbate the human resources gap by facilitating the brain drain. it is hard to argue with the numbers. i know of one african country in which none of the more than 30 united kingdom certified orthopaedic specialists trained there over a three decades span stayed in the country. even when the more skilled doctors do stay in their own country, there is a tendency to focus care on those better able to pay for it. indeed, the medical profession can exploit the poor who are without hope of recompense or prospect of litigation. although punitive approaches may not lead to decreases in medical error, a culture of accountability can only help when it comes to embedding hippocratic values and motivation. what i am proposing is a shift of the focus of intervention in medical education from the cognition of the individual practitioner to meta-cognition of the professional community. it is not enough to “teach a man to fish,” let alone “give a man a fish.” we 61 foster june 2014. christian journal for global health, 1(1):60-63. must, in this metaphor, help the community to develop a sustainable fishery. meta-cognition the term meta-cognition can be described as the awareness or understanding of one’s own thinking processes. if this seems too abstract, it might help to outline one way in which this principle could work in practice. the frustration i felt after reading the lancet article arises in large part because i have spent most of my career in war-torn countries: afghanistan, angola, and yemen. cultural difference has played a large part in my own experience and hofstede’s analysis in this area has resonated the most strongly. of the cultural dimensions that he examines, “powerdistance” relates most directly to the source of authority in medical education. 2 oddly, this point seems rather noticeably absent from the lancet report. although where i currently practice in canada, application of these same principles (meta-cognition) could stand to be improved, the benefits to be gained would be relatively less. the activity i am proposing, wherever and no matter how imperfectly implemented, must inevitably effect some measure of salutary culture change. scenario – afghan healthcare since the taliban were ousted in 2001, afghanistan’s healthcare system has seen dramatic change. western countries invested substantially and analyzed extensively. healthcare is supposed to be publicly funded and free, although the reality seems otherwise. 3 the basic package of health services (bphs) program focused almost exclusively on low hanging fruit. subsequently, this has shifted somewhat as a result of ongoing analysis towards a more pragmatic balance that incorporates some essential surgical services. with virtually all of the funding to run the system having come from outside sources such as usaid and eu monies, it has been galling to see several of the best functioning hospitals close because of an approach to funding that blocked local community input. at the same time, one of the biggest hospitals in the capital received massive injections of funding while notoriously failing to correct egregious breaches of clinical and ethical standards. 4 as an example, the same pair of latex gloves would often be used for several obstetrical deliveries. cleaning staff of decade’s long employment whose dedication was illustrated by their willingness to work often without pay through the worst of the war years were fired and replaced by relatives of the new directorate when the salary scale saw dramatic rises (personal communication). if they had shown some interest or commitment to working, then justification might be claimed. although the reader might question why i chose such an extreme example of the damaging impact of aid money, it highlights the lack of feedback both from within the hospital structure and from the local community. while not denying that large gains were made through the bphs, my purpose is to ask whether a small percentage of the aid money could be spent to leverage greater accountability. in north america, we are increasingly being encouraged to pursue practice based reflective learning to maintain competency. high-power distance cultures that also place great importance on honor/shame show resistance to exposure of weakness or ignorance, and there is more discomfort with ambiguity or change. 3 from my years in afghanistan, yemen, and angola, i am convinced that this cultural issue is crucial to medical education. could not a small part of the investment in health care be spent to promote culture change among health care professionals? the capacity-building approach of focusing on competencies and resources generally works system wide from the top down, e.g., the bphs in afghanistan. william easterly argues in his book, the white man’s burden, for more of a “local problem, local solution” approach in which the stakeholders function more directly as local stakeholders. 5 the proposal that follows is a hybrid of the two, with generic process but local content. its capacity building focuses on the local professional community rather than the individual practitioner. the goal is not so much to train better doctors, per se, as it is to develop clinical departments that function as learning communities. 62 foster june 2014. christian journal for global health, 1(1):60-63. the cities of qandahar and herat each have an example of a hospital dramatically improved through the involvement of a local businessman. while such altruistic involvement from the community is highly desirable and fits easterly’s approach, it does not constitute low hanging fruit. instead, the crucial question in relation to feasibility and fruitfulness lies in the contribution that doctors make to health care. in afghanistan, they are the dominant players, whether or not the main influencers of health care delivery. what follows is a proposal that would take a tiny proportion of the money spent on health care and use it to promote meta-cognition at the level of hospital clinical departments. a proposal clinical departments at all public hospitals in afghanistan should hold a half-hour, weekly discussion focused on a recent case. each department would be required to choose a case for discussion on the basis of at least one of these three features: (1) uncertainty, (2) controversy, or (3) bad outcome. the whole department should be involved, and the discussion should engage with the following three questions; (1) what was the case narrative? (2) were there things that we could have done differently? (3) how do others, elsewhere, manage this kind of problem? powerpoint, for all its faults as a medium of expression, can nevertheless help to essentialize and record the key elements and provide a means for coaching feedback and program assessment. in contexts where such discussions pose challenges to traditions and hierarchies, subtle interventions can be helpfully subversive. provide computer hardware and training in the use of internet access to literature through hinari as incentive. make hospital funding and accreditation conditional on fulfilling this simple program. huge gains might not be seen overnight, but the culture of authority would begin to change. an early specific benefit could be a concern for quality improvement. high-power distance cultures inevitably throw up more resistance to group self-appraisal, 2 but the benefits to the practice of medicine should be proportional to the resistance encountered. this approach has the added advantage that it is not predicated on a direct challenge to any specific person or dogma. change that comes from below, and within, is much more likely “to stick” than change brought from the outside or imposed from above. case conference learning structured around reflexive learning will not instantly fix the problems of a professional culture that has been hostile to free and open questioning, but it will begin to address the root causes in a way that curricular reform and pedagogical technique cannot. conferences can transform the medical culture of authority. purposeful repetition of an action that embodies a particular character value develops both the skill and the corresponding mind-set. regular intentional questioning by discussing one’s own uncertainties and failings as a community must surely promote communal learning and also the virtues of vulnerability, honesty, and caring. without these virtues, the profession cannot be at its best. c.s. lewis’ wellknown treatment of the virtues illustrates this phenomenon, “when you are behaving as if you loved someone, you will presently come to love him.” 6 instead of the feelings producing the action, it is the action that generally produces the feelings associated with the action, and even the capacity to experience those feelings and motives. the more we practice admitting our weaknesses, the easier it gets to do so and the easier it is to learn from the process of looking at our weaknesses. references 1. frenk j, chen l, bhutta z, cohen j, crisp n, evans t et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. the lancet. 2010 dec 4; 376 (9756): 1923-58. http://dx.doi.org/10.1016/s01406736(10)61854-5 2. hofstede, g. culture's consequences: comparing values, behaviors, institutions and organizations across nations. thousand oaks, ca: sage publications; 2001. 3. steinhardt lc, waters h, rao kd, naeem aj, hansen p, peters d. the effect of wealth status on care seeking and health expenditures. in: afghanistan, http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 63 foster june 2014. christian journal for global health, 1(1):60-63. health policy & planning. 2009; 24:1-17. http://dx.doi.org/10.1093/heapol/czn043 4. [i]dependent lens. [internet] motherland afganistan. [posted 17 jan 2007; cited 12 june 2014 ] http://www.pbs.org/independentlens/motherlandafghani stan/qa.html 5. easterly, w. the white man’s burden: why the west’s efforts to aid the rest have done so much ill and so little good. oxford: oxford university press; 2009. 6. lewis, c.s. mere christianity. new york: touchstone (simon & schuster); 1996. [p.116]. this article was peer reviewed competing interests: none declared. correspondence: dr. ken foster 21 maury's run, nobel, ontario, canada p0g 1g0 kwinfer@gmail.com cite this article as: foster, k.. beyond “teach a man to fish”: communal meta-cognition as the key to sustainable professional development. christian journal for global health (august 2014), 1(1):60-63. © foster, k. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1093/heapol/czn043 http://www.pbs.org/independentlens/motherlandafghanistan/qa.html http://www.pbs.org/independentlens/motherlandafghanistan/qa.html http://creativecommons.org/licenses/by/4.0/ commentary june 2014. christian journal for global health, 1(1):57-59. shalom & eirene: the full framework for health care apolos landa a a md, msc chdc of lshtm , mth regional coordinator for south america, luke society, moyobamba, peru our present world and society longs for meaning and wholeness. a major contributor to this state is the dualistic worldview legacy of modern western culture. rich and poor, male and female, white and black are asked at every corner to choose between different dimensions of human life as if the lines of these dimensions did not intersect at one point: the person. body and soul, health and disease, individual and community, order and freedom, power and love, god and the world, subject and object, fact and value, science and religion and so on, are viewed as if these were irreconcilable opposites. 1 cradled in this context, the mentality of the church and christianity has not given enough centrality to wholeness and harmony in all spheres of human life, especially in its temporal and physical conditions and relationships. thus health, equity, and justice, as key conditions for reconciling humanity and the world into wholeness, tend to be neglected. western theology did not escape that tendency and became profoundly influenced by greek speculative philosophy. a dualistic distinction was drawn between what is considered the eternal, spiritual, and unchanging reality and what is the temporal, material, and changing world. within that view, the end purpose of being truly human belongs only to the eternal and spiritual and not to the body, the organic, communal, and ecological relationships. furthermore, the human, as an immortal essence, does not depend on the material and temporal dimensions of existence. therefore, it is left implied that the ultimate need of a human being is the salvation of his immortal ‘soul.’ this has biased the scope of mission and health care. consequently, mission’s duty, in traditional theological terms, is to save humans, either collectively or soul by soul, from hell to heaven. thus, any other temporal concern for status or relationship is viewed only as a preparation for that ethereal destiny. 1 on the other hand, health care has become more concerned with the biological/organic, with its related technology and medical means and procedures, than with the total welfare of a person and community, in the search of common wellness and wholeness. we should not be surprised, therefore, by the tremendous human longing for wholeness and the no less tremendous search for holistic deliverance and healing that characterize the emerging post-modern society. the western influenced dualism of ‘spirit’ versus ‘body,’ in today’s christianity, is totally alien to the biblical view of the person. when god formed adam’s body from the dust of the ground and breathed life into it, he became a nefesh haya that is, a ‘living soul,’ a ,(genesis 2:7) נֶֶפׁש ַחיָּה׃ living being. this hebrew word for ‘soul’ indicates a human individual as a totality, in complete integration. and as god created male and female in his own image and likeness, “humanity bears the divine imprint, not just as disembodied soul, a spark of divinity locked up in the flesh, but as a person that, in every dimension of his being, relates to and reveals the glory of his creator in harmonious mode with the rest of his creation.” 1 when paul in 1 thessalonians 5: 23 talks about “your whole spirit, soul, and body be preserved blameless,” he is not talking of these as superimposed and separated realities or entities, but rather of a multidimensional, integrated totality as he began wishing that “the very god of peace [shalom/eirene] sanctify you wholly.” jesus at the pool of bethesda, in healing the crippled man, gives us a true picture of his perspective on wholeness for the human person. with his question, he exposes the cause of his physical condition beyond what was apparent or rationally explained. by asking “do you want to 58 landa june 2014. christian journal for global health, 1(1):57-59. get well?” or “wilt thou be made whole?” – as rendered in the king james version – jesus confronts the sick and disempowered man with the reality that his actual condition is the combined effect of his psychological hopelessness and low self-esteem, his social alienation and oppression, and his spiritual obstinacy and rebellion. his complete healing was made possible only when all these diseased dimensions, pulling apart his total person, were dealt with. 2 the word that denotes this state of completeness, harmony, soundness, and well-being, is the hebrew word shalom ( ). from the way gideon labelled the altar he built for the eternal as “the lord [is] shalom,” (‘ ’ judges 6:24) the talmud (shabbat 10b) recognizes shalom as one of the designations of god himself. this name of god derives from the perception of gideon that peace and integrity emanate from his countenance as it is bestowed in the priestly blessing (numbers 6:22-26). this is of the very nature of god, and that is what he is determined to establish in the whole realm of his creation. according to the nuevo diccionario bíblico español certeza (ndbc), 6 the word is used in the old testament (ot) to bid welfare or express harmony and concord among people, also to indicate the wellness, material prosperity, physical safety, and peace of a person, city, country, or between two entities that relate to each other. it mainly denotes health, inner peace, and spiritual well-being. it is always found in association with righteousness and truth, but not with wickedness. the source of all shalom is god. when he harnessed chaos into order in creation, he bestowed shalom for the whole of it. in fact, he claims, “i make [shalom].” (isaiah 45: 7 [kjv]) therefore, john goldingay concludes: god is the maker of shalom … [that] stands potentially for all forms of well being. it covers peace, but it is another positive term that embraces much more than the absence of conflict; it suggests a community enjoying fullness of life, prosperity, contentment, harmony, and happiness. its antonym is ra, an all-purpose word for what is bad, both covering evil and adversity. 4 this recognition has for centuries found place as a concluding declaration chanted in much jewish liturgy (including the birkat hamazon, kaddish, and personal amidah prayers). 5 the full sentence translates into english as “he who makes peace in his heights, may he make peace upon us and upon all israel; and say, amen.” true shalom, then, is not the absence of conflict or the cessation of hostility, but a state achieved by bringing equilibrium to what is unbalanced, justice where there is inequity, integrity where there is unrighteousness, wholeness where there is disintegration, and healing and health where there is sickness and disease. it is in this regard that shalom has become another way of approaching the meaning of health, which poses great difficulty and challenge to articulate, as it also touches all dimensions of life inscribed in the human person. just as shalom is not a mere “element in the description of [human] essential nature… [health] is not a part of or a function of [him] as are blood circulation, metabolism, hearing, breathing.” 6 health, then, is not just the absence of disease or sickness but is “a state of complete physical, mental, and social well-being.” 7 it is also the harmonious and balanced relationship spanning from the spiritual nature of god to the economic life dimensions of a person, in harmony with its creator as well as with the rest of creation, the natural and transcending environment. tillich says that “the multidimensional unity of life in man calls for a multidimensional concept of health, of disease, and of healing, but in such a way that it becomes obvious that in each dimension all the others are present.” 8 therefore, the wholeness of shalom includes health, and the quest for wholeness includes healing. health is disease conquered and healed, as eternal shalom is shalom by conquering chaos and disharmony. the ndbc 3 also informs us that the corresponding greek word for shalom in the new testament (nt) is eirene (εἰρήνη). this word, despite its primarily negative force in classical greek, by the way it is used in the septuagint (lxx), ends up being used in the nt with the full meaning found in the ot. likewise, it is used in greetings and benedictions. eirene’s meaning links with other key words of the nt, such as grace, life, and righteousness, and its use is holistically applied to the total human person. the multidimensionality of shalom exchanges easily for the multidimensionality of health, as both are related to the multidimensional nature of a human person. that is why, either shalom or eirene in biblical times had become the best greeting to greet one another. by saying “shalom aleichem” or “peace be unto you (plural),” one wished for the most complete state of welfare and wholeness for persons. 59 landa june 2014. christian journal for global health, 1(1):57-59. the greek translation of this greeting is mentioned in the gospels, as this is the way jesus often greeted people. also, it is how he instructed his disciples to greet people when he sent them to proclaim the advent of the kingdom of god (luke 10:5; 24:36). similar connotations are found in how the apostle john greets gaius, when he says, “i pray that you may enjoy good health and that all may go well with you, even as you soul is getting along well.” (3 john 1-2 [niv]) references 1. luscombe kl. discipleship as a paradigm for health, healing and wholeness, in health, healing and transformation. allen ea, luscombe k, myers bl, et al, editors. california: mark/world vision international; 1991. 2. allen ea. the church’s ministry of healing: the challenges to commitment, in health, healing and transformation. allen ea, luscombe k, myers bl, et al, editors. california: mark/world vision international; 1991. 3. bruce ff, marshall ih, millard ar, packer ji, wiseman dj, powell dr. el nuevo diccionario bíblico certeza, 2 nd ed. buenos aires, ediciones certeza unida; 2003, p. 1041 (author’s translations) 4. goldingay j. old testament theology: israel’s faith, vol. 2, downers grove, illinois: ivp academic; 2006. 5. scherman n, zlotowitz m. סידור חיים עץ [the complete artscroll siddur]. 1 st ed. 9 th impression, mesorah publications ltd. new york, october 2002, 56, 124, p. 376. 6. tillich paul. the meaning of health, in writings in the philosophy of culture, vol 2. palmer m, editor. new york: walter de gruyter & co.; 1990. 7. world health organization. declaration of alma-ata. alma-ata: international conference on primary health care, september 1978. geneva: 1978. 8. tillich, paul. the relation of religion and health historical considerations and theoretical questions, in writings in the philosophy of culture, vol 2, edited by michael palmer. new york: walter de gruyter & co., 1990 _______________________________________________________________________________ this is part i of a two-part series portions of this paper were previously published in the lausanne world pulse, february 2009 http://www.lausanneworldpulse.com/themedarticles.php/1090?pg=all competing interests: none declared. correspondence: dr. apolos landa. luke society, moyobamba, peru panluk@usa.net cite this article as: landa, a. shalom & eirene: the full framework for health care. christian journal for global health (august 2014), 1(1):57-59. © landa, a. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ _______________________________________________________________________________ www.cjgh.org http://www.lausanneworldpulse.com/themedarticles.php/1090?pg=all mailto:panluk@usa.net http://creativecommons.org/licenses/by/4.0/ editorial collective wisdom and practical knowledge: the new christian journal for global health the editors the christian journal for global health is an initiative of the center for health in mission. it reflects a broad and expanding collaborative movement involving a large number of individuals and organizations globally. there is a rich history of efforts in health care by people of faith with courage to change with the times. this has inspired the concept of a christian journal to explore global health issues in a manner that reflects scholarly excellence and scientific credibility. we seek to capture, catalogue and distribute christian thinking and practice that has been forged in real-time service among those in need. these experiences, and the motivations underlying them, warrant expression in an open access format, available world-wide and without cost. we hope to bring a scholarly approach to global health problems, marked by critical analysis and practical application to the world our readers inhabit. this journal will give voice to christian workers, in every area of the world seeking best practices combined with common values. few journals have as integrative an approach to health and mission, science and faith, policy and practice as we hope for this multidisciplinary resource. our aim is to maintain a missional call to bless the nations and promote the power of the gospel to heal the whole person, community and society. with interdenominational global contribution and distribution, we hope to create new conversations using the comments feature and social media platforms. to make this project sustainable and effective, we are calling for papers from around the world: editorials, review articles, original articles, case studies, short communications, field reports, current debates, commentaries, study design articles, capacity building articles, conference reports, and book reviews. these contributions will cover one or more of the following areas:  public health (health promotion/prevention, nutrition and food security, maternal and child health, community development)  health care services (primary health care, surgical service, disaster and emergency, rehabilitative services, mental health, palliative care)  organization (administration and finance, policy and advocacy, workforce)  mission and health (theology, evangelism, community transformation)  conditions of special interest (hiv/aids, non-communicable disease, neglected tropical diseases, ethics) following the scriptures which guide our work, we value strength in weakness, humility over bravado, evidence over superstition, honest appraisals over self-serving anecdotes, values over expediency. recognizing the value of the perspectives of our colleagues of various world views, we hope true wisdom can be applied to express in writing cohesive knowledge for the good of others. as the source of all good gifts, and the reconciler of relationships, god will be glorified, and the church’s role in healing the whole person and all nations will be enhanced. the tides of change in global health must include people of faith who retain and express the wisdom of god with a relevant grand narrative. by letting this light shine, as jesus taught, it becomes a http://www.centerforhim.org/ https://www.youtube.com/watch?v=l5rvh1kgbcy http://journal.cjgh.org/index.php/cjgh/information/authors 2 june 2014. christian journal for global health, 1(1):1-2 testimony to the presence and glory of god among the peoples of the world. the current issue embodies the original call for papers that speak to the past, present and future of global health work that is inspired and informed by a christian world view. ted lankester’s guest editorial is a call to commitment to broader christian engagement in global health movements with an affirmation of the role the christian journal for global health might play in those efforts. this is followed by three historical reviews. professor grundmann summarizes the history of medical missions with a focus on the tension that has always existed between evangelism and service. his denouement of this tension is thoughtful, encouraging and relevant for today. the rev. canon ted karpf reviews the relationship between faithbased organizations and official government organizations with all their ups and downs and offers an honest appraisal of the opportunities and difficulties. dr. reena george tells the moving story of the call of ida scudder to missionary service and the subsequent evolution of that call into the institution known throughout the world as christian medical college, vellore, india. this article particularly highlights the opportunity offered by the new journal to describe events best described as christian formation – personal and historical, but informed by spiritual understanding and illumination. the present is illustrated by two original articles, one describing a successful contextualized intervention for hiv prevention among the massai in tanzania, and the other reports on the challenges facing the catholic church in india in the provision of healthcare for their elderly, especially those with neurodegenerative illness. an important aim of the journal is to show the integration of faith and health and this is well illustrated by a short communication on hiv home care in zambia. for the present and heading to the future, we require a robust theological understanding of our mission. apollos landa offers a thoughtful commentary on what ought to be the full framework for healthcare. ken foster offers a proposal on what might be done for greater integrity in improving and maintaining professional training standards in countries where these lag behind. we also feature two book reviews. matthew santosh thomas’ review of a book by peter and jean rookes takes us from the past through the present into the future with a look at the organization and financing of medical missionary work in two specific contexts. meredith long’s balanced and fair review of a book describing the faith-inspired motivations and activism of dr. paul farmer in his selfless and insightful efforts to help the medically underserved. our prayer is that we can give a leading voice from christian thinkers, workers and leaders around the world, particularly those from majority world countries, who are ministering to millions of people suffering from illness and deprivation. by promoting intelligent scholarship we aim to see improvements in quality care, and to articulate theological reflections that inspire a new generation of service in a broken world. this project would not have come to fruition without hours of voluntary labor from a team of dedicated editors, reviewers, artists, technicians, donors and writers. they have been aptly supported by an expert team of advisors. we are pleased to be launching this inaugural issue of the christian journal for global health and are confident it will become everything we hope it will be. www.cjgh.org http://journal.cjgh.org/cjgh/index.php/cjgh/announcement http://journal.cjgh.org/cjgh/index.php/cjgh/announcement http://journal.cjgh.org/cjgh/index.php/cjgh/about/editorialteam http://journal.cjgh.org/cjgh/index.php/cjgh/about/displaymembership/6 http://journal.cjgh.org/cjgh/index.php/cjgh/about/displaymembership/11 http://journal.cjgh.org/cjgh/index.php/cjgh/about/displaymembership/11 http://journal.cjgh.org/cjgh/index.php/cjgh/about/displaymembership/5 original article mar 2017. christian journal for global health, 4(1): 13-23. utilizing three years of epidemiological data from medical missions in cambodia to shape the mobile medical clinic formulary jeany kim jun a , junia s koo b , amy y kang c , deborah b chien d , albert shim e , dale knutson f , eda m kim g a pharmd, mph, bcacp, aap, assistant professor of clinical and administrative sciences, keck graduate institute school of pharmacy, usa b pharmd, staff pharmacist, university of california los angeles medical center, california, usa c pharmd, post-graduate year 1 pharmacy practice resident, department of clinical pharmacy, university of california san francisco school of pharmacy, usa d pharmd, per-diem pharmacist, department of pharmacy, desert valley hospital, california, usa e md, family medicine and pediatrics physician, department of internal medicine and pediatrics, cedars sinai medical group, california, usa f md, pediatrician, medical missionary, mission to the world, cambodia g md, family practice physician at mission to the world, usa abstract objective: the purpose of this project was to gather epidemiological data on common diseases and medications dispensed during medical mission trips to cambodia to shape the mobile medical clinic formulary. methods: data for patients seen during week-long mobile medical clinics was collected in cambodia during septembers 2012 to 2014. each patient’s gender, age, weight, blood pressure, glucose, pertinent laboratory values, diagnoses, and medications dispensed were collected. blood pressure and glucose levels were measured in patients 18 years and above. data collected onto paper intake forms were transferred onto spreadsheets without patient identifying information and analyzed for aggregate means, common diseases, and most dispensed medications. this project received institutional review board approval. results: a total of 1,015 patients were seen over three years. women made up 61.4%, and the mean age was 41.8 years. the most common diagnosis was gastrointestinal disorders (22.9%) that included gastroesophageal reflux disease and intestinal parasites. next, 20.1% of patients had hypertension (bp>140/90), 18.0% had presbyopia, 15.4% had back and joint pain, followed by 8.8% with headache, including migraines. approximately 8.4% of patients had hyperglycemia (rpg >140 mg/dl). the top five medications dispensed were acetaminophen, omeprazole, multivitamin, ibuprofen, and metformin. for hypertension, amlodipine and lisinopril were dispensed. 14 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. conclusion: cambodia lacks systematic public health collection of epidemiological data for prevalence of diseases. hence, investigators collected and analyzed information from week-long mobile medical clinics over three years. proton-pump inhibitors and h. pylori lab tests were recommended for gastrointestinal disorders. acetaminophen and ibuprofen were recommended for pain. angiotensin-convertingenzyme inhibitors and dihydropyridine calcium channel blockers were recommended over diuretics since patients were already dehydrated. metformin was recommended for diabetes. vitamins and supplements were recommended for malnourished patients. hemoglobin machines and urine test strips were suggested. this information should help future teams decide what medications and laboratory tests would be the most beneficial for use by medical teams in cambodia. introduction cambodia is located in southeast asia with a population of 14.4 million. 1 approximately 80.5% reside in rural areas with 1.3 million people living in the capital city of phnom penh. 1 the life expectancy at birth averages 61 to 64 years for men and women, respectively. 2 agriculture with rice production is the country’s primary source of revenue. 1 in addition, small-scale subsistence agriculture serves as another source of revenue; this includes raising fish and livestock. 1 around the year 2000, following an era of war and civil conflict, cambodia entered a decade of rapid economic growth, along with demographic and epidemiological shifts. 3 largely from increased tourism and gains in the garment industry, cambodia’s gross domestic product grew at an average annual rate of 7% in the following decade. 4 additionally, the under-5 mortality rate per 1,000 live-births declined from 124 in 2000 to 54 in 2010. 4 even so, cambodia remains one of the poorest and most underdeveloped countries in asia, where many are living on a wage of less than $1.20 united states dollar (usd) per day. 4 about 6,400 deaths occur annually from lack of adequate nutrition. 5 malnutrition among the poor leads to stunted growth (reduced height for age) in 40% of the children and wasting (reduced weight for height) in 11% of the children. 1 despite the many improvements in the health status in cambodia, great disparities exist between urban and rural areas, and across socioeconomic groups. rural areas rely heavily on rain for drinking water during the dry season, and less developed sanitation facilities contribute to increased exposure to communicable diseases. 1 acute respiratory infection, fever, and diarrhea are common causes of childhood mortality. while many of these conditions are treatable, in a largely fee-based health care system, the cost of healthcare often creates a barrier to those seeking treatment. in addition to communicable diseases, motorvehicular accidents are a major cause of injury or death in urban areas in the age group 20-39. 1 nongovernmental organizations (ngos), sponsored by international nonprofit organizations, bridge the access gap in healthcare through supporting and serving ngos led by nationals within cambodia. 6 objective mobile medical clinics provide intermittent care in cambodia to the underserved population. however, in 2011, the lack of available epidemiological data for prevalent diseases or 15 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. medications hampered the preparation of medical teams to provide appropriate treatment for the patients. in order for future medical teams to more accurately secure medications and laboratory tests needed, this project was undertaken. for the purpose of this project, we gathered epidemiological data on the most common diseases and medications dispensed during medical mission teams to cambodia from 2012 to 2014 in order to shape future mobile medical clinic formularies. methods this study evaluated all patients seen during three years of week-long mobile medical clinics held in septembers 2012, 2013, and 2014 in cambodia. patients were seen and evaluated by a multidisciplinary team of healthcare professionals from the united states, including physicians, pharmacy students, pharmacists, physical therapists, and registered nurses, working alongside long-term medical missionaries and cambodian trained health care providers. medical mission teams visited phnom penh, as well as three rural villages in kampot province. in 2012, the medical team spent four days in neareay and two days in phnom penh, and saw a total of 317 patients. in 2013, the team spent two days in angkjay, two days in neareay, and two days in phnom penh and saw a total of 408 patients. in 2014, the team spent one day in prey thom, a very rural village without electricity, two days in angkjay, and two days in neareay and saw a total of 290 patients. each patient’s gender, age, weight, blood pressure, blood glucose, pertinent laboratory values, diagnoses, and dispensed medications were collected. blood pressure and blood glucose levels were measured in patients 18 years and older. data were collected onto paper intake forms and then organized into a computerized spreadsheet, without patient identifying information, and stored using a secure web interface. descriptive statistics were computed for all study variables. means for adults 18 years and above were reported. the numbers of medications dispensed and common disease states were identified. this study was approved by the loma linda university institutional review board. results demographics a total of 1,015 patients were included in the data analysis over three years. women made up 61.4% (n=624), and the mean age was 41.8 years with a range of 2 weeks to 87 years. infants, children, and teenagers, 0-17 years, included 15.5% of the patients. adults, 18-39 years, made up 25.7%, 40-59 years were 37.0%, and 60 years and over included 21.8% of the sample. in patients 18 years and above (n=858), the mean weight and height was 56.3 kilograms (kg) and 65.7 inches in men, and 44.9 kg and 60.7 inches in women. average body mass index (bmi) was 21.5 and 21.0 kg/m 2 for men and women, respectively. common diseases overall, gastrointestinal (gi) disorders, including gastritis and gastroesophageal reflux disease (gerd), helicobacter pylori (h. pylori) infection, dyspepsia, and intestinal parasites were the most common disorders diagnosed in 22.9% of patients of all ages. h. pylori laboratory testing was not available in 2012 and resulted in 27 patients receiving treatment without a laboratory diagnosis. investigators purchased h. pylori testing kits in cambodia for $1 usd each. in the subsequent year, only three patients received treatment with a laboratory-confirmed positive test. seven patients received h. pylori eradication treatment in 2014. all patients received albendazole for possible intestinal parasites. refer to figure 1 for the top ten most common disorders. 16 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. figure 1. top 10 diagnoses in 2012, 2013, and 2014 combined (n=1015) note: numbers within figures represent total number of patients with this diagnosis. hypertension, defined as a systolic blood pressure of 140 mm hg or above, or diastolic blood pressure of 90 mm hg or above, was the second most common diagnosis. 7 the prevalence of hypertension among cambodian adults aged 18 and over was 20.1% and was similar among men (21.7%) and women (19.7%). the prevalence of hypertension increased with age, from 9.6% among those aged 18-39, to 21.7% among those 40-59, to 43.9% among those 60 and over. blurry vision due to apparent presbyopia was a common complaint from patients over 40 years and made up 18% of the sample. a total of 183 pairs of reading glasses were given over three years. more low-diopter readers (+1.00 to +2.00) were dispensed (n=139) than high-diopter readers (+2.25 to +3.50) (n=44). back, knee, and joint pain, including osteoarthritis, was the fourth most common diagnosis at 15.4%. most of the patients in the rural villages were rice farmers and spent a bulk of their time planting or harvesting rice. furthermore, head pain, including migraine and tension-type headache, was fourth with 8.8%. patients with complaints of back and knee pain were referred to the physical therapist (pt). one pt evaluated a total of 113 patients (71 patients in 2013 and 42 patients in 2014) with complaints of back and knee pain, subsequently instructing them in proper exercises and posture. the overall prevalence of hyperglycemia, defined as a random plasma glucose (rpg) of greater or equal to 140 mg/dl, was 8.4% and was slightly higher in men (9.6%) than women (7.6%). the prevalence of hyperglycemia increased with age, from 4.2% among those aged 18-39, to 11.0% among those 40-59, and to 14.8% among those 60 and over. severe hyperglycemia, defined as a rpg of 200 mg/dl or greater, was found in 3.7% of the patients with similar rates between men (3.5%) and women (3.8%). the prevalence of severe hyperglycemia increased with age with 0.8% among 18constipation allergic rhinitis vaginitis hyperglycemia (rpg≥140 mg/dl) uri / viral uri / bronchitis headache / migraine / tension ha pain (knee / back / joint, arthritis) blurry vision / presbyopia htn (bp≥140/90mmhg) gi disorders 15 14 20 33 20 28 51 24 97 83 10 9 19 35 27 29 57 84 70 92 8 19 7 17 40 32 48 75 37 57 2012 2013 2014 22.9% 20.1% 18.0% 15.4% 8.8% 8.6% 8.4% 4.5% 4.1% 3.3% gi: gastrointestinal, htn: hypertension, bp: blood pressure, ha: headache, uri: upper respiratory infection, rpg: random plasma glucose 17 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. 39 year olds, 4.8% among 40-59 year olds, and 5.4% in those 60 years and over. the average glucose value for the 32 patients with severe hyperglycemia was 355.0 mg/dl. common medications the top five medications dispensed were acetaminophen, omeprazole, multivitamin, ibuprofen, and metformin. this paralleled the top diseases to treat gastrointestinal disorders and pain. since most patients treated for hyperglycemia required the maximum dose of metformin at 2000 mg/day, four tablets of metformin 500 mg were required daily for patients. most patients with diabetes were given 120 tablets each. hence, it became one of the top five dispensed medications to treat 8.4% of the patients. for hypertension, amlodipine and lisinopril were dispensed the most but diuretics were not used much. most of the hypertension medications were given once daily, and hence, fewer tablets were dispensed. see table 1 for a list of the top 20 most dispensed drugs during the three years. table 1. top 20 medications dispensed during 2012-2014 rank medications 2012 2013 2014 total # tabs 1 paracetamol 500 mg (acetaminophen) 3880 4095 4320 12295 2 omeprazole 20mg 2606 3318 1170 7094 3 multivitamins 1955 1172 2670 5797 4 ibuprofen 200 or 400 mg 1721 1711 960 4392 5 metformin 500 mg or 850 mg 685 1140 600 2425 6 loratadine 10 mg 310 617 910 1837 7 children's vitamin 0 600 1200 1800 8 ferrous fumarate 200 mg or sulfate 325 mg 687 420 540 1647 9 vitamin b12 510 460 300 1270 10 amlodipine 5 or 10 mg 400 515 340 1255 11 lisinopril 10 mg 375 601 210 1186 12 calcium carbonate 500 mg 810 339 0 1149 13 docusate sodium 100 mg 434 287 330 1051 14 amoxicillin 250 or 500 mg 310 329 400 1039 15 irbesartan 75 mg 0 0 990 990 16 hydrochlorothiazide 25 mg 900 0 0 900 17 aspirin 81 mg 490 270 30 790 18 diphenhydramine 25 mg 267 85 270 622 19 albendazole 400 mg 256 264 99 619 20 atenolol 50 mg 540 0 30 570 discussion epidemiological information guides overseas medical mission medication needs. in 2011, no epidemiological data existed in cambodia on the prevalence of diseases, especially in the rural areas. the investigators collected and analyzed direct data during week-long mobile medical clinics in the kampot province of cambodia from 2012 to 2014. public health epidemiological data regarding cambodia was published in september 2015 by the world bank and in 2014 by the world health organization 4,8-10 that includes major causes of death and burden of disease but does not indicate prevalence rates by province. gastrointestinal complaints were the most common health problems. included in these complaints were intestinal parasitic infections treated with albendazole 400 mg. testing kits for h. pylori minimized antibiotics and saved money. each cambodian h. pylori antibody test cost $1 usd. this test detected antibody presence, which enhanced clinical 18 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. judgment. for $5 usd, each h. pylori sequential therapy eradication packet contained omeprazole 20 mg twice daily for ten days; amoxicillin 1000 mg twice daily for the first five days; clarithromycin 500 mg twice daily for the next five days; and metronidazole 500 mg twice daily for the next five days. after utilizing h. pylori tests, the number of packets given to patients was reduced from 27 in 2012 to 3 in 2013, and 7 in 2014, saving $75 in two years. all the medications used in the h. pylori packet were easily purchased in cambodia. a cambodian survey completed in 2005 showed an unexpectedly high prevalence of hypertension in the relatively poor rural communities. the prevalence of hypertension was 12% in a rural community (siem reap) and 25% in a semi-urban community (kampong cham). 11 the prevalence of hypertension in this study was in the rang of that of the 2005 survey at 20.1% in kampot province. for reference, the prevalence of htn in us adults was 29.1% in 2011-2012. 12 u.s. trained physicians initially used the seventh report of the joint national committee (jnc 7) guidelines which recommended beginning patients with diuretics. 13 however, after viewing urinalysis results with high specific gravity (above 1.030), the clinicians recommended that diuretics not be used first line in the treatment of hypertension. the clinicians, including the pharmacist, recommended other pharmacologic options, like lisinopril or enalapril, an ace inhibitor, and amlodipine, a dihydropyridine calcium channel blocker. these medications were readily available in cambodia for patients to purchase at local pharmacies once they ran out of medications received during the mobile clinic visits and inexpensive at $0.02 per tablet for lisinopril or enalapril 10 mg and $0.04 per tablet for amlodipine 5 mg. 14 the 2005 survey also reported rates of diabetes in the two provinces. the total prevalence of diabetes was 5% at siem reap and 11% at kampong cham, and the prevalence of impaired glucose tolerance was 10% at siem reap and 15% at kampong cham. thus, total prevalence of abnormal glucose tolerance was 15% at siem reap and 26% at kampong cham. 11 however, in 2015, the international diabetes federation reported that the prevalence of diabetes in adults in cambodia aged 20-79 years was only 2.6%. 15 according to this study, the prevalence of hyperglycemia, or possibly impaired glucose tolerance, with glucose values between 140 and 199 mg/dl was 6.2% with higher rates in men (8.7%) than women (4.7%). the prevalence of severe hyperglycemia with glucose values 200 mg/dl and above, which likely indicates diabetes, was 3.7%. hence, the overall prevalence of hyperglycemia and severe hyperglycemia was 8.4%. in terms of treatment, metformin was the first-line option for diabetes, after establishing baseline renal function through urinalysis tests. metformin was readily available for purchase in cambodian pharmacies by the patient once they completed the medications provided during the mobile medical clinic visits. although inexpensive, sulfonylureas were not recommended due to the risk of hypoglycemia and lack of glucose monitoring by patients. for patients with severe hyperglycemia, insulin treatment was not considered due to limited availability of refrigeration in patients’ homes. analgesics, such as acetaminophen and ibuprofen, treated back, neck, joint, and headache pain. based on the needs of the patient population, preparing adequate supplies of these medications is recommended. interestingly, vaginitis was one of the top ten diagnoses. limited access to clean water leading to poor hygiene may provide the basis for vaginitis as a common complaint. antifungal treatments, like fluconazole or antifungal vaginal creams, should be included in the formulary. loratadine was given for allergic symptoms and mild respiratory complaints with a 10 to 30 day supply. diphenhydramine was used mostly to treat insomnia with a 14 day supply. according to the demographic health survey in cambodia released in 2011, more than 4 in 10 women in cambodia were anemic, although moderate and severe anemia was relatively rare 19 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. (8%). in addition, more than half (55%) of cambodian children aged 6-59 months were anemic. 16 thus, adult multivitamins (ranked 3 rd ) and children’s vitamins (ranked 7 th ), along with other essential nutrients such as ferrous sulfate (8 th ), vitamin b12 (9 th ), and calcium carbonate (12 th ), were given in bulk to patients with poor nutritional status. prenatal vitamins for pregnant and breastfeeding women were given in bulk for at least three to six months to cover the duration of pregnancy or lactation. reading glasses, available in low diopters, helped older patients’ complaints of blurry vision. sunglasses were given to protect against cataracts and pterygium. the investigators recommended the h. pylori blood test kit, a hemoglobin machine to test for anemia, and a glucometer. a simple dipstick urinalysis to qualitatively measure urine glucose, protein, leukocytes, and specific gravity helped diagnose infections and understand kidney function. for chronic diseases such as hypertension and diabetes, it was crucial that the medications selected and started by the short-term mobile medical team be readily available, and not be cost prohibitive for patients to continue treatment once the patients ran out of medications. hence, mobile teams should consider what medications are available locally when deciding which medications to take with them in the future to treat these diseases. for sustainability of treatment for patients seen at mobile medical clinics, the short-term medical team was hosted by long-term medical missionaries in partnership with the missionaries located in the rural villages that were visited. after the departure of the short-term team, the long-term medical missionaries went back to these villages bimonthly to bring additional medications and supplies, and provided follow-up care for those who were identified as having a chronic illness such as hypertension and diabetes. although these results are specific to the rural areas of cambodia, some aspects may be generalizable to some neighboring south east asian countries due to the similarities in climate and rural living conditions with limited access to clean water and electricity. limitations the study faced several limitations during its course. first, this was an observational study with patient information gathered heavily from rural areas, which may limit the generalizability of the study. second, this study mostly evaluated prevalence at the time of the clinic visit and did not provide information regarding diseases that may have developed after the visit. third, there was limited availability of diagnostic testing devices which may have limited the physicians’ ability to make a definitive diagnosis. furthermore, patients typically had one blood pressure measurement, whereas at least two are required for a definitive diagnosis. similarly, only one random blood glucose measurement was done for most patients, so it was difficult to accurately diagnose based on one measurement. with that said, some strategies to address these issues were to return to the same villages bi-monthly to provide follow-up care for those patients who had elevated blood pressures or blood glucose values for a firm diagnosis. conclusion delivering cost-effective, high-quality health care services in resource-poor settings remains an enduring challenge. this challenge, however, becomes more formidable for short-term medical mission teams as they are faced not only with limitations in language and culture, diagnostic tools, and treatment options, but also with limitations with respect to local epidemiological data, an indispensable tool for pre-field preparation as well as on-field diagnosis and treatment. the stakes are high given the very poor access to healthcare particularly in rural contexts, the generally high cost of medical mission trips, the limitations of time, and the unavoidable hard decisions the teams must make with respect to what diagnostic tools and medications they will take and which they will 20 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. leave behind. we submit this study not only as a resource for those teams traveling to cambodia but also elsewhere, where attention to epidemiological data promises to lead to a more thoughtful approach to medical mission trips. references 1. national institute of statistics, directorate general for health, and icf macro, 2011. cambodia demographic and health survey 2010 [internet]. phnom penh, cambodia and calverton, maryland, usa: national institute of statistics, directorate general for health, and icf macro. [cited 2016 january 12]. available from: https://dhsprogram.com/pubs/pdf/fr249/fr249.pdf 2. centers for disease control and prevention. global health – cambodia [internet]. [cited 2016 january 12]. available from: http://www.cdc.gov/globalhealth/countries/cambodia 3. the world factbook. east & southeast asia: cambodia [internet]. [cited 2016 january 12]. available from: https://www.cia.gov/library/publications/the-worldfactbook/geos/cb.html 4. world bank (2014). world bank databank [internet]. [cited 2016 january 12]. available from: http://databank.worldbank.org/. 5. department of planning and health information. annex 1 situation analysis [internet]. [cited 2016 january 12]. available from: http://www.who.int/health_financing/documents/cam _frmwrk-annex_1.pdf 6. meessen b, van damme w, por i, van leemput l, hardeman w. 2002. the new deal in cambodia: the second year [internet]. [cited 2016 january 12]. phnom penh: msf cambodia. available from: http://www.unicef.org/evaldatabase/files/cambodia_ new_deal_rec_347894.pdf 7. james pa, oparil s, carter bl, cushman wc, dennison-himmaelfarb c, handler j, et al. evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint national committee (jnc 8). jama. 2014;311(5):507-20. available from: http://dx.doi.org10.1001/jama.2013.284427 8. world health organization. cambodia [internet]. [cited 2015 september 15.] available from: http://www.who.int/nmh/countries/khm_en.pdf?ua=1 9. country statistics and global health estimates by who and un partners [internet]. [cited 2016 january 26]. available from: (http://www.who.int/gho/en/) [last updated: january 2015] 10. global burden of diseases (gbd) profile: cambodia [internet].[cited 2016 january 19] available from: http://www.healthdata.org/sites/default/files/files/cou ntry_profiles/gbd/ihme_gbd_country_report_camb odia.pdf 11. king h, lim k, seng s, khun t, roglic g, pinget m. diabetes and associated disorders in cambodia; two epidemiological surveys. lancet. 2005;366: 1633–9. available from: http://dx.doi.org/10.1016/s0140-6736(05)67662-3 12. nwankwo t, yoon ss, burt v, gu q. hypertension among adults in the united states: national health and nutrition examination survey, 2011–2012. nchs data brief, no 133. hyattsville, md: national center for health statistics. 2013. 13. the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. nih publication no. 045230 august 2004. 14. internal document for mercy medical center pharmacy, 2013. 15. international diabetes federation. cambodia 2015 [internet]. [cited 2016 june 8]. available from: http://www.idf.org/membership/wp/cambodia 16. national institute of statistics, directorate general for health, and icf macro, 2011. 2010 cambodia demographic and health survey: key findings [internet]. [cited 2015 september 29]. phnom penh, cambodia and calverton, maryland, usa: national institute of statistics, directorate general for health, and icf macro. available from: http://dhsprogram.com/pubs/pdf/sr185/sr185.pdf/ peer reviewed competing interests: none declared. https://dhsprogram.com/pubs/pdf/fr249/fr249.pdf http://www.cdc.gov/globalhealth/countries/cambodia https://www.cia.gov/library/publications/the-world-factbook/geos/cb.html https://www.cia.gov/library/publications/the-world-factbook/geos/cb.html http://databank.worldbank.org/ http://www.who.int/health_financing/documents/cam_frmwrk-annex_1.pdf http://www.who.int/health_financing/documents/cam_frmwrk-annex_1.pdf http://www.unicef.org/evaldatabase/files/cambodia_new_deal_rec_347894.pdf http://www.unicef.org/evaldatabase/files/cambodia_new_deal_rec_347894.pdf http://www.unicef.org/evaldatabase/files/cambodia_new_deal_rec_347894.pdf http://dx.doi.org10.1001/jama.2013.284427 http://www.who.int/nmh/countries/khm_en.pdf?ua=1 http://www.who.int/gho/en/ http://www.healthdata.org/sites/default/files/files/country_profiles/gbd/ihme_gbd_country_report_cambodia.pdf http://www.healthdata.org/sites/default/files/files/country_profiles/gbd/ihme_gbd_country_report_cambodia.pdf http://www.healthdata.org/sites/default/files/files/country_profiles/gbd/ihme_gbd_country_report_cambodia.pdf http://dx.doi.org/10.1016/s0140-6736(05)67662-3 http://dx.doi.org/10.1016/s0140-6736(05)67662-3 http://www.idf.org/membership/wp/cambodia http://dhsprogram.com/pubs/pdf/sr185/sr185.pdf/ 23 jun, koo, kang, chien, shim, knutson, kim mar 2017. christian journal for global health, 4(1): 13-23. correspondence: jeany kim jun, keck graduate institute school of pharmacy, united states. jjun@kgi.edu cite this article as: jun j k, koo j s, kang a y, chien d b, shim a, knutson d, kim e m. utilizing three years of epidemiological data from medical missions in cambodia to shape the mobile medical clinic formulary. christian journal for global health. mar 2017; 4(1): 13-23. © jun j k, koo j s, kang a y, chien d b, shim a, knutson d, kim e m this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:jjun@kgi.edu https://creativecommons.org/licenses/by/4.0/ original article nov 2016. christian journal for global health, 3(2): 72-90. a realist evaluation of the formation of groups of people with disabilities in north india rebekah young a , matthew reeve, b alex devine, c lawrence singh, d nathan grills e a ms-iv, the nossal institute for global health, the university of melbourne, australia b phd, senior project officer, nossal institute for global health c senior research officer at the nossal institute for global health d project coordinator, hope project, agnes kunze society, dehradun, india e mbbs, mph, dphil, nossal institute of global health, university of melbourne, australia abstract background: disabled peoples’ organisations (dpos) are organisations established by and for people with disabilities. formation of disabled peoples’ groups (dpgs) and dpos in lowand middle-income countries is currently one method for implementing disability-inclusive development strategies. while there is evidence that such groups can achieve beneficial outcomes for people with disabilities, they seem to form and function differently in different settings and little is understood about why this is the case. this study aimed to explore how and why different factors affect the development and operation of dpgs by investigating the contextual factors and mechanisms that enable and hinder the formation and functioning of dpgs in north india. methods: this study adopted a realist approach to evaluation. preliminary contextmechanism-outcome configurations were developed, tested empirically, and refined by undertaking five case studies in the state of uttarakhand, india. results: results from this study were grouped under the broad, emergent themes of factors related to: 1) external supports; 2) community and physical environment; and 3) group composition. it was found that external entities could support the development of dpgs by advocating for the rights of people with disabilities, and providing information, knowledge, and funding to groups. support from local village leadership was central to facilitating group formation and functioning, but the benefit of this support was amplified when dpgs formed strong networks with other similar groups. dpgs displayed a capacity for stimulating positive societal changes in regard to disability through influencing societal understandings of disability, and improving inclusion and participation of people with disabilities. conclusions: while the results of this study were specific to the context in which it was undertaken, many findings were consistent with those in the literature, suggesting that there may be common principles that can be applied to other contexts. by providing insight into the contextual factors that affected dpg formation and function, the findings of this study may assist those involved in dpg formation to adapt models and methods to better suit specific contexts. 73 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. background all people with disabilities include those who have long-term physical, psycho-social, intellectual, or sensory impairments that in interaction with various barriers, hinder their full participation in society on an equal basis with others. 1 disability affects over one billion people worldwide, and the world health organization (who) estimates that over 80% of people with disabilities live in low and middle-income countries (lmic) where access to health and social services is restricted. 2,3 in india, there is a growing realisation of the prevalence of disability, and an increasing understanding of the need to support the rights of people with disabilities. 4,5 disabled peoples’ organisations (dpos) are organisations established by and for people with disabilities. 6 dpos grew out of the disability rights movement of the 1970s and have a variety of functions including advocacy, promotion of mutual support, solidarity, and self-representation for people with disabilities. 2,6-8 groups like these already operate in many different parts of the world, and their formation in lmics is a key part of disability-inclusive development strategies. in some contexts, organisations involved in disabilityinclusive development work in partnership with people with disabilities to bring together groups of people with disabilities (hereafter referred to as dpgs) that may go on to become dpos. a review of the literature revealed that dpgs in lmics could promote the wellbeing, participation, and rights of people with disabilities, although little is understood about how contextual factors (particularly the involvement of external supports) influence group formation and function. 9 this paper investigates the contextual factors and mechanisms that enabled and hindered the formation and function of dpgs in a north indian context. methods realist impact evaluation realist evaluation explores theories of what works where, how, and for whom. 10-12 realist theory understands the world as an open system in which multiple (contextual) factors work together to influence what happens (outcomes) and how various factors work (mechanisms) to achieve these outcomes. realist impact evaluation addresses questions of causation (how a program or intervention causes change) and attribution (the extent to which observed changes can be attributed to the program or intervention or other factors) using a realist framework. undertaking a realist impact evaluation involves first developing a “program theory” which can then be tested and refined through data collection and analysis. under a realist approach, program theories are comprised of several hypotheses that aim to suggest for whom and in what contexts the intervention is likely to work, the mechanisms by which the intervention is likely to have an effect, and the possible outcomes that will be observed if the intervention works as expected. the strength of realist methodology is its capacity to explore not just whether or not an intervention works in a particular context, but also how and why it works in that context. it was for these reasons that a realist methodology was selected for use in this study. in applying the realist approach to this evaluation, the authors developed a testable program theory using context-mechanism-outcome configurations (cmocs) that attempted to capture the complexity of how an externally-driven intervention promoted the formation of dpgs in and among particular populations and contexts in northern india to bring about particular outcomes. these cmocs were informed by a review of the literature, a synthesis of existing program documents (provided by the field managers of the dpgs included in this study), and a preliminary field visit in 2015. 9 initial cmocs for this study were grouped under three broad themes: involvement of an external entity; the role of key contributors; and group composition (appendix 1). 74 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. case study design the initial program theory was tested empirically, and refined by conducting and analysing five case studies of externally-supported dpgs in uttarakhand, north india. three case study sites were located in the plains regions of dehradun district and two in the mountain regions of tehri garhwal district (see table 1 and appendix 2 for detail). table 1: case study demographic details site and number of dpgs at site month and year of first group meeting number of dpg members at site (m, f) age range caste* marital status ** education level of members employment location grp finance ** network with other dpo chamba 2 august 2015 61 (39m, 22f) 32-69 years sc: 2 g: 59 m: 34 u: 17 illiterate: 8 primary school: 6 high school: 21 universty: 3 not rep’ted: 5 unemployed: 8 farmer: 24 labourer: 5 shopkeeper: 1 hotel: 2 anganwadi worker: 1 not reported: 3 panchayat house b no thatyur 3 january 2015 26 (gender breakdown not available for all groups) mixture of people with and without disabilities 18-66 years sc: 11 g: 8 obc: 7 m: 23 u: 3 illiterate: 0 primary school: 1 high school: 8 university: 0 not rep’ted: 17 unemployed: 2 carpenter: 2 farmer: 22 panchayat house e no raipur 3 may 2015 56 (gender breakdown not available for all groups) mixture of people with and without disabilities 17-70 years not reported m: 40 u: 9 not reported: 6 illiterate: 17 primary school: 13 high school: 14 university: 4 not rep’ted: 7 unempl’ed: 20 housewife: 5 labourer: 8 asha: 1 driver: 1 tailor: 1 shop keeper: 4 gardener: 1 contracter: 1 guard: 2 factory work: 1 mechanic: 1 unspecified: 10 panchayat house e no 75 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. vikars nagar 1 may 2015 18 (gender breakdown not available) mixture of people with and without disabilities 20-60 years sc: 4 obc: 14 m: 9 u: 8 illiterate: 0 primary school: 4 high school: 6 university: 1 not reported: 6 painter: 3 shop keeper: 3 tailor: 1 mason: 1 labourer: 2 not reported: 8 panchayat house b no sahaspur 3 may 2015 69 (gender breakdown not available for all groups) all people with disabilities 18-76 years sc: 8 st: 20 g: 20 not reported: 21 m: 44 u: 33 not reported: 2 illiterate: 0 primary school: 19 high school: 14 university: 3 not reported: 31 shop owner: 4 house wife/at home: 45 tailor: 5 labourer: 9 teacher: 2 student: 1 anganwadi worker: 1 barber: 1 boarding house facility b no *g = general, sc = schedule caste, st = schedule tribe, obc = other backward classes **m = married, u = unmarried ***e= external support only, i= internal support only, b= both external and internal financial support the case study sites were purposively selected according to the location of several nongovernmental organisations (ngos) that were involved in implementing a disability-inclusive intervention as part of an on-going study of disability-inclusion in uttarakhand. 5 since 2015, ngos at each site have worked collaboratively with people with disabilities to form dpgs, and promote their independence in the hope that groups may sustain their activities and go on to form dpos. prior to the commencement of this study, the included ngos had been working across a range of different areas in their local communities such as in mental health, education, and community health care. the ngos were not primarily staffed by people with disabilities. the researcher (ry) visited each site between february and march 2016, and undertook a triangulated approach including: a focus group discussion (fgd) with dpg members (primarily people with disabilities and in some cases parents and/or care givers); semi-structured interviews (ssi) with key informants (usually the village leader and/or a community health worker); and an ssi with the field manager (fm) for each dpg (a representative of the ngo that was providing support to the dpg) (see appendix 3 for interview guides). the researcher also kept a field diary of observations made at each site, and compiled and reviewed key documents for each dpg. participants for this study were selected from the dpgs and networks of partner organisations with assistance from the fms at each site (table 2). participants were purposively selected for their level of involvement in the dpg with preference being given to individuals who had had regular involvement (i.e., regular attendance) with the groups. all data were transcribed and translated into english, then grouped according to major themes. cmocs were refined between site visits as data emerged, and the refined cmocs were then tested at successive sites. ethics research was undertaken with the approval of university of melbourne human research ethics committee (hrec). 76 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. table 2: demographics of study participants type of interview total number of participants male, female number of people with disabilities and type of disability tehri garhwal district ssi (ngo) 3 3m, 0f 0 ssi (key informant) 3  village leader: 1  health worker: 2 1m, 2f 0 fgd 15 9m, 6f 12  motor impairment: 7  sensory impairment: 3  intellectual impairment: 0  mixed impairment: 0  unspecified: 2 dehradun district ssi (ngo) 5 2m, 3f 1 motor impairment: 1 ssi (key informant) 3  village leader: 3  health worker: 0 3m, 0f 0 fgd 37 21m, 16f 28  motor impairment: 18  sensory impairment: 4  intellectual impairment: 1  mixed impairment: 1  unspecified: 4 results the results from this study were grouped under the broad themes of factors related to: 1) external supports; 2) community and physical environment; and 3) group composition (table 3). in summary, it was found that external entities could support the development of dpgs by advocating for the rights of people with disabilities and providing information, knowledge, and funding to groups. support from local village leadership was required for group formation and functioning, and networks between dpgs and other similar groups were also beneficial. in this study, dpgs displayed a capacity for stimulating positive societal changes in regard to disability through influencing societal understandings of disability, and improving inclusion and participation of people with disabilities. table 3: context-mechanism-outcome configurations cmocs context mechanism outcome external supports association of dpg with ngo in early phase of group formation idea of dpg formation introduced by ngo who were responsible for stimulating group formation ngo largely responsible for group functioning early on with limited ownership of groups by people with disabilities in the early phases modelling of good governance strategies and organisational structures, and acting as an initial source of information and knowledge for groups establishment of group register and record-keeping contribution of members to group funds election of leadership committees registration as an official dpo 77 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. religious background of staff of external entity (christian), and belief that people with disabilities are made in the image of god and have equal worth with all other human beings engagement with people with disabilities as fellow human beings and abandonment of moral or charity-model of engagement investment in disabilityinclusive strategies to promote participation of people with disabilities changes in societal beliefs about disabilities (curse to gift of nature), greater social inclusion for people with disabilities presence of a group champion awareness raising and education provided to the community about the value and right of people with disabilities consistent contact with people with disabilities and their families trust development and relationship building diffusion of innovation (dpg) recruitment of people with disabilities to join dpg involvement of ngos in the uttarakhand ‘cluster’ network of community health organisations existing contacts and connections between staff and programs (and therefore connections between dpgs/dpos via the fms), value placed on relational collaboration by ngo staff, intentional efforts from ngo staff to facilitate networking relationships between dpgs/dpos opportunities provided to dpgs to meet with other groups in their areas (where such groups existed) for the purpose of developing networking relationships networks with other dpgs (or similar groups) modelling of group function earlier group formation enthusiasm of dpg members after seeing what has been accomplished by other groups more rapid transfer of responsibility for group leadership from ngo to dpg members knowledge and resource sharing earlier access to government schemes and entitlements increased identity and confidence through larger group numbers increased participation of group members in broader society funding provision from external entity (ngo) in early phases of group formation ability of groups to focus on developing strong relationships in early phases of group formation retention of group members (due to the development of trusting relationships between members) protection against financial mis-dealings in early phases of group formation election of a treasurer and transition to collecting contributions for group finances modelling of good financial practices enablement of dpgs to sustain organisational costs in early phase 78 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. note: this table is designed to give a simple overview of the cmocs that have contributed to the findings presented in the results section of this paper. it necessarily simplifies complex thoughts and links between concepts and thus should be read in reference to the rest of this paper 1. summary: factors related to external supports all dpgs in this study were initiated by ngos as part of implementing a disability-inclusive intervention in uttarakhand. 5 consequently, all groups received significant external support from ngos in the early phases of group formation, which was an important mechanism in the outcomes observed. community and physical environment support of local village leadership knowledge and information sharing increased awareness of rights and of available government schemes and entitlements provision of a group meeting place (neutral location, central) diversity in group composition regular group meetings increased visibility of people with disabilities in general society when travelling to and participating in group meetings and activities increased confidence in group members (perceived legitimacy of group if supported by local leadership) increased participation of people with disabilities in broader society advocacy support given to group by pradhan changes in societal views toward disabilities assistance from pradhan in community education and awareness raising physical barriers in environment difficulty for people with disabilities to travel and to access locations and facilities tendency of groups to involve more 'well' people with disabilities (i.e. tendency of groups to exclude people with profound disabilities) increased involvement of ngo staff and family members required to link people with disabilities into groups decreased group ownership by people with disabilities low or inconsistent attendance at group meetings group composition people of diverse backgrounds (age, gender, religion, caste) disability seen as a unifying factor relational cohesion among groups working together on a common task sharing and serving food and drink together as part of meetings representation of a broad range of views and different types of people within dpg increased self-confidence participation of muslim women in dpo in plains region regular participation in meetings outside the home environment opportunities to participate in leadership roles in the group increased opportunities to participate in broader society election of a treasurer and transition to collecting contributions for group finances 79 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. 1.1 information sharing and role-modelling by ngos initial input from ngos in providing knowledge and information to dpgs seemed valuable to group members. “i feel that if we... are linked up with the ngos, they can tell us or give us information and through them our work can be done easily” (dpg member). ngo staff assisted people with disabilities to develop their skills to lead effective groups by teaching and modelling organisational practices and governance structures, and slowly transitioning leadership responsibility to dpgs. one ngo staff member reported, ... from the start our team is always there for the monthly meetings... even conducting and facilitating the meetings... even how to fill out the register, the minutes of the meeting. before we showed how to do it but now they [group members] are [doing it]. this theme of dpg members learning by example from ngos emerged repeatedly throughout the study, with modelling appearing to be a key way of conveying information to dpgs. significant ngo involvement in the early phases of group formation created reliance on the ngo for group functioning. when asked if the group would continue to function if ngo staff no longer assisted it, one dpg member reported, “it won’t work properly. the meetings wouldn’t be on time... it won’t be running.” for another dpg, although the ngo was essential in forming the dpg, members agreed that if the ngo stopped assisting them now, “it will go well.” initial assistance from ngos was seen to be beneficial to support people with disabilities to form dpgs, and promote their agency to eventually lead and govern such groups. more data is required, however, to investigate what happens to dpgs when external support is withdrawn. 1.2 religious beliefs of staff of external entity (ngo) the ngo staff repeatedly attributed their positive attitude toward people with disabilities to their christian faith. many ngo staff members echoed the sentiment of an fm who stated, “... i see persons with disability equally created in the image of god. god has given them different talents and gifts of which they can contribute.” the belief of many ngo staff in an equal worth of all people seemed to encourage staff to engage with people with disabilities as equals rather than adopting a moral or charity-based model for engagement, historically a common approach to engaging with people with disabilities in the areas visited. 13 there was evidence of societal views about disability changing as a result of dpg formation, education, and awareness-raising efforts by ngo staff and people with disabilities. cultural understandings of disability in the areas visited were often couched in religious or spiritual terms, and changes in societal views were, in part, evidenced by modifications in the language used to describe disability. a village leader described these changes when he said, “first there was the thing of curse, but now there is nothing like this that prevails in society.” 1.3 the importance of leadership within the ngo to strengthen disability inclusion the role of a leader within the ngo who assumed responsibility for strengthening disability inclusion efforts (hereafter referred to as the group champion) was central to dpg formation. the group champion was typically an ngo staff member who exercised leadership in raising awareness about dpgs, and developing trusting relationships with people with disabilities and their families to encourage them to form or join dpgs. one dpg member echoed the stories of many others when he described how his group was formed, saying, “the volunteer from the community hospital [ngo]... gave us awareness... then we made a group.” the champions did not need to have a disability to effectively fulfil their role. 80 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. 1.4 networks with other groups enhance dpg functioning all participating ngos that supported dpg formation in this study were part of a “cluster” network of community health organisations in uttarakhand. the significance of this was that ngos had links to one another and to other partner organisations before this study began. 14 these preexisting relationships facilitated the arrangement of meetings and exposure visits between groups (where one dpg visited a dpo or similar group to observe and learn from their models and practices). where collaborative relationships resulted from these meetings and exposure visits, dpgs seemed to benefit in several ways. firstly, these networks fostered peer-led information and knowledge sharing. secondly, they strengthened the identity and confidence of dpg members. an ngo staff member commented on his observations around the role of networking in group formation, saying: [the relationship between the groups has been useful for]... resources and sharing information. the other thing is... it gives them a bigger identity saying we are not just us, we also have other people out there like us. these benefits of information, resource sharing, growing confidence, and strengthened identity seemed to accelerate the formation of dpgs. this was suggested by observations that groups with pre-existing networking relationships demonstrated greater knowledge and responsibility for self-governance than other groups. in mountain regions challenged by accessibility as well as a number of other factors, groups seemed slower to mature. nevertheless, members of mountain-region dpgs affirmed, “yes, we do want to meet [other groups].” 1.5 funding provision from external entities: important for initiation of groups all groups received little financial support from ngos in the early stages of group formation. data seemed to indicate that this early financial support allowed the formation of strong relationships in the dpgs by enabling groups to form trusting relationships before having to make personal contributions to group finances. once groups transitioned to raising their own funds they began to exercise greater self-determination in allocating finances than before. we use [group funds] to buy materials... or we keep it in the account or give it to the people who do not have money and who need it... we do not save much amount of money but whatever is collected is used for a good purpose (dpg member). 2. summary: community and physical environment the formation and functioning of dpgs was influenced by the community environment and in turn exerted an influence on the community. support from local village leadership facilitated dpg formation but did not appear to be sufficient to facilitate the formation of effective dpgs. barriers in the physical environment significantly limited the ability of people with disabilities to participate in dpgs, and these barriers were slow to change in response to dpg formation. 2.1 dpgs increased the confidence of people with disabilities and stimulated changes in societal views on disability changes in societal beliefs about disabilities seemed to begin with changes in self-identification of people with disabilities. becoming a member of a dpg reportedly helped people with disabilities develop confidence in their identity as part of a group, and seemed to increase their confidence to participate in society. first, i used to be only at home and didn’t meet anybody, but after the group was formed we started coming out of our houses, we started meeting other people and we feel nice about it (dpg member). the increased confidence of people with disabilities was reported to have influenced local 81 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. community perceptions of disability. an ngo staff member reported that after dpg formation, people with disabilities were now being called by their names rather than by their disability. before, people never called the children by their name, for example, if someone couldn’t walk, they would call him a crippled man and if someone couldn’t see, they would call him blind... so after the [dpg] started, the [ngo] who works over there started calling each child by their name [and now] the people in the surroundings are doing the same. a number of the dpg members reported that the behaviour of people in society had changed since the dpgs formed. 2.2 support of local village leadership promoted dpg confidence it appeared that groups’ confidence levels increased more rapidly when the village leader (pradhan) provided the dpgs with a space in which to meet. “if a meeting is held in a government place, the confidence level is more among the dpg.” (ngo staff member) formation of dpgs seemed to encourage local village leadership to increase their support of people with disabilities. before, the pradhans didn’t do any work for us or didn’t show any interest in doing our work, but now since our group is made, the pradhans work in our favour (dpg member). although all groups reported having a good relationship with the pradhan since dpgs formed, there were reports from some dpg members that the pradhan did not always effectively communicate knowledge about government schemes and entitlements for people with disabilities. when asked about their knowledge of such information, one dpg member reported that the pradhan informed them about the schemes but that, “we [often] come to know later on when the scheme is already closed.” 2.3 barriers in the built environment hinder participation in dpgs barriers in the physical environment significantly limited the involvement of people with disabilities in dpgs and in broader society. physical barriers existed in all contexts, but were especially evident in the mountain regions. [other ngo staff]... were shocked because of the geographical condition of this place. there are many ups and downs on the road... so it’s very difficult. our place is not suitable for disabled people—we don’t have a ramp, and in hilly areas wheelchair won’t go in all places even walking with crutches is difficult (ngo staff member). a range of governmental, social, and economic factors limited the ability to make changes to the environment. when the physical environment was a barrier for people with disabilities, they seemed to rely on ngo or family support to enable their involvement in the group. “the [ngo] representatives of the group go to their house and tell what happens in the meeting so that they don’t feel left out.” (ngo staff member) 3. summary: group composition it was found that dpgs had the capacity to create environments in which members of socially and culturally diverse backgrounds were able to meet as equals, united by disability. in most groups, however, people with profound disabilities were unable to regularly participate in group meetings and activities, and so were largely excluded from the relational benefits of dpgs. 3.1 dpgs promoted equality among socially and culturally diverse members dpgs seemed to create environments in which disability was the unifying and equalising factor among individuals of socially and culturally diverse backgrounds. members of several dpgs echoed that they experienced “no problem” forming a group with people of different cultures, religions, 82 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. and castes. it seemed that relational cohesion among group members was both a mechanism that promoted group formation and function, and also an outcome of group formation that members perceived as valuable. when asked what the best thing about the dpg was, several members shared similar thoughts related to group unity. “everybody gathers and... we get to meet each other. this is the good thing that i like” (dpg member). another member reported, “the best part is unity.” 3.2 dpgs were not equally inclusive of people with profound disabilities despite all dpgs reporting strong group unity, it was clear that not all people with disabilities benefitted equally from this unity and relational cohesion. people with profound disabilities—particularly those who were unable to easily leave their homes—were often unable to attend group meetings and functions, and thus unable to participate in the process of meeting as a unified group. “there are some disabled people in society who are not able to come to this group because there is no helper for them.” (dpg member) when asked if dpgs had been beneficial to people with severe disabilities, one ngo staff member acknowledged, “i must say, not fully.” in this project there was minimal participation from people with profound disabilities in fgds, and when such individuals did participate, family members often spoke on their behalf. discussion this study demonstrated that a range of different contextual factors influenced the formation of dpgs. external organisations, village leadership, and group champions played significant roles supporting the establishment of dpgs. dpgs displayed a capacity for increasing the confidence of group members and stimulating positive community changes in regard to disability, through altering societal understandings of disability and improving inclusion and participation of people with disabilities. strong relationships within groups were of key importance, and dpgs seemed to function more effectively when they developed networking relationships with other similar groups. one of the principles of realist evaluation is that findings are provisional and largely dependent on context. 10-12 as this study was conducted in one area of india and looked at only one model of dpgs, the findings may not be applicable to other contexts. nevertheless, a review of the literature and validation from experts involved in supporting formation of groups of people with disabilities in other contexts, reinforce many of the findings of this study, and suggest that despite limitations, there are still useful observations that may be applied to other contexts. 15-23 for example, in this study, the group champion helped to facilitate the formation of dpgs. in most cases, people with disabilities were initially reluctant to join the dpg, but reported changing their minds because of the consistent efforts of an ngo staff member who promoted the importance of disability inclusion within the ngo, invested in building trusting relationships with people with disabilities, and educated people with disabilities and their families about the potential benefits of forming dpgs. this finding is consistent with literature highlighting the role of network “brokers” in the formation of networks. 14,24,25 in the literature, network brokers are often organisations that play key facilitating roles in the development of networks. the network brokers in this context, however, were typically sole ngo staff members who undertook to engage dpg members, bring together people with disabilities from different backgrounds, create channels of effective communication, and collaborate with people with disabilities to establish operating rules (or models) for the dpgs. other published literature from different settings and contexts also echoes some of the findings of this evaluation, reinforcing the suggestion that the results of this study may be applicable to other contexts. for example, a study 83 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. of dpos in nepal 18 in suggested that dpo members were more confident and more connected with society after joining groups. this was similar to the observations made in this study that development of networks between dpos improved individual and group identity, and confidence. literature from other geographical and contextual settings also reinforced many of the findings of this study pertaining to the barriers faced by dpgs. discriminatory societal views were reported to be barriers for groups in bolivia 19 and india, 21 as was observed in this evaluation. accessing dpgs in rural areas was also found to be a major barrier for dpos operating in different rural settings in india, 17 suggesting that this may be a common barrier in rural indian settings generally, rather than in the mountain regions specifically. it is important to study the relationship between groups of people with disabilities and external entities in order to understand how people with disabilities can be supported to achieve their rights on an equal basis with all others. observations made in this study suggested that involvement of external entities in dpg formation could be empowering for people with disabilities when undertaken collaboratively. it was observed that involvement of external entities was often beneficial for dpg formation by way of providing awareness and education to people with disabilities and their communities about the rights of people with disabilities, and the potential of dpgs to realise these rights. moreover, external entity financial and technical training support was beneficial to groups, promoting agency. despite initial reliance on external support, all groups in this study went on to form leadership and governance structures of their own and became officially registered dpos. this suggests that groups of people with disabilities can become user-led organisations, even after initially being externally resourced. the lancet’s recent series “faith-based health care” highlighted the important roles faith and faith-based structures play in influencing health and behaviours that impact health and development. 26-27 consistent with these articles, our research indicates that faith can impact responses to disability and that the values of faith-based organisations (fbos) affect their response. 26-27 predominant social and cultural views of disability in the areas visited in this project historically centred on the view of disability as a “curse.” past models for engagement of people with disabilities in these areas, therefore, tended to be medical or charitable—with disability seen as an issue to be fixed or a condition deserving pity. 13 although many secular groups as well as a variety of religious organisations adopt rights-based approaches to disability, ngo staff in this study attributed their involvement in collaborative, rightsbased approaches to their christian faith and their belief that people with disabilities were made in the “image of god”. ngo staff reported that this view shaped the way that they developed partnerships with people with disabilities, and the way they delivered education and awareness about the rights of people with disabilities. there was some indication that these values had helped change societal attitudes toward disability with many respondents reporting that the view of disability as a curse was no longer so prevalent after dpgs were formed. this observation suggests that faith can contribute to responses to disability and reinforces the lancet’s finding that fbos may affect healthrelated attitudes and behaviours of communities. 26 while faith and fbos appeared to play a positive role in this study, the lancet’s series highlights that this is not always the case—in some cases, religious beliefs may be counter to a human rights framework. 27 this is an area that requires further study to be better understood. regardless of the role of faith, the lancet’s call for greater collaboration with fbos ought to be considered. 26 groups of people with disabilities are designed to be inclusive groups that promote the rights and participation of marginalised persons (people with disabilities). observations in this study suggest that such groups may not fulfil this goal equitably. for example, we observed that 84 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. individuals with profound disabilities were less involved in dpgs than people with less significant functional impairments. the literature indicates that these populations, particularly individuals with intellectual or psychosocial disabilities, are the most marginalised of all people with disabilities, and thus invite further reflection on their participation in dpgs. 28,29 several factors in this study, including logistical, environmental and attitudinal barriers, disempowerment, lack of prioritisation of people with profound disabilities in the process of dpg formation, or even perceived lack of benefit from participating in groups may have contributed to the observed low participation of these populations in dpgs. these factors need to be considered in future, and it would be advantageous for organisations involved in disability-inclusion work to advocate for and promote the agency of such individuals and their participation in dpgs and broader society. limitations this study was conducted by researchers who did not have disabilities, a factor that may have affected the quality of the data obtained. an emancipatory approach—,i.e., training people with disabilities to serve as co-researchers—would likely be a better model in future studies. in this study, ngo staff assisted the researchers to recruit participants for fgds and, as such, may have introduced bias into the sampling of individuals with a tendency for inclusion of dpg members who had positive experiences of dpgs and who were more confident or able to communicate with researchers (i.e., there may have been a tendency to exclude people with profound disabilities or communication difficulties). on the whole, responses from dpg members were favourable toward the ngo and the dpg with very few critical reports from participants. fms were often present during fgds, which may have limited the extent to which dpg members felt comfortable answering questions openly. fgds by nature also may not promote equal contributions from all participants. in this study, despite training local research assistants in facilitating fgds, it was not always possible for the authors to ensure that discussions encouraged all participants to contribute their views. due to limited time, financial and personnel resources, there were limited opportunities for equal inclusion of people with communication difficulties. with more ample resources, the study could have recruited co-researchers with expertise in communicating with such populations. due to the limitations of this study, the authors did not feel they gained sufficient data from the perspective of these individuals with profound disabilities or communication difficulties to ascertain whether they had received any personal benefit from the dpgs. further research this study begins to provide some insights into the influence of contextual factors on the formation and function of groups of people with disabilities. further research of groups in other contexts would provide contrast to suggest whether the present findings apply elsewhere. longer-term follow up of dpgs that have received external support for their formation would assist with understanding what the long-term effect of external supports are on such groups. studies of dpgs that have become dpos would also be beneficial for understanding the process of empowerment and the transition of groups from external to internal resourcing. finally, investigation of the role of different religious beliefs in shaping a response to disability could provide useful insights for faithbased organisations seeking to be involved in disability-inclusion work. a cluster-randomised trial of dpgs is currently being undertaken in northern india and may provide data on all of these areas of interest. conclusion disability-inclusive development strategies in lmics often 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04_part_b_dchb_tehri%20garhwal.pdf appendix 1: primary cmo hypotheses theme hypotheses involvement of an external entity hypothesis 1: affiliation of a dpg with a community-based rehabilitation (cbr) program will lead to modelling of good organisational structures and practices, as well as providing support and training for dpg members to develop the skills needed to initiate and sustain an effectively functioning dpg (i.e. one that meets regularly, has stable governance structures and has the means to access funding and action-group ideas) provided the dpg is peer-led from the start. affiliation between a dpg and cbr program, however, may lead to disempowerment of dpg members, dependence on cbr staff external to the dpg, and lack of ownership on behalf of members. http://dx.doi.org/10.1080/09687599.2012.717877 http://dx.doi.org/10.5463/dcid.v24i3.269 http://dx.doi.org/10.1080/09614524.2010.508244 http://dx.doi.org/10.4314/ajpsy.v16i3.25 http://dx.doi.org/10.5463/dcid.v22i2.78 http://dx.doi.org/10.1080/09614524.2015.1078289 http://dx.doi.org/%2010.1080/096382899297585 http://dx.doi.org/%2010.1080/096382899297585 http://dx.doi.org/10.1016/s0140-6736(15)60250-1 http://dx.doi.org/10.1016/s0140-6736(15)60250-1 http://dx.doi.org/10.1016/s0140-6736(15)61036-4 http://dx.doi.org/10.5463/dcid.v24i3.269 http://www.un.org/disabilities/documents/best_practices_publication_2011.pdf http://www.un.org/disabilities/documents/best_practices_publication_2011.pdf http://www.censusindia.gov.in/2011census/dchb/0505_part_b_dchb_dehradun.pdf http://www.censusindia.gov.in/2011census/dchb/0505_part_b_dchb_dehradun.pdf http://www.censusindia.gov.in/2011census/dchb/0504_part_b_dchb_tehri%20garhwal.pdf http://www.censusindia.gov.in/2011census/dchb/0504_part_b_dchb_tehri%20garhwal.pdf 87 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. hypothesis 2: when family and community members, including the village pradhan, asha* and anganwadi worker*, support dpgs, groups are more likely to function effectively and achieve positive outcomes for members because of support in attending group meetings, stable and committed group membership, improved access to resources (including things like venues), and empowerment to have a ‘voice’ in the community (because of access to time with the pradhan and other community leaders). hypothesis 3: if the village pradhan is not supportive of dpgs, persons with disability (and thus also dpgs) will face continued discrimination and barriers to functioning (environmental, institutional and attitudinal). if the group is supported by other non-disabled persons or organisations who act as ‘champions’ for the group, encouraging participation of people with disabilities and activity of the dpg, the group is likely to develop a strong vision and resolve to advocate for their rights as stipulated in the convention on the rights of people with disabilities. in the absence of external support and encouragement, groups (even those with strong internal leadership) are likely to experience disempowerment and discouragement, lack of incentive or difficulty in meeting regularly and a lack of group outputs. the role of key contributors hypothesis 1: groups who have a charismatic leader will develop stable membership and gain the support of village leadership, family members and external organisations as well as obtaining stable financial support because of their ability to communicate a strong vision, become visible in the public sphere and advocate for the rights of persons with disability. groups that are led by a team of members rather than a single individual will produce greater outputs and improved outcomes for members due to leadership stability and sustainability (less burnout because of burden sharing), information sharing and pooling of skills in the leadership team, increased buy-in and involvement from group members and an increased number of member voices being heard during group meetings. when a single charismatic and strong leader runs the group, there is susceptibility for disempowerment of other members, poor representation of group opinions, burdening of the leader and group burnout in the long run although in the initial phases, groups are likely to have high outputs and gander external support as well as high membership numbers. composition of the group hypothesis 1: single disability groups are likely to experience greater levels of group unity and member involvement and participation than multi-disability groups meaning that groups can work more cohesively to develop and action goals and achieve outcomes for members. group activities are likely to be more targeted to members’ needs when groups are homogenous. groups with heterogenous membership are likely to represent the needs of a wider group of individuals, but may result in the voices of some individuals being marginalised (e.g. women, elderly, children) and the views and agendas of more vocal group members being privileged. groups that include parents or carers of people with disabilities assist the voices of severely impaired people with disabilities in being heard. *note: asha and anganwadi workers are community-health workers appendix 2: district demographic details district population (total, urban) area (km 2 ) population density (person/ km 2 ) literacy (total, female) * unemployment sex ratio ** sc, st *** dehradun(30) 1.6 million, 52.52% urban 3088 170 84.25%, 78.54% 65.65% 902 13.49%, 6.58% tehri gahrwal(31) 618, 931, 11.33% urban 3642 549 76.36%, 64.28% 54.69% 1077 16.5%, 0.14% *state average literacy: 78.82% **sex ratio is the number of females per 1000 males, state average is 963 females per 1000 males ***scheduled caste (sc) and scheduled tribe (st) 88 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. appendix 3: interview guides *n.b. in these interviews, the term dpo was used to refer to groups as this is typically the name that group members used to refer to their groups focus group discussion schedule: dpg members demographics (to be asked of individuals before commencement of the fgd) 1. what is your gender? 2. what is your age? 3. tell me about the kind of disability(ies) you have (be specific)? 4. what is your religion? 5. what is your caste? 6. do you work? if so, what do you do for work? 7. how many times have you met with the dpo*? question guide 1. tell me the story about how the dpo started and describe how the dpo was formed. prompt:  member selection (what about people with disabilities in the community who do not attend the group?)  reason for starting the group  who else was involved in starting the group (e.g., ngo, hospital, etc.) and what were their roles? 2. what was life like before the dpo started? has the dpo had any impact on your life now? if so, how? prompt:  overall life satisfaction and well being (prompt: does being in the group make you feel more confident?)  education  employment and/or income generation  attitudes in the community toward you and other people with disabilities  friendships and social interaction (have you had the chance to make more friends through your involvement in the group?)  access to people in positions of authority (e.g., the pradhan, government, doctors, etc.) and participation in community consultation)  knowledge of your rights (do you know more about your rights now?)  access to government social welfare? (are you able to access the things you know about now?)  ability and opportunity to help others (do you think you have things you can offer to other group members or other members of society?) 3. what activities has the dpo been involved in, if any? prompt:  advocacy  fundraising  environmental modifications (e.g., home modifications, improving environmental accessibility in the village, etc.)  community awareness raising  training 4. do you think the dpo is functioning well? if yes, what makes you think it is functioning well? 5. in what ways do you think the group could be functioning better? prompt:  weakness of the group  difficulties that the group has faced  areas for improvement  disappointments people have in the group 6. tell me about the following things and how each of them impacts the group.  the relationship of the dpo with the ngo (how involved is the ngo? has this been helpful? is there any way that this has been unhelpful?)  the leadership of the dpo (what is the leadership structure and how is it working?)  the location of the dpo (is the location easy to access? or are there many who would like to be part of the group who cannot be because it is difficult to access?) 89 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90.  the money or assets that the dpo has access to (what money does the group have? has the group applied for or been able to access grants or funds from the government or other organizations? does money greatly affect what the group can and can’t do?)  the group composition (types of disability represented, involvement of parents or care-givers, caste or religion, etc.)  networks with other dpos or similar groups 7. do you think that the group can have or has been advantageous for other people in society? (e.g., elderly, women, children) 8. do you think you will continue to meet as a dpo? 9. what, in your opinion, is the best thing about this group? semi-structured interview: fm demographic questions 1. when was the dpo formed and when did it first meet? 2. how many times has the dpo met since it was formed? 3. does the dpo have a constitution? and when was it formed? 4. is the dpo registered? when was it registered? 5. how many people are in the dpo? (prompt about total number of members, number of male/ female, number that regularly attend meetings, age, type of disability, education, employment, etc.) 6. does the dpo have any money or assets and if so, who/where do these come from? has the dpo been able to access funding aside from that provided by the ngo? question guide 1. tell me the story of how the dpo formed. (probe about whether the dpo faced any particular difficulties in its formation.) 2. has the dpo had any positive impact for its members since forming? (probe about the types of positive impacts and what the difference is from before the dpo formed till now.)  societal attitudes (e.g., do people in the community see people with disabilities differently since the group started?)  access to resources including government schemes and funding (and do you think access to these is likely to change once the group is registered?)  knowledge about rights  overall life satisfaction and well being  education  employment and/or income generation  friendships or social interactions  access to people in positions of authority (e.g., the pradhan, government, doctors, etc)  participation in community life and community consultation 3. has the dpo had any impact on broader society since forming? and if so, what sort of impact? (prompt: gender and caste equality outside of group) 4. do you think the dpo is functioning well? what makes you think it is functioning well?/what things would make you say it was functioning well? 5. how did the following factors impact upon the functioning of the dpo if at all? (ask only if not already covered above) prompt:  the relationship of the dpo with the ngo (prompt: do you think the group would keep meeting if the ngo stopped being involved?)  the leadership of the dpo (prompt: does the group have a leadership committee? how and why were they elected?)  the location of the dpo and its members  the money or assets that the dpo has access to  the caste/gender/religion of individual members  networks with other dpos or similar groups 6. what do you hope to gain from your involvement in this dpo? is it achieving what you want? 7. do you have any suggestions for how the dpo could become better and more effective? (e.g. do you think they should continue to meet and if so how and why?) follow-up written questions 90 young, reeve, devine, singh & grills nov 2016. christian journal for global health, 3(2): 72-90. 1. do you have a personal faith? if so, please tell me about your faith. 2. does your faith influence the way you view people with disabilities? and if so, how? 3. has your faith had any impact on the way your organisation has gone about forming dpos? if so, how? semi-structured interview: key informant question guide 1. how have you been involved with the dpo since it was formed? (prompt: why are you involved?) 2. have you had more contact with people with disabilities since the dpos were formed? in what ways? 3. has the dpo had any positive impact for its members since forming? what was life like for people with disabilities before the group was formed? prompt:  societal attitudes  access to resources including government schemes and funding  knowledge about rights  overall life satisfaction and well being  education  employment and/or income generation  friendships or social interactions  access to people in positions of authority (e.g., the pradhan, government, doctors, etc.)  participation in community life and community consultation 4. has the dpo had any impact on broader society since forming? and if so, what sort of impact? 5. do you think the dpo is functioning well? what makes you think it is functioning well?/what things would make you say it was functioning well? 6. what are some of the difficulties that this group faces? prompt:  finances  environmental barriers  diversity in group membership 7. do you know of many people with disabilities in the community who are not part of this group? why are they not? 8. how did the following factors impact upon the functioning of the dpo if at all? (ask only if not already covered above) prompt:  the relationship of the dpo with the ngo  the leadership of the dpo  the location of the dpo and its members  the money or assets that the dpo has access to  networks with other dpos or similar groups 9. what do you hope can be achieved by having dpos in your community? 10. what is the best thing about this group? 11. do you have any suggestions for how the dpo could become better and more effective? peer reviewed competing interests: none declared. acknowledgments: this work was supported by a grant from cbm india. thank you to nicole butcher for her assistance in editing this manuscript. correspondence: rebekah young, university of melbourne, rryoung1991@gmail.com cite this article as: young r, reeve m, devine a, singh l, grills n. a realist evaluation of the formation of groups of people with disabilities in north india. christian journal for global health (nov 2016), 3(2):_. © young r, reeve m, devine a, singh l, grills n. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:rryoung1991@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ conference report nov 2016. christian journal for global health, 3(2): 160-167. surgical residency training in the mission setting: current status and future directions james d smith a , dan poenaru b , david thompson c , j dwight phillips d a md. professor emeritus, oregon health and science university, oregon, united states b md, mhpe, frcsc,facs, fcs(ecsa), professor of surgery and pediatrics, children's hospital, quebec, canada c md. program director, pan african academy of christian surgeons, harpur hospital, egypt d md, professor of pediatrics, department of pediatric and adolescent medicine, mayo clinic, rochester, minnesota, united states introduction overseas professional education represents an expanding frontier of medical missions. in november 2015, 67 medical missionaries and academicians met in conjunction with the global missions health conference (gmhc) in louisville, kentucky. most of the participants involved in the discussion were of north american origin, some originated and resided in other continents, and most participants had spent years working professionally outside of north america. they reviewed the current situation of international medical education missions and discussed future directions. a subgroup of 11 surgeon educators held specific discussions about surgery residency training and then reviewed their findings with the entire group. additional discussions have been held since the november 2015 meeting. arising from those discussions, this paper represents a consensus about the current state of international surgical training as medical missions and proposes steps to take towards ensuring ongoing best practices. current status of surgical training in lowand middle-income countries (lmics) medical care in africa has rapidly evolved in the past 50 years. in the colonial era, a large part of modern medical care delivered in rural areas was by mission hospitals where they competed with traditional healers and some government outpatient clinics and district hospitals. much of the surgical care in mission hospitals was provided by expatriate general practitioners who learned on the job by propping up a surgical textbook with a step-by-step description of the surgical procedure they were attempting to perform. there were very few national surgeons or, in some countries, even medical doctors. to fill this gap, the colonial medical systems in some countries trained medical officers (similar to our physicians assistants) to be specialists and some to do what is now called essential surgery. despite this, there was and is a huge unmet need for curative and emergency surgical procedures in lmics, especially in subsaharan africa. traditional surgical training in resourcelimited countries was limited for most of the 20 th century to the major universities, in the form of a 3year masters in medicine (mmed) program. this system typically generated less than a handful of surgeons each year in each country, thus perpetuating the dire surgical workforce shortage. in recent decades, however, the formation and expansion of the west african college of surgeons (wacs) and, later, the college of surgeons of east, central, and southern africa (cosecsa) have successfully resulted in a major scale-up in yearly output of surgeons across africa. 1,2 161 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167. in the 1990s and 2000s, there was an international emphasis on the treatment of medical problems such as hiv and malaria. surgery was felt to be an expensive luxury, and there was a lack of trained surgeons, but in recent years, surgery has become increasingly recognized as a primary care priority. in fact, 2015 was dubbed “the year of global surgery,” with the world health assembly resolution wha68.15 on essential surgical care and anesthesia, the 3 rd editions of the disease control priorities (dcp-3), the amsterdam declaration on essential surgical care, and, above all, the lancet commission on global surgery 2030. 3-6 these efforts have resulted in an unprecedented enthusiasm and interest in global surgery as a distinct academic and clinical specialty that “places a priority on improving health and achieving equity in health for all people worldwide.” 7 thus, what missionary surgeons and physicians had faithfully done for centuries without much recognition suddenly became fashionable and desirable. with the interest in global surgery, there also came an unprecedented collaborative effort to train surgeons and other surgical care providers, primarily through north-south and south-south partnerships in the african surgical colleges mentioned earlier. in the last 20 years, mission hospitals have recognized the need to train national physicians in family medicine and surgery to not only help fill this need, but also for their own sustainability. one such program is the pan african academy of christian surgeons (paacs) that started as the vision of dr. david thompson, a general surgeon in a small mission hospital in southern gabon. he realized that if he identified a gabonese physician to come to the us for surgical training there was less than a 10% chance that the doctor would return to gabon and even less of a chance he would be willing to work in his small rural hospital. his vision was to train national doctors in mission hospitals through a rigorous surgical training program based on a four-year, american-style, training program. after the first graduate had completed his training, the program was expanded to five years to meet the requirements for regional certification. 8 the program now involves ten mission hospitals in eight countries, has graduated 52 surgeons and currently has 69 residents in training. the program is well on its way to exceed one of its early goals to train 100 surgeons by 2020. another program is starting in egypt to train ophthalmologists, with the plan to expand this to other residency training programs in the future. a few years ago, dr. nabil jabbour, an ophthalmologist, recognized that many egyptian residents who completed training received a local master’s of medicine (mmed) specialty certificate to practice the specialty, but had limited hands-on surgical experience. from this, he had a vision to provide these individuals hands-on, up-to-date, clinical experience using visiting expatriate faculty in mission hospitals. although this has had some success, it has been recognized that concentrating this training in a well-equipped hospital would provide better training with higher standards than scattered ad hoc training. from this came plans to build a hospital to serve as a base to upgrade the skills of ophthalmologists and expand this to include other specialties including family medicine. hospital baptiste biblique in togo plans to start a paacs surgical program in 2019, but is going to start by taking national interns. as a preliminary program to start a climate of education and training in the hospital, they plan to train these interns in some of the who designated essential surgical procedures. a former resident, who completed the paacs training program, has returned to his home country, the democratic republic of congo, to work in a mission hospital. as he became overwhelmed with surgical patients, he used his training to train nurses or medical officers to do basic surgical procedures, thus, multiplying his hands as well as freeing him up to do more complicated procedures. 162 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167. recommendations for starting a surgical residency in the mission setting the surgical training workshop at gmhc discussed surgical training in the mission setting. the following recommendations for starting a surgical training program were made based on the paacs and personal experiences. 1. to start a surgical program using expatriate faculty, there should be a minimum of two, preferably three, full-time surgeons committed to the program for 3-5 years. at least one will need to be willing to take the responsibility of being program director. 2. the hospital needs to be committed to providing 24-hour anesthesiology services and preferably an on-site pathologist. 3. there must be a formal mission statement outlining the purpose and goal of training. 4. there should be clear guidelines regarding:  who will be trained,  what the trainee is expected to do on graduation,  a contract as to how the graduate will repay their training such as work at a mission hospital, stay in the training hospital, return to their own country, etc,  a formal interview of prospective residents and due diligence taken to review their prior medical training (medical school), post-medical school experience and an evaluation of their character and spiritual life,  a plan of education for the entire five-year program that would include the surgical and spiritual curriculum and rotations for each year,  adequate operating rooms that are well equipped to do the planned surgeries and adequate clinic areas,  provision of adequate housing for faculty, residents, and visiting short term trainers. 5. there must be a plan for providing the trainees an option to obtain credentialing. in most countries this is becoming an important issue as a country’s medical system matures. 6. there must be adequate funding reserves to build housing for faculty and residents and invest in essential medical infrastructure. depending on the country and costs, some estimate this to require at least $300-500,000 in reserves. 7. the program must have political support, including the medical establishment locally and at some point nationally. this may include support from the ministry of health (moh) that may be active (financial support) or passive (good will) and recognition of the training program. in some countries, recognition may also involve the ministry of education (moe) that may control recognition of training programs in some countries. educational recommendations for a training program 1. the purpose of the program should not be to recreate the us training model, but rather adapt it to universally accepted standards of any program. these standards are available at little or no cost and should be adaptable to any training situation. 9 2. there should be both a surgical and spiritual curriculum with written goals and objectives. 3. the program director is responsible to establish a learning environment of inquiry using:  conferences,  bedside teaching rounds,  journal club,  mortality and morbidity (m&m) conference,  didactic lectures,  clinical teaching,  regular formative and summative feedback,  participation by the resident in giving lectures, case presentations etc.,  involvement in the spiritual training program. 4. there should be formal evaluations of the program by faculty and residents which must be culturally sensitive. 163 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167.  residents to receive regular formal feedback and should be informed how frequently this will occur and what to expect.  residents should give anonymous evaluation of faculty (this may be difficult to do in small programs and may require outsiders to receive this evaluation). 5. there should be a plan for regular spiritual training.  the program should be evaluated by residents and faculty.  the faculty need to model, encourage, and expect a christian attitude in the residents’ relationships with their patients, peers, colleagues, and all hospital personnel.  the residents should be encouraged to work with the hospital chaplain if one is available. 6. there should be regular, scheduled in-service type assessments. 7. there should be a plan for faculty development programs for faculty and residents to train the teachers how to teach. the faculty should be role models for the residents to see that teaching and training are an intimate part of being a good doctor. 10 potential problems for surgical training program recognition and certification one of the problems paacs recognized early on was the need to have recognition and approval of their specialty training programs by the national moh. the days of having training and being a good surgeon without some type of certification were rapidly disappearing as they have in the us. also, to be a program attractive to potential residents, eligibility for some type of certification needed to be possible at the completion of training. when paacs first started, it was recognized that there was a need for some credentialing organization to approve the training program. loma linda university was approached by a representative from paacs, and they agreed to inspect, review, and approve the training programs if the programs met their standards. this was a first step. it rapidly became apparent that to gain the moh’s approval, the programs would also need to have recognition and certification by an african organization as well. most sub-saharan african surgical training programs are based in universities and university hospitals. the specialty certification is based on a university-conferred academic degree, a master’s of medicine (mmed). moh will then recognize the successful candidate as a specialist and will list them on the “register of specialists.” an individual’s paygrade and status will be recognized by this degree. during the training period, the resident must pay tuition to the university and at the end of training will be required to take a series of examinations. this made it difficult for non-university hospitals to have training programs. in east africa, the college of surgeons of east, central, and southern africa (cosecsa) started to bring surgeons together similar to the american college of surgeon (acs) or the uk royal college of surgeons (rcs). one of the goals was to provide certification for specialists similar to what the rcs does in the uk. they have developed a similar process for recognizing training programs and examinations that they had experienced in the uk. it provide a way for nonuniversity hospitals to have their own training programs and the trainees to have a recognized certification. the problem has been that it is a parallel program in competition with the mmed. the universities have assessed that this certification is inferior to their mmed, and universities are reluctant to lose the revenue stream. the only choice paacs had was to ask cosecsa to approve their programs. this has been a long, slow, and arduous process. cosecsa has two levels of certification, the membership and fellowship. the membership is an entry level consisting of mainly basic science and basic surgery certification that would be given to a resident completing a level equal to the second year of residency in the 164 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167. american system. the fellowship is a full surgical certification, equivalent to a resident passing the specialty board exam in the us system. the advantage of the cosecsa fellowship is that it is recognized in all 10 countries covered by cosecsa. one disadvantage of the mmed certification is that it s conferred by an individual university, so the standard can vary from university to university and from country to country and may not be recognized in all countries. all of the paacs programs in east and west africa have been approved for the membership level by cosecsa, but at present only the kenyan programs are approved at the fellowship level. the problem is that at the membership level, trainees are not recognized by the moh as fully qualified surgeons, even if they have completed a five-year training program and are approved by loma linda and paacs. also some countries require separate approval of the program by the moh and ministry of education for graduates to be considered specialists. paacs has also approached the west african college of surgeons (wacs) for approval, but this has been even more difficult. so far paacs has asked them to approve programs in west africa and have only received approval at the membership level. recent negotiations may change this, and approval may be granted at the fellowship level if certain conditions are met. another problem is maintaining and attracting expatriate faculty. spiritual training one of the initial goals for training residents in mission hospitals was to encourage them to serve in rural mission hospitals and to have them be not only excellent, caring surgeons, but to be equipped to share the good news of salvation and hope with their patients. in the beginning, each program director was to provide a weekly bible study for the residents and was given recommendations on what to cover, although they were allowed to choose their own study materials. the paacs commission later added a “dean” of spiritual training as a commission member and has a standing spiritual training advisory committee. reverend stan keys has developed a four-part bible study series, each part to last one year for the program directors and residents. this allows the residents to complete the whole series during their five-year training program. this has helped the programs by having a curriculum and study material available as well as providing a more standardized program. it helps the already busy faculty and residents with the availability of developed printed material. needs and future directions one of the current catch words in global health programs is “sustainability.” it is recognized in all high income countries (hics) that surgical education takes more time and creates more expense than an experienced non-teaching, welltrained surgeon. this is compounded in low and middle income countries (lmics) where there is a shortage of trainers and an overwhelming number of patients to treat. many of the patients coming to mission hospitals can only afford minimal payments for medical care. if there is a nearby government facility that is financially subsidized, a mission hospital may not be competitive. they must depend on providing excellent medical and surgical care and a caring attitude to the patients. if the mission hospital is in an isolated rural area, most of the patients may be able to pay only a small amount of the cost, making the hospital dependent on outside funding. because of this constant financial burden, some mission organizations have chosen to turn their hospitals over to nationals and to get out of the health care “business.” this often leads to mission hospitals slowly deteriorating in supplies, facilities, and personnel leading to the eventual closure of the hospital. this raises a question as to whether a mission hospital and, even more relevant to this paper, a surgical training program can be sustainable? 165 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167. in some situations, training of national personnel in more efficient hospital administration would help. it is recognized by almost everyone involved that training in hospital administration is a huge unmet need in sub-saharan africa. addressing this need is beyond the purview of this paper, only to say that global health has concentrated on clinical care and tends to ignore the need in administration, although there are a few organizations starting programs. in some countries, the moh has recognized the important roles mission hospitals play in the delivery of health care. with this in mind, despite their strapped budgets for health care, they do provide some financial support for patient care and medicines. in the area of public health, infectious diseases, such as malaria and hiv, have a high priority by many global non-governmental organizations which help provide care. one example of the benefits of a surgeon at a hospital is demonstrated by one of the early paacs graduates who returned to his home country and the mission hospital which provided some support for his training. the 100+ bed hospital had only a medical service, was losing money, and had a declining census, dropping to just 25-30 patients. in less than one year after he returned to provide a surgical service, the hospital was nearly full and the financial balance was positive. not all graduates have been as successful, but it does demonstrate what can be accomplished. one problem is when a talented individual makes a difference like this clinically, he or she is then promoted to be hospital director, with less time for clinical medicine and, frequently, without adequate training in administrative leadership. one of the original ideas when paacs started was that mission hospitals would identify a physician to be trained, pay their stipend, and have the resident return to the hospital to work. very quickly, it was found that most mission hospitals could not do this. as a consequence, paacs started paying all the costs to train residents, and the residents agreed to serve in a mission hospital for five years after completion. at present, all of the residents completing the paacs training have remained in africa. the majority of residents have joined mission hospitals, but some are working for government hospitals. as paacs has added more residents, it is now asking for the training hospitals to contribute to the financial support of the residents. most hospitals have recognized that a training program increases their productivity and attracts patients to their hospital, so most are complying with this request which will help make the program sustainable. paacs is also heavily dependent on visiting expatriate faculty to supplement the surgical training by the full time faculty as well as experience in surgical subspecialties. the answer to the question of sustainability is not easy. the economics and budgets of most lmics will require some outside support. ideally this support should be as a partnership with mutual goals, not a free handout creating a demeaning dependency. employment opportunities when considering sustainability, one must look at paid employment opportunities for graduating residents. so far, the paacs residents have found positions. some have been willing to take up opportunities where there have been inadequate facilities to use their training to the fullest potential. some have had to sacrifice income needed to support their families. some have taken positions in rural areas while their children had to stay in the city for educational purposes, thus splitting up the family. some have been in government hospitals where they have been threatened and had to leave, but the majority are working in mission hospitals. a few have been employed at paacs training hospitals. all of them credit their role models and paacs for encouraging them to use their training to serve the lord. 166 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167. to be sustainable, training programs need to equip and train the residents to eventually take over the training programs. many times, teaching is not considered as a career opportunity. as trainers, it is incumbent upon us to be role models and look for those residents who show leadership and teaching skills, and then encourage them to consider training and teaching as a career. it is important that a training program has a goal for nationals to take over running the training program if it is to be sustainable. in many countries, visas, licenses, and approval by moh are fragile when governments frequently turnover. when a program is totally dependent on expatriates, it is vulnerable to faculty leaving for health, family, or personal reasons, and the program becoming unsustainable with possible closure. to reduce this possibility, it is important to train residents how to teach and run a program. programs should try to hire those residents showing an aptitude for teaching. if the program should become self-sustainable in this way, is there a role for expatriates? yes, there will be a strong role for them, although it may be different than merely filling traditional roles. for many years, there will be a need for expatriates to be available for counselling, mentoring, and advice, but it should be a supportive rather than a directive role. there will also be a need for expatriates to help the national faculty maintain and keep their surgical skills up-todate as they will not have the vast array of continuing education opportunities that those of us in hics have. also, they will need help in external, non-biased assessments of their residents and of the program to maintain high quality training standards. so, yes, there will still be a role for expatriate missionaries willing to train and teach. a recent concern regarding employment for graduating residents is the reluctance of mission hospitals to hire paacs residents. it is not because they feel they are not well trained, but because they will have to pay them in ways that further strain an already strained budget. expatriate missionaries have two big advantages. first, they bring their own support, and the hospital does not have to pay them. second, they will usually bring resources to help the hospital continue to operate. this may be vital to the sustainability of the hospital. a solution to this dilemma is beyond the purview of this paper, but certainly, it is an issue that needs to be addressed by mission and church organizations. finally, these training programs rely heavily on expatriate full-time missionaries, but also on short-term surgeons willing to spend time teaching residents and covering for full-time expatriate surgeons temporarily away. elsewhere in this journal is an article on the mobilization of doctors from hics willing to serve in lmics. it is not easy for doctors who wish to serve long-term or shortterm to leave practices, bring families and live in situations that most of us would find difficult. however, we can be thankful that the lord lays on the hearts of a few to serve him in this way. conclusion surgery has traditionally been an important part of medical mission services, but to make this sustainable, it is important that we include residency training as part of the mission. starting a surgical residency program will require careful preparation, recruitment of training faculty, and an appropriate educational program. it is important that there be plans for those completing the training to be able to receive credentials that will be recognized by the countries’ mohs. to be a successful, god-honoring program, there must be a strong emphasis on spiritual training and mentoring as well as surgical training. sustainability will also include the importance of training national physicians to be teachers and to make sure there are employment opportunities available. references 1. kakande i, mkandawire n, thompson miw. a review of surgical capacity and surgical education programmes in the cosecsa region. east cent afr j surg. 2011;16:6-34. 167 smith, poenaru, thompson & phillips nov 2016. christian journal for global health, 3(2): 160-167. 2. bode co, nwawolo cc, giwa-osagie of. surgical education at the west african college of surgeons. world j surg. 2009;32(10):2162-6. http://dx.doi.org/10.1007/s00268-008-9710-x 3. price r, makasa e, hollands m. world health assembly resolution wha68.15: strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage — addressing the public health gaps arising from lack of safe, affordable and accessible surgical and anesthetic services . world j surg. 2015 sep;39(9):2115–25. http://dx.doi.org/10.1007/s00268-015-3153-y 4. mock cn, donkor p, gawande a, jamison dt, kruk me, debas ht. essential surgery: key messages from disease control priorities, 3rd edition, lancet. 2015 may; 385(9983):2209-19. http://dx.doi.org/10.1016/s0140-6736(15)6000915. [epub 2015 feb 5] 5. botman m, meester rj, voorhoeve r, mothes h, henry ja, cotton mh, et al. the amsterdam declaration on essential surgical care. world j surg. 2015 june;39:1335–40. http://dx.doi.org/10.1007/s00268-015-3057-x 6. meara jg, leather ajm, hagander l, alkire bc, alonso n, ameh ea, et al. global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. lancet. 2015 aug 8;386(9993)569-624. http://dx.doi.org/10.1016/s0140-6736(15)60160-x [epub 2015 apr 26] 7. koplan jp, bond tc, merson mh, reddy ks, rodriguez mh, sewankambo nk, et al. towards a common definition of global health. lancet. 2009 june 6;373(9679):1993–5. http://dx.doi.org/10.1016/s0140-6736(09)60332-9 8. pollock jd, love tp, steffes bc, thompson dc, mellinger j, haisch c. is it possible to train surgeons for rural africa? a report of a successful international program. world j surg 2011 mar;35(3):493–9. http://dx,doi.org/10.1007/s00268-010-0936-z 9. world health organization. surgical care at the district hospital [manual]. malta: interprint limited; 2003 [isbn 92 4 154575 5] available from: http://www.who.int/surgery/publications/en/scdh .pdf 10. lockyer, jm, hodgson cs, lee t, faremo s, fisher b, dafoe w, et al. clinical teaching as part of continuing professional development: does teaching enhance clinical performance? med teach 2016 aug;38(8):815-22. http://dx.doi.org/10.3109/0142159x.2015.111289 5 competing interests: none declared. correspondence: james d smith, oregon health and science university, oregon, united states. jamesd.smith@yahoo.com dan poenaru, children's hospital, quebec, canada. dpoenaru@gmail.com david thompson, harpur hospital, egypt. justthebeginning@hushmail.com j dwight phillips, mayo clinic, minnesota, united states. jdwightphillips@gmail.com cite this article as: smith jd, poenaru d, thompson d, phillips jd. surgical residency training in the mission setting: current status and future directions. christian journal for global health (nov 2016), 3(2):160-167. © smith jd, poenaru d, thompson d, phillips jd this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1007/s00268-008-9710-x http://dx.doi.org/10.1007/s00268-015-3153-y http://dx.doi.org/10.1016/s0140-6736(15)600091-5 http://dx.doi.org/10.1016/s0140-6736(15)600091-5 http://dx.doi.org/10.1007/s00268-015-3057-x http://dx.doi.org/10.1016/s0140-6736(15)60160-x http://dx.doi.org/10.1016/s0140-6736(09)60332-9 http://dx,doi.org/10.1007/s00268-010-0936-z http://www.who.int/surgery/publications/en/scdh.pdf http://www.who.int/surgery/publications/en/scdh.pdf http://www.tandfonline.com/doi/abs/10.3109/0142159x.2015.1112895 http://www.tandfonline.com/doi/abs/10.3109/0142159x.2015.1112895 http://www.tandfonline.com/doi/abs/10.3109/0142159x.2015.1112895 http://dx.doi.org/10.3109/0142159x.2015.1112895 http://dx.doi.org/10.3109/0142159x.2015.1112895 mailto:jamesd.smith@yahoo.com mailto:dpoenaru@gmail.com mailto:justthebeginning@hushmail.com mailto:jdwightphillips@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ editorial may 2019. christian journal for global health 6(1) justice and human rights in the pursuit of global health we are pleased to have completed five years of quality publishing in the convergence of global health and christian faith. this convergence has been called a “discomfiting paradox” but also an important connection to recover and magnify for justice and global health.1 for this issue the journal editors called for papers on human rights and justice related to global health on the grounds that the christian faith-based community needs to be heard on these questions. we commend to your interest five submissions on this theme. an editorial by matthew santosh thomas, director of the emmanuel hospital association of india introduces the theme, commenting on human rights in general as deriving from the dignity of human beings created in the image of god, but also on the biblical emphasis on the duty of the privileged towards those in need, as opposed to merely the promotion of rights. he surveys some of the conflicts and conundrums associated with health and healthcare rights in other cultural contexts. robert aronson looks at these questions from a public health perspective where the focus shifts from individual behavior to social conditions and systems that promote and sustain inequality in health and healthcare. he offers reasoning based on a biblical understanding of old testament policies of land use, new jerusalem eschatology with a focus on social justice and jesus’ teaching on the kingdom of god. john patrick examines the presuppositions behind contemporary ideas on global health, human rights, and justice and finds that their success is dependent upon a judeochristian world view, as well as developing a moral framework early in subsequent generations. readers may find his conclusions challenging. we also move beyond purely theoretical considerations of this theme and offer two papers whose authors apply these principles in their global contexts. mark crouch, a cross-cultural physician educator in papua new guinea, offers practical thoughts on the collision of rights to healthcare and personal responsibility in a setting where resources can be very limited. lois armstrong, who has been involved in health care work in south asia for over 15 years, contributes keen insights on how culture influences a society’s conception of rights. she suggests, from a biblical perspective, ways in which the differences between honor-shame culture, fear-power culture, and guilt-innocence culture can be leveraged to promote effective healthcare in the absence of an explicit notion of healthcare rights. rev john lunn proposes a novel visual model for inculcating spiritual understanding into care for patients in spiritual care visualized. spirituality in healthcare is also the subject of the balbonis’ new book hostility to hospitality, reviewed with extended commentary by alan gijsbers. two articles by hunter york (a pseudonym) movingly detail the suffering and travail of treatment-resistant depression, an increasing global health problem, first in a unique autobiographical clinical case report, then in an insightful biblical reflection on the mutual identification with jesus’ passion and suffering. three papers explain how faith-based organizations working in co-operation with secular groups to advance public health and healthcare in various circumstances. karen mathias and michael burke describe the effectiveness of faithbased approaches to social justice and treatment of people with psycho-social disability in north india, being the recipients of the annual dignity and right to health award which acknowledges leadership, service to marginalized communities, successful program outcomes, and personal piety. perry jansen gives an analysis of how the unique cooperation between samaritan’s purse and https://journal.cjgh.org/index.php/cjgh/article/view/267 https://journal.cjgh.org/index.php/cjgh/article/view/239 https://journal.cjgh.org/index.php/cjgh/article/view/305 https://journal.cjgh.org/index.php/cjgh/article/view/261 https://journal.cjgh.org/index.php/cjgh/article/view/269 https://journal.cjgh.org/index.php/cjgh/article/view/253 https://journal.cjgh.org/index.php/cjgh/article/view/299 https://journal.cjgh.org/index.php/cjgh/article/view/275 https://journal.cjgh.org/index.php/cjgh/article/view/279 https://journal.cjgh.org/index.php/cjgh/article/view/277 https://journal.cjgh.org/index.php/cjgh/article/view/277 https://journal.cjgh.org/index.php/cjgh/article/view/265 2 thomas may 2019. christian journal for global health 6(1) doctors without borders helped provide effective care and containment during the 2014-2016 ebola epidemic in liberia. kristen alford and jamison koeman offer a case study on the opportunities and challenges of cooperation between a faith-based and a secular organization in providing sustainable sources of safe water in liberia. we offer reviews of recently published books dealing with various aspects of global health. this issue contains a review of reena george’s one step at a time: the birth of the christian medical college, vellore, and insightful reviews of two books by journal contributor raymond downing: global health means listening, reviewed by prof adamu addisie from ethiopia, and such a time they had, a history of medical missions in africa reviewed by prof christoffer grundmann from germany. the review of hostility to hospitality was mentioned above. we also include an excellent review of wcc’s recent contact issue on primary health care revisited by samuel adugyamfi and roopa verghese. jacob blair’s submission, jacob’s pharmacy, is a creative recasting of john 4: 4-15 into a medical context in peru. finally, a poem relating justice to the personalized dying process entitled my mother weakens by sarah larkin rounds out the issue. please be sure to read the most recent call for papers, focusing on the formative first years. this is an extremely important and emerging area for global health, poverty alleviation, and development, needing more documentation and innovative approaches from faith-based actors. it also corresponds to a recent lancet series, this year’s focus of the moral and spiritual imperative, and the human capital project of the world bank group. we are also preparing a call for papers on mission hospitals, building on the past, highlighting the present, and strategizing into the future. references 1. holman sr. beholden: religion, global health, and human rights. new york: oxford, 2015, p.5. www.cjgh.org https://journal.cjgh.org/index.php/cjgh/article/view/243 https://journal.cjgh.org/index.php/cjgh/article/view/243 https://journal.cjgh.org/index.php/cjgh/article/view/271 https://journal.cjgh.org/index.php/cjgh/article/view/271 https://journal.cjgh.org/index.php/cjgh/article/view/271 https://journal.cjgh.org/index.php/cjgh/article/view/285 https://journal.cjgh.org/index.php/cjgh/article/view/293 https://journal.cjgh.org/index.php/cjgh/article/view/293 https://journal.cjgh.org/index.php/cjgh/article/view/307 https://journal.cjgh.org/index.php/cjgh/article/view/263 https://journal.cjgh.org/index.php/cjgh/article/view/291 https://journal.cjgh.org/index.php/cjgh/article/view/291 https://journal.cjgh.org/index.php/cjgh/callforpapers closing the gap: the potential of christian health associations in expanding access to family planning www.cjgh.org july 2017 | 53 closing the gap: the potential of christian health associations in expanding access to family planning lauren vanenka, ronald kasyabab, prince bosco kananic, tonny tumwesigyed, and jeannette cachane a mph, program officer, institute for reproductive health, georgetown university, usa b md, assistant executive secretary, uganda catholic medical bureau, uganda c md, mhcds, director, caritas rwanda catholic health services, rwanda d md, mph, executive director, uganda protestant medical bureau e ma, m.ed, director of capacity building and technical assistance, institute for reproductive health, georgetown university, usa abstract recognizing the health impact of timing and spacing pregnancies, the sustainable development goals call for increased access to family planning globally. while faith-based organizations in africa provide a significant proportion of health services, family planning service delivery has been limited. this evaluation seeks to assess the effectiveness of implementing a systems approach in strengthening the capacity of christian health associations to provide family planning and increase uptake in their communities. from january 2014 to september 2015, the capacity of three christian health associations in east africa—caritas rwanda, uganda catholic medical bureau, and uganda protestant medical bureau—was strengthened with the aims of improving access to women with unmet need and harmonizing faith-based service delivery contributions with their national family planning programs. the key components of this systems approach to family planning included training, supervision, commodity availability, family planning promotion, data collection, and creating a supportive environment. community-based provision of family planning, including fertility awareness methods, was introduced across intervention sites for the first time. five hundred forty-seven facilityand community-based providers were trained in family planning, and 393,964 people were reached with family planning information. uptake of family planning grew substantially in year 1 (12,691) and year 2 (19,485) across all christian health associations as compared to the baseline year (3,551). cumulatively, 32,176 clients took up a method during the intervention, and 43 percent of clients received this service at the community level. according to a provider competency checklist, facilityand community-based providers were able to adequately counsel clients on new fertility awareness methods. integration of christian health associations into the national family planning strategy improved through participation in routine technical working group meetings, and the ministries of health in rwanda and uganda recognized them as credible family planning partners. findings suggest that by strengthening capacity using a systems approach, christian health associations can meaningfully contribute to national and international family planning goals. increased attention to community-based family planning provision and to mainstreaming family planning service delivery across christian health associations is recommended. original article christian journal for global health | http://www.cjgh.org 54 | christian journal for global health 4(2) www.cjgh.org introduction preventing unintended pregnancies could save the lives of more than 2 million infants and children annually worldwide, and could significantly reduce maternal mortality and morbidity.1 this positive impact on health outcomes, among other benefits, is why increased access to family planning information and education is one of the sustainable development goals set by the international community.2 modern family planning use among women with unmet need is lowest in sub-saharan africa.3 meeting this need remains a challenge. while faithbased organizations represent 20-50 percent of the national health sector across a number of african countries,4 their contribution to family planning service delivery is significantly less than other health services offered by these facilities.5, 6 even in light of the life-saving evidence supporting healthy timing and spacing of pregnancies, faithbased organizations have found including family planning in their programming to be challenging due to a lack of capacity or the belief that specific family planning methods are at odds with their religious tenets.7, 8 even in the midst of partnerships between faith-based and non-religious development organizations, there is a concern that religious ideologies may overtake empirical evidence in delivering information and services or, on the other hand, that core religious values may be compromised along the way.9 with their broad networks and sustained presence, faith-based organizations have the potential to increase the demand for and use of health services, and significantly contribute to achieving the sustainable development goals.10 faith is an important determinant of value systems at both the individual and community levels.11 nearly nine in ten africans identify themselves as christian or muslim, and 69-98 percent describe religion as “very important” in their lives.12 often the largest non-governmental healthcare providers in african countries are faithbased organizations. in many countries, christian health associations (chas) coordinate with faithbased health facilities (table 1).13 chas often work closely with ministries of health through established memoranda of understanding to complement public sector service delivery. their engagement in family planning, however, is limited, especially among catholic health networks. the structures are in place for chas to contribute to national reproductive health strategies, but lack of capacity along with unavailability of appropriate family planning methods have kept them from broader participation.7 given the vital role of chas in healthcare delivery, there has been an increase in engagement with international aid agencies prompting an exploration of the ways that religion may promote family planning. based on the interest among chas to offer family planning services, this intervention seeks to strengthen their programs using a systems approach and better aligns their service delivery with national strategies in rwanda and uganda. table 1. christian health associations in rwanda & uganda rwanda: caritas rwanda is a network of catholic hospitals and clinics that operates around 30 percent of health facilities nationally and has an established memorandum of understanding with the ministry of health. some staff within caritas rwanda facilities are seconded from the ministry of health, and data (including family planning) is expected to be reported through the national health management information system (hmis) in the same way as public facilities. uganda: the private-not-for-profit health sector is primarily made up of four faith-based organizations uganda catholic medical bureau, uganda protestant medical bureau, uganda muslim medical bureau, and uganda orthodox medical bureau. together they account for 35 percent of health services and training institutions in the country. they each have established memoranda of understanding with the ugandan government, and they often collaborate as a unified consortium. some staff within these private-notfor-profit facilities are seconded from the ministry of health, and data (including family planning) is expected to be reported through the national hmis in the same way as public facilities. vanenk, et al. christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 55 intervention description from january 2014 to september 2015, a systems approach was used to strengthen the family planning capacity of three chas in rwanda and uganda: caritas rwanda, uganda catholic medical bureau (ucmb), and uganda protestant medical bureau (upmb). this systems approach targeted the fundamental building blocks of family planning programs: training, supervision, commodity availability, family planning promotion, data collection, and creating a supportive environment (figure 1). the approach was tailored to the local context of each cha to ensure acceptability within their religious tradition. for example, caritas rwanda and ucmb are catholic organizations and offered only natural methods of family planning. fertility awareness methods (fams)—standard days method® (sdm) used with the visual aid cyclebeads®, twoday method®, and lactational amenorrhea method (lam)—were introduced at the facility and community levels, which allowed these chas to provide a range of modern and effective options that were consistent with their faith (table 2). for upmb, capacity was strengthened across all modern methods in addition to expanding the method mix with new fertility awareness methods. table 2. fertility awareness methods of family planning fertility awareness methods are natural methods of family planning that are classified as modern methods by the world health organization, fp2020, usaid, and other international organizations. the fertility awareness methods included in this intervention were: standard days method® (sdm) identifies a fixed set of days in each menstrual cycle when a woman can get pregnant if she has unprotected intercourse. if the woman does not want to get pregnant, she and her partner avoid unprotected intercourse on days 8 through 19 of her cycle. a woman can use cyclebeads®, a color-coded string of beads, to help track the days of her menstrual cycle and see which days she is most likely to get pregnant. sdm is 95 percent effective with correct use and 88 percent effective with typical use.14 twoday method® is a fertility awareness method of family planning that uses cervical secretions to indicate fertility. a woman who uses the twoday method® checks for cervical secretions at least twice a day. if she notices secretions of any type, color, or consistency either “today” or “yesterday,” she considers herself fertile. twoday method® is 96 percent effective with correct use and 86 percent effective with typical use.15 lactational amenorrhea method (lam) is a shortterm family planning method based on the natural effect of breastfeeding on fertility. the act of breastfeeding, particularly exclusive breastfeeding, suppresses the release of hormones that are necessary for ovulation. if the following conditions are met, the method provides protection from pregnancy: 1. the mother’s monthly bleeding has not returned since her baby was born, and 2. the baby is only/exclusively breastfed (day and night), and 3. the baby is less than 6 months old. lam is 99 percent effective with correct use and 98 percent effective with typical use.16 figure 1. a systems approach to family planning programs vanenk, et al. christian journal for global health | http://www.cjgh.org 56 | christian journal for global health 4(2) www.cjgh.org each of the system components was addressed in the following manner: training providers facilityand community-based providers were trained to offer family planning in 51 sites, and an additional 31 ucmb sites (primarily health posts) received training for facility-based providers only. community-based family planning was new across all intervention sites, and the profile of these community health workers (chw) included community volunteers, village health teams, catechists, and expert couples. the training curriculum was designed using guidance documents such as the who medical eligibility criteria and the national family planning curricula. caritas rwanda and ucmb equipped their providers to offer fertility awareness methods that were consistent with catholic teaching, and directed clients to a nearby facility or secondary post (rwanda) if they wished to use a method not offered by the site. upmb providers received a contraceptive technology update on all methods available in uganda in addition to the new fertility awareness methods. chws from upmb were trained to offer pills, condoms, and fertility awareness methods as well as referrals to the facility for other family planning options. supervision system family planning was integrated into the supervision systems at intervention sites. focal persons were identified and trained to conduct supportive supervision with facilityand community-based providers. through monthly meetings with chws, supervisors helped address challenges, ensured routine reporting of data, and coordinated resupply of commodities. supervision was also conducted by central level managers to assess progress on each component of the systems approach. promoting family planning the availability of new methods and new community-based services provided the opportunity to revitalize family planning outreach in the facility and the community. the chas produced radio spots and promotional materials to raise awareness of family planning. at the facilities, information was given in waiting rooms of various wards, particularly while women waited for pre-, ante-, and post-natal services. chws raised awareness by conducting health information sessions in their villages with women’s groups, churches, crowds during market days, etc. additionally, upmb equipped religious leaders from a variety of faith perspectives (protestant, catholic, and muslim) with knowledge about the benefits of family planning, and the importance of healthy timing and spacing of pregnancies. emphasis was placed on dispelling myths, sharing information about service availability, and creating linkages with the new cadre of chws in their area. commodity availability chas supported intervention sites to improve their forecasting, procurement, and management of family planning commodities during supervision visits. in uganda, fertility awareness methods were not offered in most health facilities, and cyclebeads® were not procured nationally. therefore, upmb and ucmb managed a separate supply chain to ensure stock of cyclebeads® at intervention sites. collecting data since family planning at the community level was a new service for these chas, a reporting structure was developed to facilitate the flow of data from the field. although facilities were recording family planning service statistics, the reports were not being transferred to the ministry of health through the health management information system (hmis). data managers and providers were then supported through supervision to ensure that family planning service delivery data from chas reached the district level. creating a supportive environment to be seen as credible partners in family planning, it was essential for chas to participate in their national strategy dialogue. under the intervention, chas briefed and regularly updated policymakers, program managers, and influential family planning practitioners about their activities as new experiences and findings emerged. they advocated with stakeholders for inclusion of their activities, including fam, into national norms and program vanenk, et al. christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 57 guidelines, the national hmis, and commodity procurement mechanisms. program evaluation methods this evaluation sought to assess the effectiveness of implementing a systems approach in strengthening the capacity of cha sites to provide family planning at the facility and community level and, ultimately, increase uptake of family planning. the intervention was evaluated using program data from family planning service statistics, program reports, competency checklists with providers (knowledge improvement tool kit), and qualitative interviews with providers. service statistics: routine service statistics documenting family planning uptake were collected on a monthly basis from intervention sites. baseline service statistics from 2013 (year preceding intervention activities) were compared with services statistics from 2014 (year 1) and 2015 (year 2) to assess the impact of the intervention on overall uptake by method and type of provider. program reports: the majority of monitoring and evaluation data was collected via routine program reports including awareness-raising activity reports, meeting reports, supervision reports, and quarterly reports. knowledge improvement tool (kit): the kit assesses provider competency in screening for and offering family planning methods. the kit was implemented periodically, beginning at least three months after initial provider training. supervisors administered the kit to a convenience sample of 172 providers through a counseling role-play and scored providers on the key messages included during counseling. scores were calculated by percent of key counseling aspects covered correctly, and aggregated to show trends across providers from different sites and levels. provider interviews: in-depth interviews and focus group discussions were conducted with focal persons and providers at the facility and community level. interview discussion guides included questions on experiences offering family planning, and perceptions of acceptability and feasibility of the intervention. in total, 88 providers were interviewed: 18 facility-based providers and 70 chws. the interviews were conducted in the local language spoken by providers, and they were recorded, transcribed, and translated into english for analysis. findings programmatic capacity building the following results demonstrate the change in programmatic capacity according to the systems approach. provider training and supervision: one hundred sixty-one facility providers and 386 chws were trained to offer family planning (table 3). providers were generally satisfied with the family planning training they received and expressed confidence in their knowledge and skills, particularly related to fertility awareness methods. several went on to become users of the methods themselves. the training was good and it has helped very many clients learn that family planning exists, and it is very effective if used in an effective way. (facility-based provider, ucmb) after the training, i was equipped and able to discern who should use the methods through the use of the screening guides, and, above all, i would not turn away clients who asked for other methods that i couldn’t provide. [i sent them] to table 3. number of providers trained in family planning by level and cha facilitybased communitybased total caritas rwanda sites=40 40 200 240 upmb sites=8 31 84 115 ucmb sites=34 90 102 192 total 161 386 547 vanenk, et al. christian journal for global health | http://www.cjgh.org 58 | christian journal for global health 4(2) www.cjgh.org get both injectable and implants of their choice. (chw, upmb) i am now very experienced. if i meet anyone in the village and they ask me about family planning, i can easily respond and give clear information. secondly, i am respected and besides, i have become a very good example of a satisfied user of a natural family planning method. i have used it to space my children very well. (chw, upmb) of the original 547 providers who were trained, the counseling capacity of 172 providers offering fertility awareness methods was measured using the kit. figure 2 shows the average provider scores for each method, site, and provider level. facility providers generally scored higher than chws figure 2. percent of key counseling messages correctly administered using kit for provider competency by method for facility and community-based providers vanenk, et al. christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 59 across all methods and sites. scores for sdm and lam were consistently higher than scores for the twoday method®. providers from ucmb and caritas rwanda (catholic organizations that offered only natural methods) had higher scores than providers from upmb (which offered the full range of methods). promoting family planning: from july 2014 – september 2015, providers from all intervention sites and 83 religious leaders trained by upmb were able to conduct a total of 24,335 awareness-raising events and reach an estimated 393,964 community members with information about family planning (table 4). data collection: in many sites, challenges were identified with reporting data. family planning service statistics were collected in provider registers but were not often transferred into monthly hmis reports sent to the ministry of health. furthermore, hmis reports in rwanda and uganda did not allow disaggregation of certain methods, including sdm, twoday method®, and lam. through targeted supervision, facilities began regularly sending family planning reports to the district allowing for the contribution of chas to be included in national level results. in particular, catholic health facilities were now able to include family planning service data in monthly reports to the government where they previously reported nothing. however, reporting was a challenge experienced by all intervention sites. focal persons struggled to integrate chw services into the facility register on a regular basis, and monthly hmis reports to the government required improvement. previously, they were not reporting anything on the natural family planning services to the government, but now it is being included in the data to the government. (facility-based provider, ucmb) i agree that we did not document properly. we would provide family planning, fill the monthly reporting form and the other gathering information tool, but we would not fill in the registers. so, a follow-up team from upmb came and showed us how we were to do it. they helped us, and again another group came at the beginning of this year with the community reports. the community reports were not being attached to hmis forms, so we corrected that. the community vht reports, we now sum it up and send to hmis. (facility-provider, upmb) partners have advocated with the ministry of health in uganda to improve accuracy of the hmis form, ensuring that the full range of methods are included. the ministry recognized this need and will consider incorporating them during the next round of hmis form revisions. commodity availability: one of the biggest challenges for program sustainability in uganda was the difficulty of obtaining cyclebeads®, which could not be procured alongside other family planning commodities. using a donation of cyclebeads® from the institute for reproductive health, ucmb and upmb self-managed facility stock levels using a parallel supply chain, which created an additional burden for the management teams. through advocacy with the ministry of health, cyclebeads® have been integrated into the costed implementation plan in uganda, though procurement has not yet moved forward. creating a supportive environment: to further collaborate with the ministry of health, caritas rwanda and ucmb joined the family planning technical working groups in rwanda and uganda for the first time, and upmb strengthened its existing involvement with them. these are committees hosted by the ministry of health to coordinate all family planning efforts nationally. as a result, they were recognized as partners supporting national family planning goals. the ministry of health in uganda requested support from ucmb to lead table 4. number of awarenessraising events and people reached with family planning information events people reached caritas rwanda 15,747 237,446 upmb 7209 98,054 ucmb 1379 58,464 total 24,335 393,964 vanenk, et al. christian journal for global health | http://www.cjgh.org 60 | christian journal for global health 4(2) www.cjgh.org development of the fertility awareness method modules in the revised national training curriculum. the ministry of health also appreciated the active engagement of religious leaders in the community as they were influential role models but often perceived as barriers to family planning uptake. both ucmb and upmb have been acknowledged by the ministry of health for their efforts to involve men in family planning services and decision-making. family planning uptake a total of 32,176 clients accepted a method after receiving counseling from a trained provider at an intervention site between jan. 2014 and dec. 2015 (figure 3). uptake of family planning grew substantially in year 1 (12,691) and year 2 (19,485) of the intervention as compared to the baseline year (3,551). chws contributed substantially to this increase, with 43 percent of new family planning clients receiving counseling at the community level (figure 4). family planning uptake across upmb sites grew by 138 percent from baseline to year 1 and then by 22 percent from year 1 to year 2. uptake across caritas rwanda sites grew by 259 percent from the baseline year to year 1 and increased another 29 percent from year 1 to year 2. baseline uptake for ucmb is assumed to be zero since their facilities had no functioning family planning program. from intervention year 1 to year 2, uptake increased by 161 percent. family planning use increased for all methods offered by upmb sites except female and male sterilization (figure 5). uptake of methods newly available at the community level substantially increased (pills, sdm, lam, and twoday method®). the most frequently provided method was sdm, followed by injectable and implant. for both ucmb and caritas, the most frequently provided method was lam, followed by sdm (figures 6 & 7). figure 3. family planning uptake by quarter between jan. 2014 dec. 2015 figure 4. comparison of family planning uptake at the facility and community level at baseline (2013), year 1 (2014), and year 2 (2015) of the intervention. caritas rwanda and ucmb uptake data include only natural methods. upmb uptake data include all methods. vanenk, et al. christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 61 according to interviews with providers, there was a demand for fertility awareness methods among clients, both men and women. the primary reason clients were interested in these options was their lack of side effects. figure 5. upmb family planning uptake by method at baseline (2013), year 1 (2014), and year 2 (2015) figure 6. ucmb family planning uptake by method at year 1 (2014), and year 2 (2015) figure 7. caritas rwanda family planning uptake by method at baseline (2013), year 1 (2014), and year 2 (2015) vanenk, et al. christian journal for global health | http://www.cjgh.org 62 | christian journal for global health 4(2) www.cjgh.org the number of clients coming to access the service at the facility is increasing. when you teach a group, they tell others and they send them here. (facility-based provider, ucmb) people like those methods and say that they are good because they do not have side effects. (chw, caritas rwanda) when they announce in the church that after the mass those who want natural family planning will meet with the provider, men attend counseling sessions. moreover, men come when we invite them to attend counseling sessions here at the health center. (facility-based provider, caritas rwanda) discussion the program evaluation results point to a significant increase in family planning uptake among potential clients when chas use a systems approach to program strengthening. these findings demonstrate that faith-based health networks have the potential to meaningfully contribute to family planning outcomes, and they are willing and able to do so with capacity strengthening. across all intervention sites, uptake of family planning grew significantly and quickly when comparing baseline service statistics to service delivery during the intervention. providers and religious leaders were active in awareness-raising and reached nearly 400,000 men and women with family planning information. clients from ucmb and caritas rwanda most frequently opted for lam, likely due to efforts that chas made in integrating family planning into pre-, ante-, and post-natal health services at the facility. this was a critical time for women and couples to receive family planning information and counseling as data globally revealed a large unmet need among postpartum women. while providers actively followed up with lam users to support their transition to another family planning method, data on the total number of women who succeeded in transition was not available. clients from upmb most frequently opted for sdm, followed by injectable and implant. this finding contrasted with overall rates of method use in uganda where rates of sdm use were low. however, it is important to recognize that availability of fertility awareness methods in uganda was low even though the methods were included in the national family planning norms. in reality, providers were not trained to offer any fertility awareness methods, and cyclebeads® were not available in the majority of facilities across the country. fertility awareness methods were also not generally included in awareness-raising messages, so the community knew very little about their effectiveness and availability. with the information, skills, and commodities from this intervention, sdm became a viable part of the method mix. furthermore, it was available for the first time at the community level, which made access easy and cost-effective. even though sdm was the most popular among upmb clients, uptake across other methods continued to increase during the intervention. exceptions were a minimal decrease in male and female sterilization (which were already low) and a decrease in implant use during the second year of the intervention. this was most likely due to the closing of a separate program intervention that had focused on improving access to the implant in several shared sites. competency scores from fam counseling indicate that the majority of providers scored 75 percent or above across the three methods, which suggests adequate service provision. providers consistently scored the lowest on the twoday method®, which could be attributed to a number of factors including fewer opportunities for counseling practice due to the smaller number of clients opting for this method and apprehension about women monitoring signs of fertility like cervical secretions. scores among upmb providers were consistently lower than scores for providers of a similar profile at caritas rwanda and ucmb. since upmb provided the full range of methods, there were fewer opportunities for providers to practice counseling clients in fam. similarly, providers at caritas rwanda and ucmb vanenk, et al. christian journal for global health | http://www.cjgh.org www.cjgh.org july 2017 | 63 received more focused mentorship on fam during supervision visits because they did not offer the full range of methods like providers at upmb. this indicates the important role of supportive supervision across all programs, regardless of method mix. catholic health networks, in particular, have a wide reach in many african countries, but they provide few to no family planning services. the experience of ucmb and caritas rwanda reveal that offering modern fertility awareness methods presents a culturally appropriate way to contribute to national and international family planning goals. where ucmb facilities were providing very limited family planning services before, they are now able to offer multiple options. providers across ucmb’s network have shown an enthusiasm about offering these services, and the increase in use of these methods signals that clients also have a demand for natural options. a demand for fertility awareness methods was also seen across upmb sites and has been previously documented in muslim populations17, 18 signaling broad acceptability across faith communities. while chas are meeting this demand for natural methods, their contribution is not often reflected in national level statistics because the hmis does not include these methods. moreover, contraceptive forecasting relies on accurate user data from facilities as this represents demand for each method. in the case of fam, accurate user data through hmis reports is essential to advocate for cyclebeads’® inclusion in national procurement tables and integration of fertility awareness methods as part of the method mix. data reveal that one-third to one-half of clients received their method from a chw, signaling the importance of bringing family planning services closer to the user. upmb and caritas rwanda had previously offered family planning services only at the facility level. during the intervention, they saw the biggest impact from the expansion of family planning at the community level. competency scores and provider interviews confirm that chws are able and willing to offer family planning to their community, and they perceive it to be consistent with their religious beliefs. many chas have community health programs but are not currently offering family planning methods at the community level due to lack of funding and capacity. therefore, support is needed to integrate family planning into the services already being provided by chws. by and large, advancements were made toward integration of cha family planning service delivery into the national strategy. however, without a strategic investment in capacity building among chas, their family planning contribution is likely to remain minimal. family planning reporting tends to be weak across both public and cha facilities, and parallel reporting structures often exist among chas. considering the challenges of harmonizing reporting structures with the ministry of health and the absence of fertility awareness methods in the hmis, one can assume that the contribution of christian health associations is underrepresented. by strengthening cha capacity using a systems approach, their contributions can be aligned with national family planning goals such that they are considered essential partners in achieving universal access and reducing unmet need. further research is needed on the quality of family planning service provision within chas, the comparative contribution to family planning service delivery by the public sector and by chas, and the added value of engaging religious leaders in promoting healthy timing and spacing of pregnancy. limitations the source of our family planning uptake data was program service statistics. considering that providers were often overburdened and reporting structures were weak, such data was prone to errors. data quality audits were conducted in select sites throughout the intervention, but the majority of data was not verified externally. we had to assume that program service statistics sufficiently reflected intervention results. although providers at caritas rwanda and ucmb directed women who wanted to use a method that the site did not provide to a nearby facility, referral data was not collected. this should be strengthened in the future. vanenk, et al. christian journal for global health | http://www.cjgh.org 64 | christian journal for global health 4(2) www.cjgh.org conclusion in light of the present momentum to increase access to family planning through expanding options and engaging non-traditional partners, chas play an important role. there is significant untapped potential for family planning among chas. they can contribute to important increases in uptake when given a viable way to contribute to family planning goals. fertility awareness methods offer a unique opportunity to encourage the participation of catholic service delivery organizations in family planning, and they add to the choice of options women and couples receive from mixed-method settings. accurate service delivery reporting in the hmis is essential for documenting cha contributions in family planning. increased attention to strengthening and mainstreaming family planning service delivery across chas is imperative to meeting the sustainable development goals, fp2020 goals, and improving the health of women and children. references 1 rutstein so. effects of 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institute for reproductive health georgetown university; 2011. sponsored by usaid. available from: http://irh.org/wp-content/uploads/2013/04/ famprojectreport_mamansansardrc_final.pdf 18 family health international. the standard days method® in kenya’s ijara district: final results and implications for programs. nairobi: family health international; 2009. available from: https://www.k4health.org/sites/ default/files/sdm%20brief%20kenya%20110609%20 %281%29.pdf peer reviewed competing interests: none declared. acknowledgements: the authors would like to thank marie mukabatsinda (irh), janet komagum (ucmb), judith kiconco (upmb), bishop dr. anaclet mwumvaneza (caritas rwanda), agnes icyizanye (caritas rwanda), and christine uwizeye (caritas rwanda) for their help on the implementation and evaluation of this intervention. correspondence: laura vanenk, institute for reproductive health, georgetown university. lauren.vanenk@georgetown.edu cite this article as: vanenk l, et al. closing the gap: the potential of christian health associations in expanding access to family planning. christian journal for global health. july 2017; 4(2):53-65; https://doi.org/10.15566/cjgh.v4i2.164. © vanenk l this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ vanenk, et al. christian journal for global health | http://www.cjgh.org https://doi.org/10.1016/s0010-7824(02)00288-3 https://doi.org/10.1016/s0010-7824(02)00288-3 https://doi.org/10.1016/j.fertnstert.2004.03.040 https://doi.org/10.1016/j.fertnstert.2004.03.040 https://doi.org/10.1016/s0010-7824(97)00040-1 https://doi.org/10.1016/s0010-7824(97)00040-1 http://irh.org/wp-content/uploads/2013/04/famprojectreport_mamansansardrc_final.pdf http://irh.org/wp-content/uploads/2013/04/famprojectreport_mamansansardrc_final.pdf https://www.k4health.org/sites/default/files/sdm%20brief%20kenya%20110609%20%281%29.pdf https://www.k4health.org/sites/default/files/sdm%20brief%20kenya%20110609%20%281%29.pdf https://www.k4health.org/sites/default/files/sdm%20brief%20kenya%20110609%20%281%29.pdf mailto:lauren.vanenk@georgetown.edu short communications may 2016. christian journal for global health, 3(1): 89-94. community health global network and sustainable development rebekah young a , nicole hughes b , elizabeth wainwright c , ted lankester d , nathan grills e a md candidate, the nossal institute for global health, the university of melbourne, australia b research assistant at the nossal institute for global health, the university of melbourne, australia c msc, ncta, managing director, community health global network, london, uk d ma, mb, bchir, mrcgp, rcpsglasg is founder of community health global network and director of health services, interhealth, uk e mbbs, mph, dphil, associate editor, cjgh; nossal institute of global health, university of melbourne, australia introduction with the achievements, failures, and passing of the millennium development goals (mdgs), the world has turned its eyes to the sustainable development goals (sdgs), designed to foster sustainable social, economic, and environmental development over the next 15 years. 1 communityled initiatives are increasingly recognised as playing a key role in sustainable community development and in aspirations for universal healthcare. 2 in many parts of the world, faith-based organisations are some of the main players in community-led development and health care. 3 community health global network (chgn) creates links between organisations, with the purpose being to encourage communities to recognise their assets and abilities, identify shared concerns, and discover solutions together, in order to define and lead their futures in sustainable ways. 4 chgn has facilitated the development of collaborative groups of health and development initiatives called “clusters” in several countries, including india, bangladesh, kenya, tanzania, zambia, and myanmar. in march 2016, these clusters met together in an international forum to share learnings, experiences, challenges, achievements, and to encourage one another (figure 1). discussions held throughout the forum suggest that the chgn model is helping to promote effective, sustainable development and health care provision on both a local and a global scale. background the millennium development goals (mdg) led to significant achievements in addressing extreme poverty across the world, yet persistent inequality and widespread poverty endures. 5 the world has now turned its eyes to the transition from mdgs to the sustainable development goals (sdgs), designed to foster sustainable social, economic, and environmental development over the next 15 years through investments in education, health, equitable growth, and sustainable production and consumption. 1 although health and health care receive little specific attention within the sdgs, the goals illustrate an understanding that the determinants of health are complex and multifactorial, and include interactions between economic, environmental, and social factors, which contribute to the overall health and wellbeing of communities. 1,6,7 community-based and community-led approaches, in addition to policy and top-down approaches, will be important in working towards sustainable health and development in the coming years. 8 in many parts of the world, faith-based groups are some of the most active groups working at the community level to promote health and development. in a develop90 young, et al may 2016. christian journal for global health, 3(1): 89-94. ing context, local faith-based organizations can be uniquely placed to contribute to meeting the developmental needs of communities and are increasingly recognised as key contributors to sustaining progress in development. 9 however, small community organizations, such as these faith-based organizations are often ill-equipped to promote large-scale changes independently. collaborations between community organisations, and with the formal health systems, are needed if they are to play an active role working towards long term, sustainable development. community health global network the community health global network (chgn) was first conceived in 2005 after observing that many community-based organisations working in similar areas, or delivering similar health-based initiatives, lacked any formal collaboration with one another. chgn founder, dr lankester, commented that these organisations were “often not linked with other charities or local government services and (were) usually unaware that 10 miles down the track another group (were) doing almost exactly the same thing for the community they (were) serving.” 10 chgn was created out of a desire to link together community organisations and to develop low-cost, high-impact clusters for the purpose of collaboration, knowledge, and resource sharing around community health. this collaboration facilitates chgn’s ultimate goal of promoting health, wellbeing, and happiness for communities around the world. chgn recognises that through cooperation and collaboration, clusters can achieve far more for communities than any individual organisation acting on its own. 4 to be effective, clusters should be built on trusting relationships whereby diverse organisations can come together in unity to work toward shared goals and visions. chgn supports the formation of clusters as they work together for the benefit of the local community. in the several years since its initial formation, chgn has supported the formation of clusters in several countries around the world, including in india, bangladesh, kenya, zambia, tanzania, and myanmar. aside from helping to establish and support the formation of countrybased clusters, and thus locally-led health and development, an important role of chgn is to link together clusters from different countries to promote sustainable health and development on a global scale. in march 2016, representatives from each of these partner clusters met together in india for the inaugural international chgn forum to collaborate and share learning and experiences. the discussions held during this international forum highlighted how cluster-based community development can contribute to the realisation of the sdgs by promoting greater coordination between grassroots organisations, strengthening the voice of the community on important issues, and increasing integration between the community, government, and other health system players. what are the chgn clusters doing and achieving? the chgn global forum was an opportunity to bring together partners from around the world to learn from each other through the work that is taking place within each individual cluster. this three-day event held in dehradun, india was encouraging and reinforced the capacity that clusters have to contribute to achieving sustainable development. each cluster has a different focus, skill set, goals, and method of collaboration. therefore, each cluster leads different initiatives for health and development that are specific to their own cultural context. two case examples of cluster work are shown below. 91 young, et al may 2016. christian journal for global health, 3(1): 89-94. case example 1: the kenya cluster since its formation in 2014, the kenya cluster has worked with its member organisations to coordinate health care delivery. through the development of sub-clusters in different locations throughout kenya, the group has worked to foster relational collaboration despite the fact that member organisations are geographically dispersed. the cluster has been involved in a variety of different community-based interventions including training community health workers who are able to provide sustainable, low-cost health care. they have also been involved in health promotion and education activities by engaging with community organisations such as schools and training institutions. through these networks, the cluster has provided education around reproductive health and hiv. the cluster has also focused on disability awareness and youth empowerment. case example 2: the uttarkhand cluster the uttarakhand cluster in north india is the oldest and most well-established cluster involved in chgn. formed in 2008, the uttarakhand cluster now comprises 50 partner organisations and is involved in a range of different activities including disability inclusion, mental health education, tobacco control, and disaster relief. in 2013, the cluster mobilised its resources to respond to the north indian floods, providing relief and assistance to over 600 villages. because of its reach and reputation, the uttarakhand cluster has been contracted by the indian government to provide services on a local scale. approaches to promoting collaborative capital feedback from the participants at the international forum highlighted the importance of common values in promoting cooperation. in some clusters, it was reported that a common faith background between organisations was a strong platform for relational collaboration within the cluster. the idea of trust and unity between organisations was identified as being key to developing effective collaboration and repeatedly emerged as playing a key role in making chgn what it is. chgn cluster representatives identified that because of their shared values, organisations within clusters were able to quickly develop trusting relationships with one another. this trust was built on an understanding that each contributor shared a common vision to work together for the benefit of the other rather than for the benefit of self. members identified that their clusters differed from many other community-led initiatives in terms of their approaches (i.e., a relational and collaborative approach) and achievements (i.e., clusters reported achieving changes in community health where other organisations had not in the past). they described the importance of sharing ideas with each other to increase capacity in their individual programs. they also described examples where coming together had facilitated their work with the government on programs such as disability and tobacco control, as in the case of the uttarakhand cluster. sharing experiences such as these encouraged the smaller and newer clusters to consider how they could better integrate with the government health and development activities within their country. a number of the clusters shared that they are more effective when each organisation contributes its own strength to the common program. some cluster members described their function with reference to 1 corinthians 12:12 as a body that has many parts but comprises a unified whole. 11 this imagery encapsulates the belief that each individual part (i.e., each member organisation or individual contributor) may have a different function, but each is valuable and necessary for the body (i.e., the whole cluster and 92 young, et al may 2016. christian journal for global health, 3(1): 89-94. chgn) to function. recognising the unique role and worth of each contributor allows organisations to work together rather than competing with one another. cooperation between clusters, and within clusters, was usually very open, with resources and knowledge being freely shared for the benefit of cluster communities and the chgn body as a whole. new ways forward chgn is currently exploring how better to engage with non-faith based organisations, or indeed organisations of diverse faith backgrounds, without compromising the trust and common values that have been integral to a number of the clusters’ functioning. some clusters, such as those in africa, are predominantly made up of christians, but also have non-christian members involved. if the ultimate goal of chgn is to promote the development of holistic health and wellbeing around the globe, it must continue to seek innovative and appropriate ways to engage and partner with all types of organisations, regardless of their faith background. during the forum, chgn explored the formation of three additional new clusters: nepal, the mekong region, and bihar (india). champions for these clusters attended the forum and were able to glean important information to help them as they go forward. drawing on their personal experiences and the evidence generated on cluster formation, members from other clusters and the chgn hubs in the uk and australia committed to helping these clusters form and grow. 10,12 this cluster mentoring was seen by the forum participants as an important way to facilitate new clusters to grow and effectively cooperate. this nurturing of new clusters is also consistent with the chgn vision and clustering model. to encourage sharing between different clusters, it was recommended that communication and social media be more effectively utilised. face-to-face interaction, however, was seen to be the most important medium to build collaboration between groups; therefore, annual regional forums and international forums every two to three years were recommended. regular collaboration between clusters from different countries appears to be an effective way of extending the work of clusters from a local to a global scale. conclusions and summary of learning from the chgn forum  cluster formation at the community and primary care level provides a sustainable model for development and health-care provision, where local organisations formally link with one another for the purposes of collaboration, resource, and knowledge sharing.  a common geographical and value system and a recognition that more can be achieved by working together, provides a unique platform for diverse organisations to come together in a collaborative relationship based on trust.  existing clusters and the chgn hubs in the uk and australia need to play a facilitating role in the formation of new clusters in other areas and countries.  improved inter-cluster communication is required and should be promoted through email groups, social media, and face-to-face meetings. references 1. united nations development programme. a new sustainable development agenda 2016 [internet]. available from: http://www.undp.org/content/undp/en/home/sdgovervie w.html 2. walley j, tinker a, de francisco a, chopra m, rudan i et al. primary health care: making alma-ata a reality. the lancet. 2008;372(9642):1001-7. http://dx.doi.org/10.1016/s0140-6736(08)61409-9 http://www.undp.org/content/undp/en/home/sdgoverview.html http://www.undp.org/content/undp/en/home/sdgoverview.html http://dx.doi.org/10.1016/s0140-6736(08)61409-9 93 young, et al may 2016. christian journal for global health, 3(1): 89-94. 3. grills, n. 'believing' in hiv: the effect of faith on the response of christian faith based organizations to hiv in india. [doctor of philosophy]. nd. 4. community health global network (chgn). collaborative networking for community health. 2014 [cited 2016 30/04/2016]. available from: www.chgn.org 5. united nations. mdg gap task force report. 2015 contract no.: ibsn 78-92-1-101317-7. 6. united nations development policy and analysis division (desa). un system task team on the post2015 un development agenda 2012 [internet]. available from: http://www.un.org/millenniumgoals/pdf/think pieces/8_health.pdf 7. marmot m, houweling t, taylor s. closing the gap in a generation: health equity through action on the social determinants of health. the lancet. 2008;372(9650):1661-9. http://dx.doi.org/10.1016/s0140-6736(08)61690-6 8. blas e, gilson l, kelly mp, labonté r, lapitan j and muntaner c et al. addressing social determinants of health inequities: what can the state and civil society do? the lancet. 372(9650):1684-9. http://dx.doi.org/10.1016/s0140-6736(08)61693-1 9. the lancet series on faith and global health. the lancet. 2015;386(10005). http://dx.doi.org/10.1016/s0140-6736(15)60250-1 10. safe m, wainwright e, lankaster t. community health global network: "clustering" together to increase the impact of community led health and development. cjgh. 2014;1(2):71-80. http://dx.doi.org/10.15566/cjgh.v1i2.9 11. 1 corinthians. in: the holy bible: english standard version. illinois: good news publishers. 12. grills n, philip m, porter g. networking between community health programs: a team-work approach to improving health service provision. bmc health services research. 2014;14(1). http://dx.doi.org/10.1186/1472-6963-14-297 figure 1. community health global network international forum may 2016 competing interests: none declared. http://www.chgn.org/ http://www.un.org/millenniumgoals/pdf/think%20pieces/8_health.pdf http://www.un.org/millenniumgoals/pdf/think%20pieces/8_health.pdf http://dx.doi.org/10.1016/s0140-6736(08)61690-6 http://dx.doi.org/10.1016/s0140-6736(08)61693-1 http://dx.doi.org/10.1016/s0140-6736(15)60250-1 http://dx.doi.org/10.15566/cjgh.v1i2.9 http://dx.doi.org/10.1186/1472-6963-14-297 2 young, et al may 2016. christian journal for global health, 3(1): 89-94. correspondence: for more information on chgn please see www.chgn.org, or contact elizabeth.wainwright@chgn.org or grills@unimelb.edu.au cite this article as: young, r, hughes, n, wainwright, e, lankester, t, grills, n. community health global network and sustainable development. christian journal for global health (may 2016), 3(1):89-94. © young, r et al this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.chgn.org/ mailto:elizabeth.wainwright@chgn.org mailto:grills@unimelb.edu.au http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ field report may 2019. christian journal for global health 6(1) dignity and right to health award: icmda leadership in christian health and development initiative kaaren mathiasa and michael burkeb a mb chb, mph, fnzcphm, public health physician and project director of burans community mental health project and program manager in mental health for the emmanuel hospital association, india b mbbs bsc ma mph&tm, msc (clin epi) phd fracgp factm faicd, executive officer, healthserve australia, and co-joint associate professor, western sydney university, australia the dignity and right to health award (drh) is an activity of the international christian medical and dental association (icmda) leadership in christian health and development initiative. the who constitution (1946) envisages “... the highest attainable standard of health as a fundamental right of every human being.” the drh award is an international award acknowledging the contributions of christian doctors, dentists, nurses, and other health workers who address health and development issues including hiv. the award recognises, supports, and publicizes the most outstanding role models and champions acting to address health and development issues including the hiv global epidemic. it is an important symbol to ensure that voices from diverse communities and countries are acknowledged and championed. the drh award aims to model and encourage creative and sustainable ways that individuals and organisations enhance the dignity and human rights of people all made in the image of god in diverse settings, including the hiv/aids epidemic. the award commenced in 2006 at the icmda (http://icmda.net/) world congress in sydney, australia. from 2006 to 2011, it was called the dignity and right to health award of the icmda hiv initiative. since 2012, the scope of the award has been broadened beyond hiv activities, while still maintaining the initial scope. as an annual award, a diverse range of individual and community groups from nearly all continents of the world have been nominated. the award is overseen by an international award committee of diverse practitioners. the award is given to individuals and/or community-based and national organisations for excellence, outstanding leadership, and compassion in responding to various health challenges. the award seeks nominees who demonstrate the following four criteria: criteria 1. leadership demonstrated visionary and innovative leadership. criteria 2. target group: marginalised or hard to reach communities provision of health services for communities who have difficulties in accessing care due to ethnicity, caste, behaviour, and/or other reasons, or are hard to reach due to geographical difficulties, violence, or conflicts. criteria 3. program outcomes • impacts significantly at local and wider levels. • empowers others in integrated community responses. • facilitates church integration and participation in best practice models of care. • demonstrates excellence in full community 87 mathias & burke may 2019. christian journal for global health 6(1) involvement and empowers the target communities. • works, facilitates, and advocates for gender equality in community participation, and provides response to issues faced by the target communities. • links well with government and other actors in a comprehensive approach to issues faced by the target communities. • models creative and compassionate responses that inspire many to similarly enhance the dignity and human rights of the target communities. criteria 4. personal life • exemplifies a life that does justice, loves kindness, and walks humbly with god, and • assists individuals to be worshipers of the living god. an important part of this award process is to seek appropriate publicity that will allow christian witness and action to be an encouragement and model to others. the 2017 drh winner was the burans community mental health project from the state of uttarakhand, north india. this program is part of other activities of the wider emmanuel hospital association (eha). “burans” is the local name for the rhododendron, an evergreen shrub or small tree with a showy display of bright red flowers. it is the state flower of uttarakhand, north india. burans is a partnership project led by eha (www.eha-health.org), working with the uttarakhand community health global network (chgn) (http://www.chgnukc.org/), and started in 2014. the context is one where mental health disorders contribute to 11.8% of the indian disease burden, yet mental health services are allocated less than 1% of the national health budget. uttarakhand has one specialist psychiatric hospital and seven government psychiatrists for a population of more than ten million. burans works in five communities of the dehradun district (uttarakhand, north india) with a total population of 80,000 people, with teams of employed staff and community volunteers seeking to build community knowledge, safe social spaces, and partnerships for action. as a team, burans has deliberately chosen communities that are systematically disadvantaged and socially marginalised, including a peri-urban area in temporary housing on the edges of an open drain, a rural muslim area, and a slum area with very high numbers of people from the most oppressed castes. the gospel mandate for social inclusion (illustrated in jesus’ intentional attention to migrants, women, children, people with stigmatizing disabilities like leprosy, and epilepsy-type symptoms) is something that burans tries to reflect in their team composition; for example, seeking gender equality in leadership as well as representation of oppressed castes and excluded religious minorities. burans uses an outcome mapping framework. the broad project vision statement is: communities in uttarakhand state welcome all people, including those who are mentally distressed. they use their knowledge and skills to remain mentally healthy as well as support others. people with mental disorders participate in all aspects of family and community life, and can access effective and well-resourced health services. they are supported by resources, knowledge and skills that they need to live life to the full.1 burans collaborates with key stakeholder groups seeking to strategically influence attitudes, behaviour, and relationships related to mental health. in particular, people with psycho-social disability (ppsd), caregivers of those with ppsd, community leaders, and community-based government functionaries. the burans team has set an “outcome challenge” for each stakeholder group which describes ideal behavior, relationships, and attitudes. details on the burans program, methods, and outcomes are provided in a case study publication.2 the team has had a focus on robust documentation. an early baseline survey performed by the team demonstrated the importance of social determinants as risk for 88 mathias & burke may 2019. christian journal for global health 6(1) mental ill-health which received significant media attention. 3,4 a further study showed that people with ppsd are socially distanced and excluded.5 they also collaborated with members of the chgn team to demonstrate the multiple barriers to participation for ppsd in dehradun.6 in response to these findings, the teams focus on helping community members to know “life to the full.” for example, burans developed an initiative to increase social inclusion among young people affected by ppsd, and this successfully increased mental health and social participation, and reduced behavioural difficulties for those participating.7 burans' key achievements to date include: • identifying more than 1,250 people with ppsd and supporting their recovery with counselling, psycho-social support groups, and access to mental health services. some have dramatic stories of improvement (reintegrating into family and community life). • systematically documenting process evaluations and learnings in formats that are shared with the broader community, health and christian communities.8-10 • delivering an emotional resilience curriculum for girls at government schools and girls who have dropped out of school.11 • training in mental health for 150 community health and development workers from christian ngos, 400 church members, and over 1,000 government community health workers. • developing educational resources about mental health in hindi and english (https://projectburans.wixsite.com/burans/re sources). • partnering with the uttarakhand department of health in an implementation research project funded by who seeking to promote access to primary epilepsy care. burans is a project that has made significant progress in promoting mental health and social inclusion in uttarakhand, using robust documentation and partnership with the government, faith-based organisations, and others to increase dignity and right to healthcare for many people in the community with mental health problems. the drh award seeks to share stories of inspiration and imagination. these demonstrate excellence in service by individuals or organisations. christianity, from the time of its founding to its current time, has exemplified a compassionate commitment to justice and mercy within health initiatives. the award is publicised in the latter part of each year. a committee of reviewers oversees the process. nominations are warmly welcomed. (see https://www.healthserve.org.au/icmda-hivinitiative.html ). references 1. earl s, carden f, smutylo t. outcome mapping. building learning and reflection into development programs. ottawa: international development research center. 2001. 2. mathias k, mathias j, goicolea i, kermode m. strengthening community mental health competence — a realist informed case study from dehradun, north india. health soc care comm. 2017;00:1-12. 3. the indian express. inequality driving mental health problems in uttarakhand. the indian express. 2016. 4. mathias k, goicolea i, kermode m, singh l, shidhaye r, sebastian ms. cross-sectional study of depression and help-seeking in uttarakhand, north india. bmj open. 2015;5(11). https://doi.org/10.1136/bmjopen-2015-008992 5. mathias k, kermode m, goicolea i, seefeldt l, shidaye r, san sebastian m. social distance and community attitudes towards people with psychosocial disabilities in uttarakhand, india community ment hlt j. 2017. 6. mathias k, pant h, marella m, singh l, murthy g, grills n. multiple barriers to participation for people with psychosocial disability in dehradun district, north india: a cross-sectional study. bmj open. 2018;8(2). https://doi.org/10.1136/bmjopen2017-019443 https://www.healthserve.org.au/icmda-hiv-initiative.html https://www.healthserve.org.au/icmda-hiv-initiative.html https://doi.org/10.1136/bmjopen-2015-008992 https://doi.org/10.1136/bmjopen-2017-019443 https://doi.org/10.1136/bmjopen-2017-019443 89 mathias & burke may 2019. christian journal for global health 6(1) 7. mathias k, singh p, butcher n, grills n, kermode m. promoting social inclusion for young people affected by psycho-social disability in india — a realist evaluation of a pilot intervention. under review global health. 2018. 8. mathias k. small steps — context, learning and models of community and primary mental health in north india. medico friends circle bulletin 2015;365-6(march-october 2015). 9. mathias k. shadows and light — examining community mental health competence in north india. umea, sweden: umea universitet; 2016. 10. mathias k. community based responses to noncommunicable diseases. medico friends circle bulletin. 2017(373-74). 11. mathias k, pandey a, armstrong g, diksha p, kermode m. outcomes of a brief mental health and resilience pilot intervention for young women in an urban slum in dehradun, north india : a quasiexperimental study. int j ment health sy. 2018. https://doi.org/10.1186/s13033-018-0226-y submitted 29 jan 2019, accepted 13 feb 2019, published 31 may 2019 competing interests: none declared. correspondence: michael burke, executive officer, healthserve australia, and co-joint associate professor, western sydney university, australia. michael.burke@kildaremedical.com.au cite this article as: mathias k, burke m. dignity and right to health award: icmda leadership in christian health and development initiative. christian journal for global health. may 2019; 6(1):86-89. https://doi.org/10.15566/cjgh.v6i1.277 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1186/s13033-018-0226-y https://doi.org/10.15566/cjgh.v6i1.277 http://creativecommons.org/licenses/by/4.0/ book review may 2019. christian journal for global health 6(1) such a time of it they had global health pioneers in africa, by raymond downing, manqa books, nairobi, 2018 christoffer h grundmanna a mth, dth, professor, religion and the healing arts, valparaiso university, indiana, usa. the book under review here is written by a seasoned global health care worker (of apparently mennonite background [p. 2;80]) stationed in kenya, adamantly advocating genuine solidarity with the people with whom one engages to secure the success of any such venture. downing, now in his seventies, is an american family practitioner who, together with his wife (a family practitioner, too, but also a pediatrician [p. 118]) has spent his entire professional career in serving underprivileged communities in the us (appalachia; indian reservations in arizona) and africa (sudan, tanzania, and kenya). while writing this book, his sixth, he served as senior lecturer in the department of family medicine at moi university medical school, eldoret, kenya (p. 309). contrary to its subtitle and the writer’s explicit intention to present “a window into the time our forbearers had... in africa” so to provide “a biopsy of the past” and “a sampling of what global health was like in the beginning” (p. 7) insinuating biographical sketches of noteworthy individuals, the book is anything but just that. it, rather, is a complex, multi-layered composition of well told stories of things past (in plain print) interspersed with autobiographical snap-shots of the author’s own life (in bold) while at the same time pondering issues of principle regarding global health and questioning not only today’s practices but biomedicine, too. there is rigorous self-examination and frank sharing of personal failures (p. 92f; pp. 152–154) though not in an exhibitory fashion but owed to the resolve to deconstruct the hero image medical missionaries often garner (dedication; p. 183) and the author’s conviction that one does not “really feel the hypocrisy until it becomes personal” (p. 40). every bit of this paperback is carefully considered: the african publisher, the title (taken from a poem by malawian david rubadiri [given in full in the front matter]), and the design of the yellow cover, which shows a pith helmet in the upper right margin as an acronym for global health in times gone by, and an upwards pointing syringe replacing the i of the “it” in the center of the book’s title, referencing not only biomedicine but indicating also pricks one should be prepared to receive when reading. the introduction (pp. 1–9) is preceded by 6 unpaginated leaves of front matter (dedication, 3 murky maps of “africa as seen by europe” in 1880, 1900, and 1950, and the poem stanley meets mutesa by d. rubadiri), while the conclusion (pp. 298–310) is followed by acknowledgements (pp. 311–312), chapter notes (pp. 311–318), and bibliography (pp. 319–333). the introduction and conclusion bracket nineteen chapters of chronologically arranged historical vignettes beginning in the early nineteenth up to the middle of the twentieth century with the dutch physician t. van der kemp (1747–1811) who worked in south africa (chap. 1), and a. schweitzer (1875–1965) stationed in gabon (chap. 19) as “bookends” (p. 284). in between these unfolds a plethora of stories about foreign “global health 99 grundmann may 2019. christian journal for global health 6(1) heroes”/heroines and foreign “global health villains” (dedication) who worked in africa, including an account of the development of tropical medicine in america (chap. 12) and of the work of philanthropic agencies engaged in programs on that very continent (chap. 14). however, the stories are not “a random sample.” they, rather, “provide mirrors to us of our own global health” attitudes (p. 9) since they illustrate the drive for exploration and adventure (d. livingstone, chap. 3 & 4), for pursuing one’s own or a donor driven agenda (chap. 5), for dwelling “like gods” (chap. 10), and for “making a name” (chap. 13). other chapters feature the craving for promoting science (chap. 11), for “winning hearts and minds” (chap. 15), and for “slaying superstition” (chap. 17). exposing these and like motives subtly at work in many global health care programs, downing persuasively drives his point home: while almost everyone engaged in global health honestly wants to solidarize with the disadvantaged through sharing of resources and volunteering time and expertise, it is a lack of discourse about the meaning of solidarity which causes what “we often get... wrong” (p. 16). the “legacy” of misconceived solidarity with “africa is a thundering silence” (p. 297), which so enrages the passionate author that he bursts out decreeing, “as long as solidarity remains unexamined, we will continue to try to marry africa and end up f[…] it” (p. 303), that is: to abuse and mistreat it. he does not leave it there, though. in the conclusion, presumably that part of the book where readers will experience several uncomfortable pricks, he finally examines solidarity in more detail. the reason that “dreams of public health and social medicine... often fail” (p. 301) has, first, to do with not really grasping the impact of scientific biomedicine on which such dreams are based. biomedicine is an effective “means of control” (p. 299; original emphasis), be it in designing and monitoring health programs, in treating patients, or when conducting research. since controlling all the variables makes for biomedicine’s success, “god and ritual and ancient wisdom” must be excluded (p. 59), an aspect not realized by many medical missionaries who carried on the work without losing their faith because “they simply fenced it off” (p. 299), a no-go for downing. claiming to know what the issues are and how to resolve them effectively makes “expatriate do-gooders” (p. 5) every so often to “fight the wrong battle” (p. 300), and when they set priorities, which are not such for indigenous local populations, “the massive power of biomedicine” becomes “either dangerous or reduced to smoke and mirrors” (p. 300). however, the actual reason for the failure of many well-intending global health programs is a rampant misconception of solidarity, which “now in the secular humanitarian nongovernmental organization world” stands for “compassionate feelings” (p. 307) producing an infuriating attitude “that reaches down or imitates” instead of being “close enough to people and powerless enough to be infuriated” (p. 298). while being fully aware that “attempts... at solidarity can be pathetic” and that “solidarity with africans does not fix things,” downing still holds on to it because it is “a start” (p. 303) even though “today in global health our selfimposed mandate does not include living with people, sharing their lives and problems“ (p. 301f; original emphasis). living with people is not confined to learning the local language or riding local buses, but requires full immersion into “the reality that is there, and allowing that reality to inform our response” (p. 298), which might also “mean working in a corrupt government agency... or watching an acquaintance die because the local hospital doesn’t have enough iv fluids or nurses.” hence, solidarity “implies ‘suffering with,’” as well, which, in fact, is “the literal meaning of compassion” (p. 304). solidarity thus lived not only clarifies the perception of reality “as much for us as . . . for them” (p. 303f; original emphasis). such “suffering of solidarity,” which “doesn’t try to explain itself, 100 grundmann may 2019. christian journal for global health 6(1) doesn’t seek results, does not vaunt itself” (p. 26) can also “be redemptive” for all (p. 307). failuredoomed compassionate feelings attempt to fix problems “by some secular alchemy,” biomedicine, without the “pain of solidarity.” even though this makes the “old painful suffering solidarity,” which according to “classic christianity... is redemptive” and looks “outdated” (p. 307), “true solidarity” (p. 26) does not get achieved otherwise. such a time of it they had is a worthwhile, stimulating reading, and it is a very entertaining one, too. its author delights in telling stories in an easygoing style. sometimes, however, he gets carried away, occasionally at the expense of historical accuracy or drawing unwarranted conclusions like speaking of the “bellicose inauguration of tropical medicine” as “the beginning of ... global health” (p. 8) and “we like wars because they are defining moments” (p. 94), to name only two. yet, the reviewer strongly recommends this book to all engaged in global health for clarifying their personal motivations and purifying their commitment to solidarity for the benefit of global health. submitted 22 mar 2019, accepted 10 april 2019, published 31 may 2019 competing interests: none declared. correspondence: cristoffer h grundmann, former professor, religion and the healing arts, valparaiso university, indiana. now in germany. christoffer.grundmann@valpo.edu cite this article as: grundmann ch. raymond downing, such a time of it they had global health pioneers in africa, manqa books, nairobi, 2018. christian journal for global health. may 2019; 6(1):98-100. https://doi.org/10.15566/cjgh.v6i1.293 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ original article nov 2016. christian journal for global health, 3(2): 91-106. maternal and child health from a human rights perspective: the indian scenario and nuns as community health enablers tomi thomas a , anto maliekal b a phd, former director general, the catholic health association of india (chai), india. b phd, the catholic health association of india (chai), india. abstract all women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. this discussion tries to look into the life context of maternal and child health, and the health scenario of women/girl children in general in india from the perspective of human rights. currently, most of the public and private health experts and organizations do not talk and act on the human rights perspective of health service delivery. reversely, only a very few rightsbased organizations advocate directly the right to health for the marginalized. within the framework of a rights-based approach, the right to (maternal) health on practical terms means “availability, accessibility, acceptability and quality.” concluding, in the background of the catholic health association of india (chai), the discussion also focuses on how the nun nurses play their role as “community health enablers” to improve the situation. introduction all women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. in spite of the committed efforts by who, the state parties and other stakeholders, the preventable maternal and infant/children mortality is unacceptably high across the developing countries. only 51% of women in low-income countries benefit from skilled care during childbirth. 1 this discussion tries to look into the context of maternal, and child and female health in india in general from the perspective of human rights. currently, most of the public and private health experts and organizations do not talk and act on the human rights perspective of health service delivery. reversely, only a very few rights-based organizations advocate directly the right to health for the marginalized. the present discussion on this discriminating life context includes inadequate maternal and child health services, obstetrics abuse, child/early marriage, epidemic of sex selection and abysmal child sex ratio, malnutrition, hiv, tb, disability, social determinants of health, etc. also, we take a brief look at the negative impact of climate change and environmental pollution, exploitation of women in surrogacy, maternal mental health, and so on. 92 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. as christian teaching and various international treaties emphasize, human rights are universal, inviolable and inalienable. within the framework of a rights-based approach, the right to (maternal) health on practical terms means “availability, accessibility, acceptability, and quality.” 2 it also means participation and inclusion, equality and non-discrimination, and accountability from the part of the duty bearers (responsible parties), especially the government which has to respect, protect, and fulfill its obligations with respect to the right to health. 3 concluding, in the context of the catholic health association of india (chai), the discussion also focuses on how nun nurses play their role as “community health enablers” to improve the situation. maternal and child health: indian context mothers and children not only constitute a large group, but they are also the most vulnerable in a developing country like india. women of childbearing age (15-44years) constitute 22.2% and children under 15 years of age about 35.3% of the total population, and together they constitute 57.5% of the population. 5 according to the latest report of india’s sample registration system (srs), the maternal mortality ratio (mmr), in the period 2011-13 has declined to 167 per 100,000 live births from 212 in 2007. 6,8 the advance is largely due to key government interventions such as the janani shishu suraksha karyakaram (which encompasses free maternity services for women and children, a nationwide scale-up of emergency referral systems and maternal death audits, and improvements in the governance and management of health services at all levels) and other schemes and measures. 6,7,8 the primary causes of maternal deaths are hemorrhage (mostly bleeding after childbirth), hypertension during pregnancy (pre-eclampsia and eclampsia), sepsis or infections, and indirect causes mostly due to complications caused by pre-existing medical conditions and pregnancy. 47 apart from these, the other determinants, such as, early marriage and child bearing, low literacy, economic constraints, and cultural misconceptions may also influence maternal mortality. the main causes of infant mortality in india are perinatal conditions, respiratory infections, diarrhoeal diseases, other infectious and parasitic diseases, and congenital anomalies. 52 various steps taken by india have reduced maternal and infant mortality (figure 1). the advance is largely due to key government interventions. programs like the janani suraksha yojana, that pays pregnant women to give birth in health facilities and health workers for bringing them in, have pushed up institutional deliveries from 40% to about 80%. 11 lal mohan, a daily wage labourer, has no clue what took his wife’s life. sarita devi, 25, was expecting her third child and was on her way to a good hospital at bhagalpur district in bihar. “she was normal all through the nine months of pregnancy,” he says. “when labour pains began, we took her to a community health centre (chc), 15 km from our house in the godda district in jharkhand. at around 11 pm, doctors advised us to take her to sadar hospital, 20 km from the chc. here again, doctors referred her to jawaharlal nehru medical college and hospital in bhagalpur, another 70 km away.” she passed away on the way to hospital. all safe motherhood programmes of the government are focused on institutional deliveries, but health centres are in disarray. 4 93 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. figure 1. key steps taken by the indian government to reduce maternal and infant mortality however, these measures did not result in a proportionate reduction of maternal mortality in the country. as per the world health statistics (whs) 2016, the mmr of india is 174. 47 taking this whs 2016 estimate and a birth cohort of around 26 million per year in india into consideration, one can reasonably estimate that nearly 45,000 women die due to childbirth-related causes every year in india. that means nearly five women die every hour in india from complications developed during childbirth with heavy blood loss caused by hemorrhage being a major factor. 48 according to the sample registration system (srs) 2013, an estimated 1.26 million children under the age of five die in india every year, i.e., nearly 3,500 children under 5 die in india every day. the under-five mortality rate (u5mr) is 49 per 1000 live births (with imr at 40 – children dying within one year of birth). fifty-seven per cent of under-five deaths occur in the neonatal period, which is within the first 28 days of life, [i.e., 718,200 newborns die within the first four weeks of birth every year in the country]. the major causes being prematurity and low birth-weight, neonatal in a written reply to lok sabha by shri j p nadda, the union minister for health and family welfare, govt. of india, highlighted the following key steps taken by the government of india to accelerate the pace of decline in maternal and infant mortality 6,8 :  promotion of institutional deliveries through janani suraksha yojana (jsy)  janani shishu suraksha karyakaram (jssk) operationalization of sub-centers, primary health centers, community health centers, and district hospitals for providing 24x7 basic and comprehensive obstetric care, neonatal, infant, and child care services  mother and child protection card in collaboration with the ministry of women and child development to monitor service delivery for mothers and children  mother and child tracking system  identifying the severely anaemic cases of pregnant women at sub centres and phcs for their timely management  maternal death review (mdr)  establishing maternal and child health (mch) wings at high caseload facilities  ifa supplementation programme  capacity building of health care providers and setting up of skill labs  prevention of post partum hemorrhage (pph) through community-based advance distribution of misoprostol by ashas/anms for high home delivery districts  emphasis on facility-based newborn care, i.e., special new born care units (sncus), newborn stabilization units (nbsus), and newborn care corners (nbccs) at different levels to reduce child morbidity and mortality  launch of india newborn action plan (inap) with an aim to reduce neonatal mortality and stillbirths to single digit by 2030  vitamin k injection at birth, antenatal corticosteroids for preterm labour, kangaroo mother care and injection gentamicin to young infants in cases of suspected sepsis to reduce newborn mortality  diagnosis & management of gestational diabetes mellitus and hypothyroidism during pregnancy to reduce maternal mortality and morbidity  de-worming during pregnancy, maternal near miss review, screening for syphilis during pregnancy, and dakshata guidelines for strengthening intra-partum care  home-based newborn care through ashas to improve newborn practices at the community level, and early detection and referral of sick, new-born babies  integrated action plan for pneumonia and diarrhoea (iappd) launched in four states with highest infant mortality (up, mp, bihar, and rajasthan)  nutritional rehabilitation centres (nrcs) for management of severe acute malnutrition in children  promotion of appropriate infant and young child feeding practices  village health and nutrition days in rural areas  universal immunization programme (uip) to protect children against seven vaccine preventable diseases  mission indradhanush has been launched in 201 high focus districts to fully immunise more than 8.9 million children  rashtriya bal swasthya karyakram (rbsk) for health screening and early intervention services to all the children in the age group of 0-18 years, etc 94 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. infections, birth asphyxia, and birth trauma. the major causes of under-five deaths in post-neonatal period are pneumonia and diarrhea. 9 india has the highest number of child deaths in the world, with an estimated 1.2 million deaths in 2015 — 20 per cent of the 5.9 million global deaths. 10 obstetric violence the fact is that obstetric abuse is not limited to remote villages or distant towns, it happens quite often in big cities as well. there are instances where the pregnant women were forced to deliver on the floor even though beds were available at the public primary health centres as the attendants reportedly did not want to deal with soiled sheets. pregnant women are beaten up badly and, worst of all, the doctors feel it was justified. women face varying degrees of obstetric violence in most settings. but the worst is the treatment meted out in government hospitals to the poor and most vulnerable population, people who cannot stake a claim to their rights and who do not know their entitlements. it is made worse by a culture of impunity, where health providers know they will get away with it. 11 a study published in june 2015 which analyzed 65 studies from 34 countries, including india, categorized the abuse into seven domains: physical abuse (e.g., slapping or pinching); sexual abuse; verbal abuse such as harsh or rude language; stigma and discrimination based on age, ethnicity, socio-economic status, or medical conditions; and loss of autonomy. 11 there exists a distinct class bias towards the vulnerable women from socially and economically excluded communities/families in labor rooms. while the doctors are being extremely decent with patients in their private practice, the same health professionals proceed to shout and use crude language to abuse their patients in government hospitals. commenting on the untold obstetric abuse, the madhya pradesh high court in one of its judgments had to state the obvious — "a woman's right to survive pregnancy and childbirth is a fundamental right." 11 child/early marriage — a rights violation and a primary cause for unacceptable levels of imr and mmr child marriage is a violation of child rights and has a negative impact on physical growth, health, mental and emotional development, and education opportunities. it also affects society as a whole since child marriage reinforces a cycle of poverty and perpetuates gender discrimination, illiteracy, and malnutrition as well as high infant and maternal mortality rates. 12 in india, almost half of all girls between 20 and 24 years marry before the legal age of 18 years. they become pregnant as adolescents. one in six girls begins childbearing between the ages of 15 and 19 years. early pregnancy increases the risk of delivery complications and maternal and child mortality. the infant mortality rate is 76 per cent for women aged less than 20 years, compared with 50 per cent for women aged 20-29 years. 12 epidemic of sex selection and abysmal child-sex ratio a revealing cross-cutting fact running through data about children perhaps is the neglect of and discrimination against the girl-child — be it in mortality, morbidity, and nutrition — on account of misguided and unacceptable socio-economiccultural-religious factors. in spite of the much trumpeted economic prosperity in the country, the epidemic of sex selection is still on the rise due to male child preference on account of socialeconomic-cultural-religious factors. the decline of child-sex ratio (age group of 0-6 years) is sharper, recording a decline from 945 girls for 1000 boys in 1991 to 914 in 2011. 13 india’s declining child-sexratio indicates that girls are increasingly being aborted, killed (infanticide), or otherwise dying due to gender biased neglect. more than 50 million 95 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. women have been systematically exterminated from india’s population in three generations, through the gender-specific infliction of violence in various forms, such as female feticide through forced abortions, female infanticides, dowry murders, and honor killings. 14 a bride was murdered every hour over dowry demands in 2010, according to india's national crime records bureau. 15 according to 3 rd national family health survey (nfhs) data, 56% adolescent girls (15-19 years) are malnourished and anemic, as compared to 30% adolescent boys. 16 adverse impact of climate change and environmental risks evidence has shown that climate change will affect the distribution and quality of india's natural resources, which will ultimately threaten the livelihoods of the most poor and marginalized population, especially those engaged in agriculture and its allied sectors. among the marginalized population, the adverse impact of climate change more greatly affects women and girls, especially in rural areas, excluding them from opportunities like education and equal participation in development. 17 indoor and outdoor air pollution together cause about one-fifth of the global mortality from stroke and ischemic heart disease, and more than one-third of deaths from chronic obstructive pulmonary disease. 18 indoor air pollution causes significant global mortality and morbidity among women and children below 5 years of age. they are regularly exposed to high levels of indoor air pollution in cramped rooms — exposed to use of biomass fuels, including wood, animal dung, or crop residues, that produce particulates, carbon monoxide, and other indoor pollutants. add to this the uncontrolled use of artificial manure and pesticide, adulteration and poisoning of the food thus produced pose serious health risks, especially to children. this brings into context, the relevance of the recent discussions from various quarters on not just the right to food, but the right to good food for all, which is also a matter of equity. hiv, tb and gender discrimination the total number of people living with hiv (plhiv) in india is estimated at 2.1 million in 2015 as compared with 2.2 million in 2007. two-fifths (40.5%) of total hiv infections are among females, while children (<15 years) account for 6.54%. 19 when compared to men affected/infected with hiv/aids, women and girl children suffer more from the negative social (education, family, and institutional care), economic, psychological/ emotional (stigmatization and discrimination), health (nutrition), and medical (life prolonging drugs) impact of hiv/aids. disclosure of women’s hiv status is likely to cause abuse or abandonment by their families and loss of their rights to children and property. 20 according to the 2014 who, global tuberculosis report, india has the highest burden of tuberculosis, with an estimated 2.16 million cases out of a global incidence of 9 million. despite its prevalence, the stigma surrounding tuberculosis is such that patients, especially women, often delay or deny themselves treatment even after diagnosis. the stigma around the disease is so strong that women detected with or suspected of having tuberculosis have been abandoned or even ostracized by their families. 21 gender discrimination, in addition to directly affecting vulnerability to tb and access to tb services, can deny girls and women access to education, information, and various forms of economic, social, and political participation, that can increase health risk. 22 people with disabilities a 2004 survey in the state of orissa found that virtually all of the women and girls with disabilities were beaten at home, 25 per cent of women with intellectual disabilities had been raped, and 6 per cent of women with disabilities had been http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2882973/ http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2882973/ 96 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. forcibly sterilized. 23 girls with disabilities are also less likely to get an education, receive vocational training, or find employment than boys with disabilities or girls without disabilities. exploitation of women in surrogacy commercial surrogacy, or “womb for rent”, is a growing business in india. in a country like india with an already alarmingly high maternal death rate, the surrogacy business is exploiting poor women, especially the illiterate from rural areas. 24 often, a surrogate mother may get treated like a commodity, too, as she may be, against her will, coerced by the family for economic gain. frequently, women who rent out their wombs in such situations are poor and ignorant, and often have no idea of possible consequences. 25 in many cases, children “produced” out of surrogacy become “objects/ commodities” of custody disputes. often, the child with disability born out of surrogacy is treated like a damaged commodity to be rejected. apart from psychological stress, depersonalization and commoditization of women as surrogate mothers, surrogacy may ultimately shatter the traditional (christian) concept of motherhood. on the other side of the spectrum, childless couples, especially childless women, due to superstitious beliefs, also face a certain degree of social rejection; for instance, the presence of a childless couple is considered a bad omen, especially the woman. maternal and child/adolescent mental health mental health problems are a key determinant of maternal and child mortality and morbidity, but are not currently recognized in existing initiatives to promote maternal health, and improve sexual and reproductive health and child health. 26 cases of perinatal depression are on the rise among young mothers. 27 the prevalence of antenatal depression reported in india ranged between 9.2 % and 16.2 %. 28 the issue of maternal mental health apart, the prevalence rate of child and adolescent psychiatric disorders in the country is on the rise. as per nfhs-3, in 2005-06, 22% of adolescents (14-18 yrs) had a mental or behavioral problem, and depression was on the rise. 29 53.22% of children reported to have faced some form of sexual abuse. 30 in sum, maternal and child/adolescent mental health — with a treatment gap of 90% — is indeed a human rights issue. 31 gender differences in social-economicbiological determinants of health and illness health and well-being depends not merely on curative medical care, but on one’s access and capacity to afford social determinants of health, such as, food, water, shelter, sanitation, education, and other basic needs. any health-care reforms have to be placed within a national effort to provide these social determinants on an equitable and universal basis. 32 in the context of maternal and child mortality, one has to take note that in spite of so much talk on economic growth, as per 2011 census, the female literacy rate in the country was only 65.46% as compared to an 80% male literacy rate. 33 the school dropout rate amongst adolescent girls was a high 63.5%. 13 health and education are closely interrelated. literacy not only increases women’s selfconfidence but also makes them more exposed to information thereby altering the way others respond to them. female literacy improves the chances that women will obtain meaningful employment, reduces their demand for children and improves healthseeking behaviour, makes them aware of nutritional requirements all these combined improve the chances of survival of both the mother and the baby. 34 the lower social status of women influences how society responds when they are affected by stigmatizing illnesses, such as hiv/aids, leprosy, 97 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. tuberculosis, and mental illness. while both men and women suffer considerable discrimination from society, women are more marginalized by these health problems. 35 the situation further severely worsens when they are from the socially and economically excluded communities. moreover, women, especially in the developing countries, are engaged in reproductive household labour (food preparation, child birth, child rearing, water and fuel collection, shopping, housekeeping, and family health care, care of livestock, kitchen garden, etc.), which are often unaccounted/invisible and considered voluntary. 35 the biological determinants of health and illness, such as, differential genetic vulnerability to illness, reproductive and hormonal factors, and differences in physiological characteristics during the lifecycle, call for a differential approach to female health issues. 35 maternal and child health — from human rights perspective maternal health is a human rights issue that has implications for the rights to life, health, equality, nondiscrimination, privacy, freedom from cruel or degrading treatment, and equitable distribution of the benefits of scientific progress, among others. 36 the indian health context of maternal and child health brings to the fore, the urgent need of assessing it from the human rights perspective that “. . . every woman, every newborn, everywhere has the right to good quality care. . . good maternal health is a human right, as well as a pre-condition and a determinant of newborn, child, and adolescent health, and of sustainable development more generally.” 51 it is evident that the high unacceptable mmr and imr is a question of equity, be it in india or any other developing country. the lowest socioeconomic strata in india, especially women and children, are grossly deprived of health care facilities leading to poor health outcomes as accessibility to basic health care depends on the socio-economic status of an individual. they are deprived of essential determinants of health, such as safe and secure shelter, safe water supply and sanitation, environmental health and hygiene, and access to food. the untreated ailments are higher in rural areas than in urban areas, among females than males, and the socially and economically excluded dalit and tribal communities than among the nondalits and non-tribals. 37 from the perspective of human rights, women are entitled to certain rights simply by being human. this means, as the various international treaties on human rights and christian teaching emphasize, each human person, endowed with intelligence and free will, has rights and duties that are universal and inviolable, and, therefore, altogether inalienable. each human person “has the right to bodily integrity and to the means necessary for the proper development of life, particularly food, clothing, shelter, medical care, rest, and, finally, the necessary social services.” 38 the un declaration on human rights (article 25.1) states: everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 39 art. 12(1) of the international covenant on economic, social and cultural rights (icescr), ratified by india in 1979, recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. this includes the state’s responsibility to take measures towards the reduction of the stillbirth-rate and of infant mortality, and for the healthy development of the child, etc. “health is a fundamental human right indispensable for the exercise of other human rights. every human being is entitled to the enjoyment of the highest attainable standard of 98 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. health conducive to living a life in dignity.” 2 additionally, the right to health is recognized, inter alia, in article 5 (e) (iv) of the international convention on the elimination of all forms of racial discrimination of 1965, in articles 11.1 (f) (ratified by india in 1968) and 12 of the convention on the elimination of all forms of discrimination against women of 1979 (ratified by india in 1993) and in article 24 of the convention on the rights of the child of 1989 (ratified by india in 1992). the components of the highest attainable standard of health are: availability, accessibility, acceptability and quality. 2 these components reiterate women’s rights from the perspective of maternal and child health/safe motherhood to scientifically and medically appropriate (quality) healthcare; effective functioning public health and health care facilities, goods, services, and programs in sufficient quantity (availability); accessibility without any discrimination of affordable (economic) physical facilities and services, ethically and culturally appropriate, sensitive to age and gender (acceptability). each woman is also entitled to the required information needed to make an educated decision. 2 woman’s right to health also implies, inherently, the underlying principles of participation and inclusion, equality and non-discrimination, accountability and capacity development of duty bearers (responsible parties) in relation to health (policy makers, hospital managers, health professionals, inspectors, and parliamentarians, among others) to meet their obligations and of rights-holders (women and children) to claim their rights. the accountability of the duty bearer implies categorically that the state and the others concerned must respect a woman’s right to health, including safe motherhood (without interfering directly or indirectly). duty bearers have the obligation to protect it by taking measures that prevent third parties, including her own family, community, religion, private and public health facilities, health personnel under whose care they are entrusted, from interfering in the exercise of her rights. duty bearers have the obligation to fulfill women’s and children’s right to health by adopting appropriate legislative, administrative, budgetary, judicial, promotional, and other measures to fully realize the right to health. 2 it is true that in india, government programs and various interventions under the national health mission have brought down maternal and infant mortality. there has been a remarkable increase in institutional deliveries. however, this surge in institutional deliveries does not necessarily mean a proportionate reduction in maternal and infant mortality. for this, one needs to ensure a proportionate increase in investment in quality public health facilities and human resources, affordable and accessible, especially to the socially and economically marginalized. this will significantly contribute towards india’s achieving universal health coverage / sdg3: “ensure healthy lives and promote well-being for all at all ages” leaving no one behind. mere technological advancement, increase in facilities like emergency obstetric care (emoc) and skilled birth attendants, without them being equitably and available to rural and poorer women, may in reality, only mask poor quality care. this may be all the more true where birth facilities lack basic resources such as water, sanitation, and electricity. “it is unethical to encourage women to give birth in places with low facility capability, no referral mechanism, with unskilled providers, or where content of care is not evidence-based. . .” 49 as the authors of the latest lancet series on maternal health point out, two extreme situations of “too little, too late” (tltl) and “too much, too soon (tmts)” exist on the continuum of maternal health care. tltl, associated with high maternal mortality and morbidity, depicts inadequate resources, low evidence-based standards, or care withheld or unavailable until too late to help. tmts represents over-medicalization of normal antenatal, intrapartum, and postnatal care, which may eventually cause harm and increase health costs. often, tmts results in disrespect and abuse 99 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. of maternal and child health services. for instance, on the one hand, lack of timely facility for caesarean section, a globally recognized maternal healthcare indicator and, on the other, unnecessary use of the same for non-medical indications, portray tltl and tmts, respectively. 50 the state as a duty bearer in india was not consistent with its draft national health policy 2015 where the health budget is concerned. the draft national health policy also envisages raising progressively the public health expenditure to 2.5 percent of the gdp. however, the total expenditure for health is only 1.62 percent of the whole budget, out of which the national health mission has a share of less than one percent. here too, the government is deviating from the core strategies of the national health mission as there is no increase in allocation for the health sector. 40 the question here is also one of net utilization, whether even this meager government expenditure on health actually reaches the real beneficiary, thereby effectively increasing the universal health coverage, benefitting the neediest, mostly residing in the most remote areas. “the main concern is that out of the total government spending on the health sector, only 20 per cent of poor people are able to get the true benefit of healthcare facilities.” 41 the health systems in the country have to focus not only on the reduction of maternal mortality but also on maternal morbidities, resulting from poor quality of maternity care. respectful care at birth is very important. 42 the attempts to “normalize” labor room abuse cannot be accepted but must be fought against by all means, without which all other attempts to improve maternal and newborn health care services will become futile. in this process of advocating quality maternal and child health services, not only women but equally also men need to be involved. men can play an important role in changing attitudes that restrict women’s access to health care and economic opportunities and in reducing violence against women. 43 chai — growth of an organization from a welfare and need-based approach to a rights-based approach in healthcare delivery founded in 1943 by sr. dr. mary glowrey — an australian medic and catholic nun, the catholic health association of india (chai) is one of the largest not-for-profit faith-based healthcare networks. 44 from the late 1980s, akin to the historical shift in the development sector from welfare to need to rights-based approaches with the un declaration on the right to development in 1986, chai gradually started shifting its focus to one of rights-based interventions. it started to undertake community health projects, with emphasis on primary health care to the marginalized at their doorsteps. the declaration of alma-ata 1978, declaring primary healthcare as the first element of a continuing healthcare process, was also an impetus to this shift to community health. chai has a membership base of over 3,500 healthcare institutions to date. 90% of them are headed by women religious; 80% of them are located in remote medically underserved rural areas, operating under 11 regional units across the country. under the chai network today, there are, altogether, over 2,300 health centers and 627 hospitals spread across all states — with a total of over 50,000 beds. chai member institutions (mis) extend medical care to over 21 million patients in a year with a special emphasis on maternal and child health. it has a fulltime dedicated volunteer core of over 600 nun-doctors; 25,000 nun-nurses; 10,000 plus nun-paraprofessionals and over 15,000 nun / priest social workers, along with over 100,000 lay employees/collaborators. chai mis maintain rehabilitation, care, and support centers for adults and children living with hiv, children/youth with disabilities, elderly and terminally ill, mentally ill, etc. chai has 218 social service societies across the country as its members, advocating the health rights of the 100 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. marginalized and socially excluded communities, with special emphasis on the health rights of women and children. chai also implements 20 major community health projects across india in collaboration with its member institutions (mis), other ngos, and the government. some of chai community health projects in maternal and child health under its community health service project, supported by misereor, during the last one year alone, chai has trained and mentored 462 women community health volunteers/activists of 390 villages covering 9 states and involving 60 member institutions. they are mainly involved in facilitating antenatal-intranatal-postnatal services, ensuring quality services through public health facilities and programs for pregnant women/ mothers and newborns. supported by kindermissionswerk — germany, chai has initiated a pilot project “promoting mch through mothers' clubs” in 7 states partnering with 10 member hospitals. the project provides comprehensive maternal healthcare (antenatal/intranatal/postnatal care, nutrition support, childcare, mothers’ club for awareness creation, etc.) to 1000 pregnant women of bpl families in rural and remote areas, over a period of 1000 days — from pregnancy to the child’s 2 nd birthday. mothers’ clubs are formed to create awareness among pregnant women/young mothers about their rights and entitlements along with the health issues pertinent to them and their newborns. with support from world diabetes foundation (wdf) — denmark and medtronic — usa, chai implements a prevention and control of diabetes project, covering 5 districts of uttar pradesh and one district in rajasthan, with special emphasis on pregnant women. in collaboration with global fund, the union, and the revised national tuberculosis control program (rntcp), since 2010, chai has been implementing project axshya (“civil society engagement in prevention & control of tb”), involving over 1600 community health volunteers (axshya mitras) of 384 ngos, in 96 districts, including 9 cities, across 10 states. within 24 months of the project’s 2 nd phase, axshya mitras visited 2,390,510 households creating awareness about tb, actively identifying people with symptoms, and linking them to diagnostic and treatment services under rntcp. the project resulted in 256,411 people getting screened and tested. of these, 22,134 (8.63%) tested positive (including over 8,900 women), and 21,726 were put on treatment. the project established tb forums in all the target districts, constituted of volunteers who facilitate medical-social-economic support for tb patients and their families, especially from the government. chai, with support from various donors, especially liliane foundation (lf), provides education, health, and rehabilitation support annually for over 10,000 differently-abled children/young adults, mainly in partnership with 116 partner organizations (pos) spread across 8 states of india. the project provides support for comprehensive rights-based assistance to persons with disabilities, belonging to marginalized families. chai mis continue to administer 90 holistic care centres (hccs) supporting people living with hiv (plhiv) — formerly community care centres (cccs), in spite of the fact that the government/naco stopped supporting them in april 2013, as part of mainstreaming hiv/aids into the general health system but without a proper transition plan. supported by misereor — germany, 30 of these hccs alone provided care and support for 88,341 plhiv during a period of two years. over 40 mis provide nutrition and education support to over 5,000 orphan and vulnerable children (ovcs), infected/affected by hiv/aids. during the last 5 years alone, chai trained over 16,990 health professionals, frontline health workers, allied professionals, social workers, and 101 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. community health volunteers on various health issues, including maternal and child health. for instance, in partnership with unicef-andhra pradesh, chai implemented a pilot project for enhancing quality newborn care and extending routine immunization coverage. the aim was to complement the government’s efforts to reduce infant mortality (imr) through intensive social and behaviour change communication (sbcc) trainings to 177 health educators and 600 accredited social health activists (ashas) of two high-priority districts. way forward — the indian church’s response today’s health scenario of the country is marked by the growing commercialization of healthcare and the increasing tendency of exploitation in the midst of sickness and suffering; growing legal requirements of standards for quality care and patient safety; increasing erosion of ethical care, holistic health, and spirituality of healthcare; double burden of communicable and noncommunicable diseases, etc. all the more, internally, the catholic health facilities are ministering in isolation leading to unnecessary duplication and wastage of resources. these external and internal challenges forced the catholic health association of india and its mis to initiate a participatory strategic planning process (spp) in collaboration with the catholic bishops conference of india (cbci) office for healthcare in 2013. the goal of the spp is to enable the church’s health ministry to reposition itself to meet the emerging challenges and to advocate the right to health (accessible, acceptable, and affordable quality healthcare) for all, especially the marginalized and vulnerable women and children. most of the catholic healthcare facilities and personnel belong to various women religious orders, most of them being chai’s mis. hence, the key to repositioning of catholic health ministry is to enable them to revisit their health ministry and discern the challenges, rediscover their place and role in the emerging context, and reposition themselves accordingly. the situation also calls upon these orders for a metamorphosis in organization, management, and operations — to transcend the culture of ministering in isolation to work together as part of the larger church for a better impact in the society, i.e., to become an intercongregational entity. nun-nurses as “community health enablers” — advocates of the right to health taking action 2020: repositioning for the future (resulting from the spp) from the conceptual level into practice, chai currently implements a project “repositioning of religious orders,” supported by the conrad n. hilton foundation. in fact, rather than a project, we may have to consider it as a process of aggiornamento— spirit of change and open-mindedness to be swept into the healing ministry of the catholic church. the process supports measures towards networking and capacity building of religious orders/sisters in order to reposition the health ministry of the church in today’s context. one of the measures is to facilitate various religious orders to reposition their members as “community health enablers,” as grassroots level workers. this means nuns, who are nurses, get involved in local communities, especially as women leaders, in planning, implementation, and monitoring of health care delivery. it means empowering people to be in charge of their own health. the nun-nurses, as community health enablers, must accept people as health resources for their own cause, rather than merely viewing them as sources of pathology and as targets for preventive/ therapeutic services. they must build and nurture caring groups of local community health volunteers. the paradigm shift in this whole process is that the nun-nurses, instead of waiting for people to come to their health centers, have to go out of their four walls to reach out to people at their door steps. as pope francis exhorts, “i prefer a church which is bruised, hurting and dirty because it has been out 102 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. on the streets, rather than a church which is unhealthy from being confined and from clinging to its own security.” 45 supporting these nun-nurses in this endeavor, their respective religious orders, in particular, and the indian catholic church, in general, have to refrain from being the “opportunistic” faces of christ’s mercy. facilitating this paradigm shift, chai is in the process of training nun-nurses, currently managing health centers singlehandedly in remote rural areas. this is so they can not only to reposition themselves as community enablers, but also equip themselves to capacitate and mentor community health volunteers, and provide quality community outreach services, with special emphasis on maternal and child health. this also means to mentor, technically support, and collaborate with the existing frontline health workers, such as accredited social health activists (ashas), anganwadi workers, etc. the nunnurses as community health enablers along with the health volunteers make the women aware of the right to quality maternal and child care. communitizing maternal and child health, they enable women with information and skills on govt. programs and interventions, to demand and access their rights and entitlements; to organize to fight against mistreatment, abuse, disrespect, and neglect that they face, especially in maternal and child health facilities. thereby, they complement the country’s efforts towards achieving universal health coverage / sdg3: “ensure healthy lives and promote well-being for all at all ages,” leaving no one behind. the mentoring of caring groups of active community health volunteers means also that these nun-nurses, as community health enablers/activists, have to replicate themselves. they have to enable some of the community health volunteers as community health activists, advocating the rights and entitlements of their respective communities so that eventually the nun-nurses as community health enablers can recede to 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http://articles.economictimes.indiatimes.com/201606-16/news/73818480_1_maternal-deaths-childbirthwhs 49. campbell omr, calvert c, testa a, strehlow m, benova l. keyes e, et al. the scale, scope, coverage, and capability of childbirth care. the lancet. sept 2016; 388 (10056): 2193 – 2208. http://dx.doi.org/10.1016/s0140-6736(16)31528-8 50. miller s, abalos e, chamillard m, clapponi a, colaci d, commandé, et al. beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. the lancet. oct 2016; 388 (10056): 2176-2192. http://dx.doi.org/10.1016/s0140-6736(16)31472-6 51. the lancet. maternal health: an executive summary for the lancet’s series. the lancet series. maternal health 2016. 2016 september 15; [cited 2016 oct 15]. available from: http://www.thelancet.com/pb/assets/raw/lancet/stori es/series/maternal-health-2016/mathealth2016-execsumm.pdf 52. national health mission (nhm). child health. ministry of health and family 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http://indiatoday.intoday.in/story/indias-health-woes-budget-for-the-national-health-mission-remains-stagnated-at-rs-19-000-crore/1/609824.html http://indiatoday.intoday.in/story/indias-health-woes-budget-for-the-national-health-mission-remains-stagnated-at-rs-19-000-crore/1/609824.html http://www.dnaindia.com/health/1891984/report-3-a-s-availability-affordability-and-assurance-must-for-improving-healthcare-in-in http://www.dnaindia.com/health/1891984/report-3-a-s-availability-affordability-and-assurance-must-for-improving-healthcare-in-in http://www.dnaindia.com/health/1891984/report-3-a-s-availability-affordability-and-assurance-must-for-improving-healthcare-in-in http://www.sahaj.org.in/uploads/4/5/2/5/45251491/understanding_maternal_health_from_a_gender_and_rights_perspective.pdf http://www.sahaj.org.in/uploads/4/5/2/5/45251491/understanding_maternal_health_from_a_gender_and_rights_perspective.pdf http://www.sahaj.org.in/uploads/4/5/2/5/45251491/understanding_maternal_health_from_a_gender_and_rights_perspective.pdf http://healthbridge.ca/programs/reproductive-maternal-and-child-health http://healthbridge.ca/programs/reproductive-maternal-and-child-health http://chai-india.org/ http://w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium.html%23the_joy_of_the_gospel http://w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium.html%23the_joy_of_the_gospel http://w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium.html%23the_joy_of_the_gospel http://w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium.html%23the_joy_of_the_gospel https://www.google.co.in/search?tbo=p&tbm=bks&q=isbn:0595351417 https://www.google.co.in/search?tbo=p&tbm=bks&q=isbn:0595351417 http://www.who.int/gho/publications/world_health_statistics/2016/en/ http://www.who.int/gho/publications/world_health_statistics/2016/en/ http://articles.economictimes.indiatimes.com/2016-06-16/news/73818480_1_maternal-deaths-childbirth-whs http://articles.economictimes.indiatimes.com/2016-06-16/news/73818480_1_maternal-deaths-childbirth-whs http://articles.economictimes.indiatimes.com/2016-06-16/news/73818480_1_maternal-deaths-childbirth-whs http://dx.doi.org/10.1016/s0140-6736(16)31528-8 http://dx.doi.org/10.1016/s0140-6736(16)31472-6 http://www.thelancet.com/pb/assets/raw/lancet/stories/series/maternal-health-2016/mathealth2016-exec-summ.pdf http://www.thelancet.com/pb/assets/raw/lancet/stories/series/maternal-health-2016/mathealth2016-exec-summ.pdf http://www.thelancet.com/pb/assets/raw/lancet/stories/series/maternal-health-2016/mathealth2016-exec-summ.pdf http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html 106 thomas & maliekal nov 2016. christian journal for global health, 3(2): 91-106. peer reviewed competing interests: none declared. acknowledgements: rev. dr. tomi thomas presented this paper in 100th german catholic convention 2016, held on 28th may 2016, at leipzig, germany. correspondence: rev. dr tomi thomas, the catholic health association of india (chai), india. directorgeneral@chai-india.org dr anto maliekal, the catholic health association of india (chai), india. antoseena@gmail.com cite this article as: thomas t, maliekal a. maternal and child health from a human rights perspective: the indian scenario and nuns as community health enablers. christian journal for global health (nov 2016), 3(2):91-106. © thomas t, maliekal a. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:directorgeneral@chai-india.org mailto:antoseena@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ poetry nov 2018. christian journal for global health 5(3):55-58. what is the cry of your heart? collective reflections from 7th triennial micah global consultation sarah larkina a ba (religious studies), ma (pastoral theology), poet, works for integral alliance, london, uk the axe is laid at the root of the tree and we are laid bare what do we need to recover to endure ------ invasive interactions fragile states race hate virtual reality unending strife the spirit behind repeated lies that makes us despair of all life? from home-less to human-ness to jesus-ness; o lord, let there be salt and light to overcome the night. let there be a way to close the chasm between people in the church-fractured o let the church-bride in all her glory arise, so that people world-wide would see jesus with new eyes, catch his sacred heart from the days of john the baptist until now the kingdom of god advances. so let us passionately lay hold that our work would truly serve thy kingdom and not my ego. because god is not a donor, an ngo, a ceo, a nation-state god is god 56 larkin nov 2018. christian journal for global health 5(3):55-58. not an entity made in our image and likeness or an instrument of our own global agendas. that’s a lie! the utter opposite is true. we are made in god’s image and likeness to reflect his glory. so let us reframe the story! from home-less to human-ness to jesus-ness; let us stop talking about disasters as one-off events and really start reducing risks, cover vulnerability’s living village with jesus’ blood-stained robe of righteousness. let us be counted amongst the wise and build on the rock of refuge and not on the sinking sands. and let us hold the hand of the many orphaned sons and daughters of the living almighty – all forgiving – all loving – all knowing god of all gracious-ness. but knowing deeply that we too are orphaned sons and daughters, eternal life inheritors – adopted and adopting forgiven and forgiving – loved and loving – known and knowing, that the god of all gracious-ness holds our hand through the storm, as we reach for others’ and oppose the hand of the oppressor. what is the cry of my heart? to see, taste, and hear the emergence of new and abundant life and health, and know it’s all from god and together, globally not so much to go forth but to accept the great invitation to come to his table, the feast, the marriage supper of the lamb. the table is laid, though there may be enemies all around, all are invited but what, what is that sound? rain pouring, pounding, battering the hard, hard ground. let us stand out in it and get soaked through to our many-shaded skins. but what, what is that sound? wind blowing, billowing, bending the bamboo. let us stand out in it to blow the century’s old dust away. lock our roots like the mangrove 57 larkin nov 2018. christian journal for global health 5(3):55-58. from home-less to human-ness to jesus-ness; let us reframe and not be ashamed, tell our stories with honest abandon tales of the one who loved us, re-made us, healed us and loves us still, that we too may deeply love and nourish the whole wonderful cosmos that the god who is god has made. creator, sustainer, healer and judge, matchless in your majesty, wonderful in your wisdom, glorious in your beauty. let us ask each other and the nations: what is your story? what is the cry of your heart? that the local church begins to see their vital place in bringing holistic transformation to people regardless of religious affiliation for the common good. and let the church be the church: the responsible and gifted community of the god who is god and let her be who he has ordained her to be, the only truly transformational change agent in this wide-world what is the cry of your heart? to see the church-bride empowered to sincerely serve the community, to be manifest-ors and bring-ers of abundant, overflowing life carrying as vessels, living water in dry and thirsty lands. what is the cry of your heart? to learn the dance of renewal and then to dance the dance of the all-renewing god who is god. what is the cry of my heart? to see with my inner eye god's new day, his new heaven and earth, his new morning mercy and that the deepest cry of my heart be the deepest cry of his heart that the god who is god, would give the modality, the solidarity to be a visible expression in the community of his unending, everlasting love. what is the cry of our hearts? o let the joy of the lord be our strength – may we take off our disguises and let that god-infused strength be enough for all our sunrises. 58 larkin nov 2018. christian journal for global health 5(3):55-58. from home-less to human-ness to jesus-ness; let us live in the eternal mystery revealed that the god who became man hallowed our human-ness that we would never need to stay in everlasting same-ness so let us pray together now as our lord and master, saviour, teacher and friend taught us to pray our father who art in heaven hallowed be you name… competing interests: none declared. correspondence: sarah larkin (née fordham), london, uk. sarahlarkin68@gmail.com. http://scfordham.blogspot.com. integral alliance (www.integralalliance.org) acknowledgements: micah global (www.micahglobal.org) and the participants of the 7th triennial micah global consultation on integral mission and resilient communities held 10-14 september 2018 tagaytay city, cavite, philippines (http://micahgc2018.org). responses to the question “what is the cry of your heart?” were collected during the 5-day consultation and the original draft of the poem was recited by the author during the main closing session, thus representing a diverse expression of participants, integrated with some compelling didactic content from the speakers, to capture some of the collective spirit of the gathering of 452 leaders from 68 countries. cite this article as: larkin s. what is the cry of your heart? collective reflections from 7th triennial micah global consultation. christian journal for global health. nov 2018; 5(3):55-58. https://doi.org/10.15566/cjgh.v5i3.257 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:sarahlarkin68@gmail.com http://www.integralalliance.org/ http://www.micahglobal.org/ http://micahgc2018.org/ https://doi.org/10.15566/cjgh.v5i3.257 http://creativecommons.org/licenses/by/4.0/ conference report health disparities: a time for action a conference of the consortium of universities of global health daniel w. o'neilla a md, ma(th), assistant clinical professor, family medicine, university of connecticut school of medicine, usa the theme of this conference, held in new york city from march 16-18, 2018, was based on the observed resource inequality that exists despite global economic growth. this can be a destabilizing force, yet receives little attention, particularly for the 50% of the world population with limited access to modern health services. given the complexity of subjects and sessions, the emphasis of this report is on key-note addresses, refugee health, research, and application. reducing health disparities in his opening address, steven lewis, former un special envoy for hiv/aids and ambassador to the un, and co-director of aids-free world, canada, noted that inequality was obvious, with “far too much pain in the world remaining in the poorest countries of the world.” climate change is the “single greatest threat to human kind,” due to emerging dislocations serving as a recipe for profound illness, death and despair affecting the poorest parts of the world. this begs the question, “what to do about it?” he highlighted the ongoing problem of hiv and tb, and its effects on the poor. “marginalized communities at the fragile edges of society are mostly beleaguered, without voice, submerged in feelings of hopelessness... poisoning the anatomy and the soul.” he called for identifying and confronting disparity with “crescendos of activism, unrelenting advocacy, and pressure on the governments.” highlighting the problem of gender inequality and sexual violence, he criticized the united nations’ system, ironically rife with sexual abuse and the absence of effective security council resolutions. there was “energy missing” to implement justice at the government and multilateral levels. interestingly, he called health the “tie that binds” – the one unifying force that engages attention in all sectors. it has enormous appeal. when you concentrate on health, you touch the mind and heart. he then quoted jesus’ service-oriented rallying cry: “in biblical language, ‘go forth and do likewise.’ the world is worth saving.” a plenary panel discussion followed. jimmy volmink, dean of stellenbosch university, south africa, defined resource inequality as existential inequality – disparities in dignity and respect – and vital inequality – disparities in life chances. a commission report delineated 8 areas for action: people-centered health systems, health stewardship/ accountability, sustainable financing, essential commodities, epidemic preparedness, training, research, institution strengthening, and enhancing the health workforce. a type of universal health coverage (uhc) which addresses social determinants of health is needed, attending to social and cultural aspects of health by governments. shaping health systems to reduce disparities in a plenary session, rejoice nkambule, deputy director ministry of health, kingdom of swaziland, listed the main health threats: hiv, tb, ncds (cancer, obesity, hypertension), trauma/ injuries, and mental health. she called for the imperative of defining national strategy for delivery of health services with a backbone of primary health care (phc). she suggested nurse-led action with o’neill sep 2018. christian journal for global health 5(1):43-51. mentoring of policy-makers from community to national levels, using data for decision making at all levels, and evidence-based health action in other sectors – maximizing technology to reduce disparities. paulo ferrinho, director, instituto de higiene e medicina tropical, universidade nova de lisboa, portugal, emphasized closing gaps in quality performance of health work by focusing not just on clinical skills but also providing training in nonclinical capacities such as leadership skills, supervision, incentives, and community health worker (chw) empowerment. professor morten jerven, university of edinburgh, noted that population statistics and data were sorely needed, since, “we cannot manage if we do not measure.” however, he cautioned on the inaccuracies and political drives for population health statistics. health and armed conflicts building on the research of the lancetamerican university of beirut (aub) commission on syria, this panel explored the global health challenges resulting from armed conflict. ghassan abu sitta reported on the development of the global health institute (aub). the majority of refugees were children and women. 72% worked in agriculture. the lebanese health care system absorbed acute care but not chronic diseases (ncds). he highlighted the importance of academic centers being active partners in areas affected by refugees. samer jabbour noted that the preliminary report of this new multidisciplinary commission, due september 2018, stressed health care delivery and targeting health facilities used as daily weapons of war, and that one-third of global cases of cholera were in the middle east (mena). global health institute was the first and only one in mena, since north-based institutions were the responders until now.1 aub had begun contextualizing global health dialogue/knowledge (in arabic) through smart learning and informing the world through evidence.2 wars have changed: they are more protracted, imbedded, and factional, with more civilian casualties, preferential treatment, and mdr bacteria (65.1%). conflict never ends in this region, so taking responsibility to have a system of response was imperative. he quoted kathleen sebelius, former u.s. secretary of the department of health and human services: in many ways, human health is the great global connector. it aligns our interests and impacts all of our economies. it compels us to work together and actually punishes us if we drift apart. it calls upon the greatest human impulses for compassion, for health and for love, and it motivates our greatest human capacities for discovering innovation and invention.3 middle eastern & mediterranean refugee crisis nathan bertelsen, assistant professor of global health and medical education, koç university, turkey, observed that every torture victim was depressed or had ptsd. their key focus was on symptoms but noted common despair of the future (“i see nothing”) as a major problem, noting common features in child labor and child marriage. in 2015, 1 million people migrated through the mediterranean, and there were thousands drowning in an attempt to migrate through boats. there were three waves of health problems encountered: physical injuries & diarrhea, shelter challenges, then chronic disease management, with mental health problems in all three. this led to a three-part approach to needs: establish safety, hope, and dignity – they needed to restore humanity & identity. [thus, addressing the first order questions of life: origins, identity/purpose, and destiny were necessary to foster resilience]. omar ahmed abenza, head of mission for the north syria response, doctors without borders (msf), spoke of the 13.1 m needing humanitarian assistance 5.6 m refugees, 6.1 m internally displaced. health disparities were made worse with violations of health rights (granted in 1966 to be impartial, inclusive, accessible, and a o’neill sep 2018. christian journal for global health 5(1):43-51. state obligation). but proportionality and distinction were repeatedly violated, and medical missions and hospitals became targets (were weaponized).4 the forced displacement & torture was compounded by low access to quality care, availability of staff, and little accountability (justice system) or health governance. capacity building was needed for strategic direction of policy, to correct trends, regulate funds, and enhance accountability. the syrian tax base was replaced by donors (with some political motivation), and service gaps were filled by ngos (private actors who didn’t manage the public health system). however, there was a lack of coordination and efficiency, and no funding was provided by the ministry of health. he emphasized the urgency for primary health care (phc) emphasis, to tackle ncds, to rise above politics, to foster more coordination, and to advocate toward warring parties. vicki fumado, head of cooperation unit, jant joan de deu, basrcellona, spain, reported 172,000 refugees in 2016 fled to greece with 38% being children and 21% being women, who primarily needed phc to treat chronic pathology, malnutrition, psychological/social problems, and vaccinations. she noted difficulties due to language barriers and poor collaboration between ngos. they conducted a prospective morbidity surveillance over a 2-month period for refugees (75% syrian) and top health seeking behavior was for respiratory infections and acute malnutrition (16% chronic). though the study had limitations, children were found to be the most vulnerable, with sanitation, vaccination, and behavioral evaluations being the highest assessed needs. anna makenna, clinical researcher on migrant health, institute of global health, university of barcelona, showed multiple “routes to a better life.” focusing on the morocco to spain route, she said that theirs were often long journeys (many from sub-saharan origin), with limited water and poor transportation. they were trying to monitor migrant health, but needed more data, a migrant-sensitive health system (training health work force), a policy/legal framework considerate of migration needs, and partnerships and networks. their goals included better public health policies, access to healthcare, quality of care (defined effective intervention strategies) in order to strengthen capacities for all actors. this included identifying victims of sexual violence, communicable diseases, mental health problems, and cultural mediators, as well as planning data collection and analysis efforts. ngos had data but not analysis. she highlighted the role of ngos [which would include faith-based organizations and faith groups], increasingly taking responsibility instead of the state, and providing human resources for collecting data and sharing it between ngos to enable better strategies in the future. there was a need to mobilize public outcry to take action while fighting media and compassion fatigue. she called for workforce training, empowerment of community health workers to multiply health impact, supporting families to build communities, [creating reflexive therapeutic communities of care through the church might be an example], and “bearing witness” with the ngo. passion did not publish papers, but data drove public action and policy, giving voice to ones without a voice. the great global health debate: is equity the defining objective of global health in the 21st century? sheryl healton, dean, college of global public health, new york university, voted yes. health equity is a public good to society, narrowing the gap between groups. she was not against other social determinants of health, but inequity is a destabilizing force, robbing one of hope. equity is a key social determinant in the sdgs, but is there a political will to view health as a human right? health, she said, is a societal asset that drives more prosperous economic indicators and is feasible, but it receives the least attention and needs more focus. health enables people to contribute – giving hope and optimism, as well as more of a tax base leading to overall prosperity. this is an evidence-based, o’neill sep 2018. christian journal for global health 5(1):43-51. essential priority but not the only one. she quoted rev. martin luther king, jr, “the arch of the moral universe is long, but it bends toward justice,” and called us to, “bend it faster.” richard horton, editor-in-chief, the lancet, uk, professor, london school of tropical medicine, voted no. he agreed that equity is essential in this wounded world, where the power of the few is exerted over the many, the rich over the poor. but equity is not the defining objective – it is liberty, that each could realize their aspiration to selfdetermination without interference or coercion. this is what it means to be human, and the precursor of a fairer society. health, he claimed, has an explicit connection to liberty. liberty is the central objective because of human dignity. humans are not objects tied to the unjust ropes of society. without dignity there cannot be equity. those working in global health, therefore, have a duty to hold accountable those governments and sources of power that deprive people of their liberty: authoritarian regimes, military force, religious dogmatists, corporate powers with their tools of exploitation, repression, discrimination, and censorship. equity without liberty leads us toward oppressive conformity, the death of the human spirit. we need emancipation from enslavement, the “rebirth of the social soul.” it leads us, if not to paradise, at least to realizing our full humanity, finding truths about ourselves and the world, embracing a diversity that is welcomed and celebrated. in his rebuttal, dr horton agreed with the moral imperative of equity, but reminded us of the four freedoms expressed by franklin roosevelt in 1943: freedom of speech, of worship, from want, and from fear – and this included adequate healthcare. amartya sen’s book development is freedom was the signature argument for this view, whereby individuals were seen as active agents of change, not passive recipients of dispensed benefits. liberty was the clarion call of the enlightenment projects. maximum flourishing is available in a pluralist social context where there is freedom – to “remove the chains that enslave the human mind,” which subjugate us to the oppression of others with unaccounted power which strip away our dignity. in her rebuttal, dr healton agreed that liberty was important for social justice, but that liberty and freedom is elusive and illusory. liberty could mean the freedom to oppress. there should be a 5th freedom – the right to survive. after the debate, a show of hands revealed about an equal number of votes for equity vs. liberty as the defining objective for global health. war on women geeta rao gupta, deputy director, unicef, noted that there has been enormous progress in the last 100 years, but still significant gender disparities in health, education, economics, and political power. sixty-eight countries actually showed an increase in gender gaps, and there is a pushback view which sees women’s rights as threatening – a shift in the distribution of power.5 she evidenced mutual benefit for empowering women and opposing “rigid cultural norms” of masculinity which may lead to dominance, homophobia, accidents, lower life spans, addiction, and violence. there are large gaps in the literature (eg. >1/3 do not disaggregate based on gender). instead of competing with other movements, she suggested linking with other movements with common goals of equality and social justice. latanya mapp frett, executive director, planned parenthood global, eschewed as unjust the mexico city policy or “global gag rule” for us foreign aid. she called for who to “destigmatize” the issue of provision of “safe abortions” as a “key public health measure” [which implied that those who morally oppose abortion were creating stigma instead of defending the basic human right to life]. admittedly a contentious issue which divides the un, there is no moral consensus making it difficult to create a public health policy or for access to abortion to be considered a fundamental human right. natalie kanem, un population fund, noted the greatest un goal is peace – mediated through transmitting facts and sharing knowledge, o’neill sep 2018. christian journal for global health 5(1):43-51. but they recently lost $70m in funding, half of which would have been used in humanitarian relief. war on women is literal among victims of gender-based violence in myanmar (rohingya), and in iraq and yemen where health services and mental health support is also disproportionally low. calling for “sexual and reproductive rights” as part of universal health coverage, she noted growing coalitions for “abstinence-only” approaches vs “evidence-based decision making” [spoken of as if they were mutually exclusive]. goals included the “3 zeros”: end unmet need for family planning, end preventable maternal deaths, end violence against girls and women (including fgm) toward a world where the inherent dignity of every girl and women is upheld. k. srinath reddy, president, public health foundation of india, started by quoting nobel laureate gunnar myrdal, “health leaps out of science, and is nourished by the totality of society.” it is, he said, the social determinants that determine how health is accessed. in the last 2 centuries, women struggled and gained several rights but there remains active aggression (domestic abuse, fgm, sexual violence) but also passive aggression (denied education, workplace discrimination), reflected over the entire life course – from selective abortion of female fetuses, to neglected underweight girls, to anemic adolescents, to sexually-exploited young women, to preferential access to health services for adult males. the advertising and marketing industries actively target women (eg. tobacco ads), and there is intergenerational inequity: maternal malnutrition affecting the human fetus and particularly the female ova (epigenetic effects). he called for gender justice not through militancy but through liberating women to participate in social transformation in all its dimensions. women naturally care about next generational nurture. in india, panchats (village counsels) led by women spent more on education, health, nutrition and sanitation. this movement needs to include women across all levels of the heath care systems, including leadership and research as critical change agents. to see this happen, men also need to be willing to be inclusive with gender equity, and mutual gender respect is needed with common social commitment for a healthier society. the health implications of climate change and environmental degradation several sessions at the conference focused on how the climate crisis affects all aspects of global health, and the need to be open about our values and pursue evidence-based ways to reduce warming and mitigate these effects. john balbus, director, national institute of environmental health sciences, nih, noted 2017 was the costliest year for natural disasters due to the increasing power of storms, increased number of wild fires, higher degree of air pollution, limited water supplies, protracted periods of heat waves, all with worldwide distribution, but with a disproportionate effect on low-income countries. global temperature change from 1890 is approaching 1.5 degrees celsius. direct impacts of weather, ecosystem effects, and human system mediation indicate that we can address, adapt to and mitigate effects. some activities include the belmont forum working on a research framework and funding, who adding climate resilience to their operational framework, world bank focusing on climate and healthcare effort, nih initiating a disaster research response (dr2) program, and developing the climate change and human health literature portal (https://tools.niehs.nih.gov/cchhl/index.cfm). madeline thompson, international research institute, climate and society, columbia university, focused on extreme events and children and the needed linked responses to this vulnerable population, having multigenerational impacts. she emphasized the forecasting of climate-sensitive health outcomes with the help of supercomputers and noted the emergence of many environment and health alliances in order to develop enough of a work force to accurately predict and respond while engaging with the local health community for capacity building. https://tools.niehs.nih.gov/cchhl/index.cfm o’neill sep 2018. christian journal for global health 5(1):43-51. james hospedales, director, caribbean public health agency, overseeing 24 countries (median population of 100,000), indicated that he was a christian, believing that god made the world and spent a little more time creating the beauty of the caribbean, but that, as a scientist, he observes “problems in paradise,” namely climate becoming hotter, drier with more monster storms and subsequent infectious outbreaks. the physical, biological, social and policy environments are all affected, but “health professionals are sleepwalking.” the objective is resilience building by filling big gaps in knowledge, and they are developing a climate roadmap to meet the challenges. win de villiers, rector and vice-chancellor, stellenbosch university, south africa, focused on the water crisis in the southern cape. there are 783m without access to clean water globally, and in south africa, there has been a significant drop in water levels more than typical variations, affecting agriculture and human health. the government announced a day zero “in somewhat apocalyptic terms” when they would run out of water. the response plan: reduce, reuse, and use alternative sources using a multipronged approach, showed a 50% reduction of use at the university and increased understanding of water as a key resource. kim knowlton, mailman school of public health, colombia university, noted there is enough climate change evidence to take action here and now through the power of science, law, and people. science has proven the human impact, and natural resources defense council (www.nrdc.org) has sought to educate the public on the localized effects to produce change and use a health-impact framing to enhance “implicit engagement” for action. health impacts (pain and suffering) and economic effect has been measured in 6 climate events in the us between 2002 2009, costing $14b in health costs. through the global consortium on climate and health education, 162 countries have litigated against multiple executive orders, but it is the people who need to express concerns to see change.6 health data can be tied in to external factors. she highlighted a need to teach preventive and systems-thinking to medical students (vs individual and curative), integrating climate change and the social sciences into the curriculum, and localizing its impact on migration, conflict (looting), drought, and food price spikes. [christian movements to address environmental concerns are also emerging such as arocha, renew our world, and lausanne creation care.]7 discussion with global health leaders ann kurth, dean and professor of nursing, yale university, noted a lack of faith in science/evidence in the general public. universities are intended to welcome diversity of thought but need to demonstrate their value as producers of the health workforce with innovations needed in availability and pricing. “meds & eds” can make a work force accessible (using tools and gifts) and pedagogy (160 courses on global health cataloged on cugh) to transform health systems. nick lemann, director global reports, columbia university, discussed the power of the pen, speaking truth to power, and how to be better communicators. journalists and scientists, he said, have common goals – to be independent truth seekers but face the oldest problem in political theory and is realistically not achievable. journalists are doing poorly and need to be more scientifically literate, and need to locate real experts in the democratic movements for change. patricia garcia, dean of school of public health, cayetano heredia university, and former minister of health, peru, highlighted corruption which has led to significant health compromise with “no solutions,” but she also highlighted the value of journalism and the need to start addressing new professionals with ethics to confront issues like bribes in order to create “new citizens.” a more structured education with a scientific basis and peerreview is needed, she said, but can we use other truth-seeking fields, with structured solutions? there is a deep gap in the production of knowledge http://www.nrdc.org/ o’neill sep 2018. christian journal for global health 5(1):43-51. being scaled up. academia is starting to work with greater zeal in translation to the public. she cautioned to avoid the basic science vs applied science dichotomy (privileging one over the other), since innovation truncated from application is a form of waste, and waste is corruption. new knowledge and tools that do not connect with people’s lives are useless. translational science is next year’s cugh conference theme, and academia needs to focus more on social determinants of health and application, such as upscaling community health workers, training in rural primary care, and enhancing emergency medicine. transnational products need to be interdisciplinary, locally relevant and regionally impactful. efforts at governance and social justice in law cannot ignore working with local civic agencies – translating action into communities. most countries do not have scientific journalists. social media and stories move behavior, but scientific rigor is insufficient – we need to speak clearly and closely to community leaders and to those who make a difference (legislators). it is said, “if it bleeds it leads. if it thinks, it stinks.” journalists are story tellers, and “narrative imperatives are persuasive.” the “scientists as heroes” narrative can be problematic, so we need a “personal narrative” to understand scientific truth. institutions can better protect those who point out corruption, who might be at risk of death. there has been a democratization of data and citizen activism, but it is also a time of distrust of government or nationalism, and significant suppression of freedom of speech. corruption is a diffuse and complex problem. academics can work toward accountability in systems, empowering the community as part of the continuum of health. free press has not become a global norm. turkey and india have regressed with regard to freedom of the press. elitism related to academia creates a distance with communities undermining good community of practice in this area: working with communities, local governments, taking a chance to see how things are done in the real world. the health department of peru addressed stunting successfully via evidencebased coordination, commitment, and continuity, working with several actors and different disciplines [including churches as civil society actors]. the business side of medicine is separate from the social enterprise aiming toward health equity. cooperation with business schools can empower and create capacity to improve, but financial motivation can undermine community health. critical thinking training is essential for a safe clinician but is also a universal outcome in an ideal university, which needs to be careful about “left-wing politics and group think.” wim de villers’ conclusion was to surrender privilege for the sake of others, like giving the 3-ts (time, talent and treasure) to reduce inequity of privilege. accountability in academics and development there was an interesting discussion on how to evaluate things that cannot be measured like “love”. the discussion stated that the overreliance on data may be problematic, so humility is required when dealing with data, knowing its limitations. with the movement toward measuring everything, the numbers become ultimate goals. the first step is to ask what the motivation is for collecting the data. proxy indicators may miss the mark, such as measures of enrolment in insurance vs. access (outputs vs outcomes). global donors are beginning to enforce penalties if data are fudged. it is not what we do not know that will hurt us, it is what we think we know but actually find to be false. are sdgs too reliant on figures that computers can read? there are places where it is difficult to count – armed conflict, failed states, fragile states – and social determinants are also hard to measure. proxies may be good measures, but these are not accepted by governments as a method. publication has become a requirement for funding a source of accountability. o’neill sep 2018. christian journal for global health 5(1):43-51. strengthening governance and public health institutions in the final plenary session, chelsea clinton, vice chair of the clinton foundation, moderated a panel with laurie garrett, science journalist; agnes soucat, director, health systems and governance and finance, who; and willy mutunga, former supreme court justice, kenya. they highlighted a retreat from globalization since 2008, with isolationism and nationalism on the rise countering principles of cooperation. multilaterals (such as the un), they claimed, are also declining with shifts in financing to the private sector. achieving universal health coverage and the sdgs will require political will, primary health care focus, and domestic public financing (85% financing predicted to be able to come from within each country). the stakeholders are a triad of people, market, and government. freedom of the press is the key element to driving action but is being increasingly restricted in countries such as central african republic, turkey, mali, burundi, and bahrain. peoples’ agency is the key for freedom of information – science anchored in debate as well as action on that information. profits superseding people’s needs corruptly dominate the world. the solution offered is a restoration of more global governance with a scientific basis – “veracity with transparency” – with solidarity between the healthy and the sick, anchored in the social contract, giving agency to those who are excluded. the debates will continue on what uhc looks like – what is covered on the public dole, and what is provided by civil society [including churches and fbos]. conference reflections there was excellent content and conversation on some significant global health issues throughout the conference, especially as they related to health equity, justice, and civic action. the emphasis on the importance of research and publication to be of influence for effective policies while also cautioning on being too data driven or enamored with statistics was noteworthy. evidence-based action was the clarion call, but there was less emphasis on values or narratives which drive the action. there was, conspicuously, no recognition of the importance or language of the faith community. in that 80% of the world population adheres to religious beliefs, narratives that cohere with daily life will be especially critical for translation, localization, capacity-building, buy-in, and community transformation. global health goals cannot be accomplished from distant, theoretical, academic platforms, transposed onto communities. neither health equity nor liberty fully describe the best of global health priorities. rather, through speaking the truth in love to neighbors in need at the community level, speaking truth to failed powers and systems, recognizing the intrinsic dignity of every person and people group, elevating health-promoting biblical values, affirming and mobilizing existing resources, and liberating them from the powers that destroy will be the defining objective for a christian approach to global health and transformation in the 21st century. references 1. lancet commission. syria: health in conflict. march 15, 2017. available from: https://www.thelancet.com/commissions/syria 2. refugee health program at american university beirut. available from: https://www.ghi.aub.edu.lb/rhp 3. kathleen sebelius at cwa: human health is 'great global connector' newsok. 8 april 2014. available from: https://newsok.com/article/feed/671328/kathleensebelius-at-cwa-human-health-is-great-globalconnector 4. the center for strategic and international studies. the new barbarianism – documentary of healthrelated and humanitarian targets. https://www.csis.org/features/new-barbarianism 5. world economic forum. global gender gap report 2017. available from: http://www3.weforum.org/docs/wef_gggr_2017.p df. https://www.thelancet.com/commissions/syria https://www.ghi.aub.edu.lb/rhp https://newsok.com/article/feed/671328/kathleen-sebelius-at-cwa-human-health-is-great-global-connector https://newsok.com/article/feed/671328/kathleen-sebelius-at-cwa-human-health-is-great-global-connector https://newsok.com/article/feed/671328/kathleen-sebelius-at-cwa-human-health-is-great-global-connector https://www.csis.org/features/new-barbarianism http://www3.weforum.org/docs/wef_gggr_2017.pdf http://www3.weforum.org/docs/wef_gggr_2017.pdf o’neill sep 2018. christian journal for global health 5(1):43-51. 6. global consortium on climate and health education. colombia university, mailman school of global health. www.mailman.columbia.edu/research/globalconsortium-climate-and-health-education 7. arocha (http://www.arocha.org/en/); renew our world (https://renewourworld.net/); and laussane creation care issue network https://www.lausanne.org/networks/issues/creationcare competing interests: none declared. correspondence: dr. daniel o’neill, university of connecticut school of medicine, usa. dwoneill@cjgh.org cite this article as: o’neill d w. health disparities: a time for action a conference of the consortium of universities of global health. christian journal for global health. sep 2018; 5(2):43-51. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.mailman.columbia.edu/research/global-consortium-climate-and-health-education http://www.mailman.columbia.edu/research/global-consortium-climate-and-health-education http://www.arocha.org/en/ https://renewourworld.net/ https://www.lausanne.org/networks/issues/creation-care https://www.lausanne.org/networks/issues/creation-care mailto:dwoneill@cjgh.org http://creativecommons.org/licenses/by/4.0/ original article the gospel of science raymond downinga asenior lecturer, department of family medicine, moi university school of medicine, kenya abstract medical missionaries have always been a part of global health. one of their greatest potential assets as global health workers was that they carried with them a spiritual understanding of life. although they didn’t always realize it, the people they came to serve, especially in africa, also functioned within a spiritual understanding of life. in the early 19th century, before medical science had much to offer, some of the medical missionaries were aware of this and recognized that their spirituality had something in common with people in africa. however, as medical science grew in effectiveness, the role of spirituality in medicine began to diminish, even for medical missionaries themselves. by the early 20th century, their spiritual understandings, while often still very strong in the religious realm, had been replaced by science in the medical realm. how did this come about? introduction in 1803, dr. thomas winterbottom, writing about superstition and “witchcraft” in west africa, noted that west africans “conceive that no death is natural or accidental, but . . . is the effect of supernatural agency,” and commented on how strongly “is the notion of medicine being a supernatural art imprinted on the minds of the people on the western coast of africa, that they look on every person who practices it as a witch . . . ”1 many european visitors to africa in the 19th century used the word “witchcraft” promiscuously. in this text, dr. winterbottom seems to use the term almost interchangeably with “supernatural” – but the distinction is important. africans then held– and mostly still hold– an understanding of the world as peopled with ancestors and spirits, and above them all, the supreme being. those ancestors (the “living dead”) and spirits maintain communication with people, often through dreams, diviners, and healers.2,3,4 this is the supernatural world to which winterbottom referred. in addition, africans understand that there are witches, separate from the diviners, mediums, and healers. witchcraft is always evil, and witches are the enemies of life. in this sense, there are no witch doctors; there are diviners who seek the causes of disease and healers who treat it – and there are witches who seek to do evil.2 they are not at all the same. despite calling this belief in supernatural agency “gross superstition,” winterbottom saw great potential value in african indigenous medicine. the entire second volume of his treatise is entitled “an account of the present state of medicine among the natives of sierra leone,” supporting his hope that europeans could find new medicines there to add to their own remedies.5 dr. david livingstone also had a gentler view of these “superstitions.” in his lectures at cambridge university, published in 1858, he said that “most of the south african tribes have more or less clear ideas of a supreme being; but . . . they almost generally worship directly or indirectly the spirits of departed human beings, and this more from fear than love . . . it is a great step in advance towards a purer faith that they are not materialists; their very fears and superstitions are in the right direction.”6 as a christian missionary, livingstone well understood that africans were already very religious. even at the end of the century, a few europeans maintained this respect for african traditions and values. dr. w.a. elmslie, a medical missionary writing in 1899, said that the traditional healer is “the visible and accessible agent of the ancestral spirits whom they believe in and worship.” he then went on to dispassionately describe the characteristics and functions of these healers. to him, the implications of this african cosmology for evangelism were similar to what livingstone noted: . . . how is it that the materialistic writers and unbelieving critics of missions affirm that the high moral and spiritual truths of christianity cannot be grasped by them? . . . to talk of spiritual things is not to them an absurdity, much less is it impossible for them to conceive that such things may be . . . the native lives continually in an atmosphere of spiritual things.7 livingstone saw no conflict between spiritual, scientific, and commercial goals. he resigned from the london missionary society – but not from the christian faith – half way through his 32 years in africa. his goals then were clear: medical research, promoting commerce, and “diffusing a knowledge of christ”s gospel, the best antidote for the wars of the world.’8 his mission board had already let him know that they would be unable to undertake these sorts of projects, so livingstone sought support elsewhere – and found it with the british government. nevertheless, just before returning to africa for his government–sponsored zambezi exploration, he delivered his oft–quoted speech at cambridge university in december, 1857, ending with his appeal: “i go back to africa to try to make an open path for commerce and christianity. do you carry out the work which i have begun? i leave it to you.”8 this early merging of the science of the day with christ’s gospel might be summarized in the motto of some mission hospitals even today, “we treat, jesus heals.” but more than this, these insights by 19th century doctors could have provided a foundation for all mission work, and the qualified respect for african cosmology would have benefitted all explorers and colonists, providing a basis for dialogue. but these were minority views, even among missionaries, and getting rarer as scientific successes pushed them aside. in fact, as early as 1842, the year after livingstone first arrived in africa, dr. daniel macgowan gave an address on medical missions in new york. macgowan was an american, shortly to become a medical missionary to china. yet at age 28, he was clearly impressed with the potential of scientific medicine. even before the germ theory of disease was clearly elucidated, and even longer before tropical medicine was called a specialty, macgowan saw immense potential in this scientific medicine. speaking of the physician, he said, it is his province to assuage human suffering, in all its varieties and aggravations, and, in imitation of the saviour, ‘to heal all manner of diseases.’ to extend the influence of science then, thus reduced to an ark of mercy, in the form of a profession, is obligatory upon us . . . 9 if the bible was the ark of salvation, scientific medicine was the ark of mercy. but, it was not just an ark of mercy. macgowan, commenting on our responsibility as “civilized men” toward the “wretchedness” of the uncivilized, continued: “medical science may thus become more than the fabled wand of esculapius, and in its humble manner be like the brazen serpent raised by the prophet in the wilderness, mighty to save a nation from impending ruin.”9 scientific medicine, to him, could also bring salvation. a few years later, the edinburgh medical mission society published a collection of lectures on medical missions (1849) in which the confidence in scientific medicine was stated even more strongly. the rev william swan, who had been a missionary in siberia, wrote on “the importance of medical missions.” he saw this importance as twofold: i. the first is – the advancement of medical science in countries where ignorance in regard to it, and where a medical practice, founded on grossly erroneous principles, entails a fearful amount of suffering on the victims of disease in such countries. ii. the second and more direct object is – the promotion of evangelical truth in countries overrun with ignorance, idolatry, and superstition –the medical missionary rendering his practice as a physician and surgeon subservient to the promotion of that high object. the last of these is by far the most important object, and yet the first deserves the attention of the disciples of him who went about continually doing good, healing all manner of disease among the people.10 the first purpose of medical missions, he says, is the advancement of medical science; the second “more direct” and “most important” object is the promotion of “evangelical truth” in countries overrun with ignorance, idolatry, and superstition. in other words, the context of the more important object of evangelization is not merely idolatry or lack of christian faith, but also “ignorance” and “superstition.” medical science is completely blended with the gospel; scientific truth remains on a par with gospel truth. then, toward the end of the 19th century, especially after europeans had fine–tuned their germ theory in the 1870s, european attitudes toward african understandings of disease changed significantly. in a book published in 1886, john lowe describes the context of medical missions: first of all, there is the lamentable ignorance existing in all heathen communities as to the cause, prevention, and cure of disease . . . this ignorance is a fruitful source of superstition, and, consequently, one of the most effectual barriers in such lands to the uprooting of idolatrous rites and ceremonies.11 by the 20th century, such attitudes were often reduced to contempt. dr. martin edwards writes in 1909 about the work of the medical missionary: the ignorance of the people of mission countries along the lines of municipal, household and social hygiene and regarding the cause and treatment of diseases is most deplorable and constitutes a great factor in the need for medical missionaries. their superstitious, blind faith in fetishes and gods lays them open to the most rampant ravages of disease . . . their theories regarding health and disease are absurd and wholly directed by their superstitions.12 dr. neil macvicar is a unique example of this gospel of science. he, like dr. james stewart, the missionary doctor who recruited him, “came early under the spell of science,”13 a spell as strong as the witchcraft he was determined to eliminate and the christianity that was responsible for him being in africa. his profound belief in an empirical scientific approach informed both: he simply could not accept anything supernatural. “my belief,” he wrote, “is that god reveals himself, not by interruptions of the majestic order of his universe, but in and through that order, not through the abnormal but through the normal; that, though to our limited minds occurrences may not always be explicable, inherently there is nothing truly super-natural . . . “he called africans’ spiritual explanations for disease “witchcraft” and “superstition” – and apparently felt the same about christian beliefs such as miracles, the incarnation, and the resurrection. those beliefs – or non-beliefs – caused him some difficulty in his early interviews with the mission board and were the reason he was dismissed from his first missionary assignment with the church of scotland in blantyre, malawi.14 clearly, doctrinal beliefs such as the resurrection have little to do with practicing medicine; macvicar’s biomedical practice was impeccable. however, practicing biomedicine in a culture very different from the one that developed it requires some understanding of that culture and of the concepts of disease there. as a christian, macvicar had access to a spiritual understanding that could have helped him understand his community. but, being “under the spell of science,” he had rejected aspects of that spirituality and forfeited an opportunity to have a deeper understanding of “witchcraft” and “superstition.” instead, he believed they were untrue and detrimental. of course, to hope that christian spirituality could have infiltrated rational empiricism was perhaps too much to ask at this early stage of biomedicine. science created the categories and assigned spirituality to the category of religion and then ignored it. when “jesus heals”married “we treat,” it was an unequal marriage; when biomedicine organized the family, it looked more like a divorce. consider dr. macvicar’s occupational twin, dr. albert cook. they arrived in africa in the same year, 1896, both as british missionary doctors – macvicar to south africa, cook to uganda – and they both stayed for the rest of their lives. they did, however, differ theologically: whereas macvicar doubted anything supernatural, cook maintained the evangelical dogma. but this evangelical fervor did not provide for him a window into african views of disease. he too bemoaned “the distressed native [whose] morass of misery [was] caused by unhygenic and superstitious surroundings that engulfs so many of them.” and he had little patience with african concepts of disease.15 cook did not draw on the spiritual basis of his own life to try and understand african spirituality. both macvicar and cook divorced the spiritual side of life from medicine. the difference was that after the divorce, macvicar sent the supernatural packing, whereas cook held on to it as a ‘kept woman’ in the protestant club. but kept isolated or sent away, they both lost the opportunity to understand spiritual africa. then, in the midst of this contempt, we find the reflections of dr. albert schweitzer, winner of the 1952 nobel peace prize. early in his sojourn in africa, reflecting on what he had observed in the church on his mission station, he wrote, but now, how far does the negro, as a christian, really become another man? at his baptism he has renounced all superstition, but superstition is so woven into the texture of his own life and that of the society in which he lives, that it cannot be got rid of in twenty-four hours; he falls again and again in big things as in small. i think, however, that we can take too seriously the customs and practices from which he cannot set himself entirely free; the important thing is to make him understand that nothing – no evil spirit – really exists behind his heathenism.16 for more than a century, europeans had been trying to come to grips with “the other” in africa–the people, the customs, and the cosmology, including its “germ theories” which the europeans called superstition and witchcraft. their struggles had ranged from respect to contempt, and now schweitzer introduces a more modern approach. we need not worry about this whole african cosmology, he said, because not only is there no real evil there, “nothing really exists behind” it. schweitzer took the final step beyond the divorce of “jesus heals” and “we treat”: in separating biomedical treatment from spiritual healing, he chose “we treat” and killed the other. medical missions had common ground with african cosmology: both were rooted in spirituality. but most medical missionaries were not interested in comparing cosmologies; they had come to bring the christian gospel and western medicine, not explore their own assumptions. in opting to only give and not receive, they let go of one of their most valuable means of understanding and learning from africans. they were not interested in evaluating the scientific method according to a spiritual world view; they were content to maintain the duality of “we treat, jesus heals.” it doesn‘t need to be this way. most african patients maintain their spiritual cosmology and still selectively use the offerings of medical science. many african healthcare providers maintain the balance as well. there is no inherent contradiction. yet global health research is currently focused on how the latest scientific medical advances of the west can be applied in africa. it may be time to return to what winterbottom and livingstone and elmslie recognized, that there is value in traditional african understandings. perhaps our christian spirituality can enable us to see this african spirituality and, as a result, begin to redirect global health research and practice. we have, until now, been researching secular western approaches to healing. with our spiritual background, might we also be well–placed to research healing approaches based on traditional spiritual values? but more than this: might there be an opportunity here to reexamine our own spirituality, to see ourselves as african healers might see us? how deeply do we believe that god is still involved in this world? christians in the middle ages believed that “the birthing power of nature was rooted in the world’s being contingent on the incessant creative will of god.”17 this is a sentiment consistent with the west african proverbial question “what is not sacred?” have we separated the science/treatment part of medical missions from the gospel/healing part, where the healing part is sacred but the treating part is not? can we be reminded by africans of the incessant creative will of god in the world? can we relearn from africa that everything is spiritual?3 references winterbottom t. an account of the native africans in the neighborhood of sierra leone. vol 1. london: c wittingham; 1803. available from: https://archive.org/details/accountofnativea01wint magesa l. african religion: the moral traditions of abundant life. maryknoll, ny: orbis books; 1997. [p. 161 ff..] magesa l. what is not sacred? african spirituality. mayknoll, ny: orbis books; 2013. mbiti j. african religions and philosophy. nairobi, east african educational publishers; 1969. winterbottom t. an account of the native africans in the neighborhood of sierra leone. vol 2. london: c whittingham; 1803. available from: https://archive.org/details/accountofnativea02wint livingstone d. dr. livingstone’s cambridge lectures. monk, w, editor. cambridge: deighton, bell, and co; 1858. available from: https://archive.org/details/cambridgelecture00liviuoft elmslie wa. among the wild ngoni. new york: fleming h. revell; 1899. available from: https://archive.org/details/amongwildngonibe00elms gelfand m. livingstone the doctor: his life and travels. oxford: basil blackwell; 1957. [p. 121-5] . macgowan dj. claims of the missionary enterprise on the medical profession. new york: william osborn; 1842. available from: https://archive.org/details/62740930r.nlm.nih.gov . swan w. the importance of medical missions. in edinburgh medical missionary society. lectures on medical missions. edinburgh: sutherland and knox; 1849. p 87-134. available from: https://archive.org/details/lecturesonmedic00socigoog lowe j. medical missions: their place and power. new york: fleming h. revell; 1886. available from: https://archive.org/details/medicalmissionst00lowe . edwards mr. the work of the medical missionary: eight outline studies. new york: student volunteer movement; 1909. available from: https://archive.org/details/workmedicalmiss00edwagoog wells j. stewart of lovedale: the life of james stewart. london: hodder and stoughton; 1909. available from: https://archive.org/details/stewartlovedale00wellgoog macvicar n. believing in god. [1946] quoted in lunde mj. north meets south in medical missionary work: dr. neil macvicar, african belief, and western reaction. south african historical journal. 2009;61(2):336-56. http://dx.doi.org/10.1080/02582470902859666 cook a. quoted in white l. they could make their victims dull: genders and genres, fantasies and cures in colonial southern uganda. the american historical review, 1995 december;100(5): 1379-1402. http://dx.doi.org/10.2307/2169863 schweitzer a. on the edge of the primeval forest: experiences and observations of a doctor in equatorial africa. london: a&c black, ltd.; 1924. available from: https://archive.org/details/cu31924029349788 illich i. brave new biocracy: health care from womb to tomb. new perspectives quarterly. winter 94;11(1):4-13. available from http://brandon.multics.org/library/ivan%20illich/against_life.html peer reviewed. competing interests: none declared. correspondence: raymond downing, moi university school of medicine, kenya. armdown2001@yahoo.com cite this article as: downing r. the gospel of science. christian journal for global health (april 2015), 2(1):43-48. ©downing r this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ original article nov 2016. christian journal for global health, 3(2): 27-37. continuing medical and dental education on the global stage: the nexus of supporting international christian healthcare workers and developing educators lyubov d slashcheva a , mark a strand b , ruth e vanreken c , collin sanford d , j dwight phillips e , gloria halverson f a dds,resident/fellow, university of iowa department of preventive and community dentistry, iowa, usa b phd, mph, professor, college of pharmacy and department of public health, north dakota state university c bsn, co-founder, families in global transition d dmd, professor emeritus, university of connecticut school of dental medicine, farmington, ct e md, mph, professor of pediatrics, mayo clinic, 200 first street sw, rochester, mn f md, professor emeritus, medical college of wisconsin, madison, wi abstract one of the challenges facing international healthcare missionaries is that of maintaining up-to-date knowledge and staying current with professional certification. since 1978, annual programs by the christian medical and dental associations have offered professional continuing education to thousands of us healthcare professionals serving as missionaries in the regions of africa, asia, and, in more recent years, globally. in addition, conference programming is designed to prepare, train, and support healthcare missionaries to, in turn, serve as educators in their places of ministry. the program is designed for both professional education and personal encouragement. utilizing historical documents from program facilitation and interviews from those involved with its implementation, this paper describes the history, vision, and favorable quantitative growth and qualitative impact on participants. the program continues to grow as healthcare missionaries are educated near their places of service, while reinforcing their own roles as educators. medical missions as a catalyst in global health healthcare missions have a long history and have been closely linked with the development of modern medicine. medical missions began with the catholic orders in the 14 th century. protestant missions began with dr. john thomas in india in 1773. 1 throughout the 19 th century, the number of missionary doctors on the field reached an initial peak of 1,125 in 1925, not counting the number of nurses and ancillary medical workers. 2 medical missionaries helped to establish modern medicine in many countries of the developing world. 3,4 yet, despite the historical role that christian expressions of mission have played, 1 reports of the scale and 28 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. impact of medical missions often goes unnoticed in wider global health circles. 3, 5, 6 this paper sets out to describe one aspect of healthcare missions globally that is the shared foundation of all healthcare missionaries: the need to engage in evidencebased learning, maintain current knowledge, and employ standard practices in healthcare. one contribution to this foundation is the role of a professional continuing education program of the christian medical and dental associations to provide educational opportunities for us healthcare missionaries working around the world. the term, healthcare missionaries, in this paper, refers to healthcare professionals who have devoted themselves to long-term, cross-cultural, missionary service through clinical work under the auspices of a christian missionary organization. synonymous terms used to refer to the population served by the program described in this report include healthcare missionary, those engaged in missionary service, missionary physicians, and international healthcare workers. those who are eligible for professional continuing education credits at these meetings include physicians, dentists, physician assistants, nurse practitioners, nurses and pharmacists. the authors estimate that worldwide there are approximately 1000 missionary physicians serving cross-culturally for ≥ 2 years, and another 1000 individuals serving in other health professions. less than 50% of these individuals work in mission hospitals; the others work in government hospitals, community offices, or other settings depending on regional accessibility of faithbased organizations. hence, the historical stereotype of a solo missionary doctor who provides all the medical care for a large population of extremely needy people is no longer the norm. most of these international healthcare professionals work for organizations where healthcare is only one aspect of many areas of service, and these organizations may not be prepared to provide strategic and healthcarespecific leadership or training. this contributes to frustration among these workers. 7, 8 the professional continuing education program described in this report exists to provide cutting-edge medical, surgical, dental, and community health education to these long-term healthcare missionaries to improve their skills and to maintain their licensure and has been able to fill the gaps in support of educational and professional development by providing education, resourcing, and encouragement to international healthcare workers who are then able to more effectively carry out their work and serve as educators themselves within each diverse ministry setting. the program relies on the commitment of volunteer healthcare educators from reputable academic institutions to attend conferences as faculty to teach on current medical knowledge and practices. this faculty also has experience working in low resource countries, an asset that improves the practical application of didactic concepts to the practice settings of conference participants. a natural process of mentoring has been established, creating lifelong friendships with professional colleagues across the world. since its inception and through current years, the program has also provided a source of professional and spiritual support to these missionaries, helping to connect their work to modern standards of global health. 9 healthcare missionaries are vulnerable to mental health challenges. 10, 11 missionary doctors are the “poorest and most isolated of [their] profession.” 12 traumatic experiences, including natural disasters, warfare, terrorism, and epidemics, are experienced frequently by healthcare missionaries. they also experience significant levels of anxiety associated with occupational issues, acculturation, and physical illness. 13, 14 isolation and added administrative and leadership responsibilities are also contributing factors to stress. 15, 16, 17 the program described has proven to be a safe setting in which healthcare missionaries could receive succor and counsel within a safe community of likeminded individuals, thus helping them to remain in their 29 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. field of service beyond what they might have in the absence of such programming. 18 the christian medical and dental associations serves a membership of nearly 18,000 christian healthcare professionals through more than 40 programs and services with the mission to “change hearts in healthcare.” 19 recognizing the above-mentioned opportunities nearly 40 years ago, the cmda embarked on an endeavor that continues to respond to the genuine needs of healthcare missionaries through the following aims: 1) supporting, educating, and resourcing international healthcare workers, and 2) developing effective international healthcare educators. the establishment, evolution, and impact to date of these two program aims are described in this paper. history and framework of cmda’s professional continuing education program in 1976, the christian medical and dental association began the process of developing a continuing educational program for healthcare workers serving in overseas settings where they had limited access to professional continuing education. this led to the first cmda-sponsored professional continuing education conference for cross-cultural healthcare workers. the first conference held in liberia, in january 1978, had two goals. the first was to send short-term healthcare workers in to replace long-term workers to give them a short time of respite. the second goal was to provide the longterm workers medical education on current healthcare topics through the conference program. the first conference in liberia required substantial flexibility and much onsite coordination, both of which encouraged facilitators to focus on the overarching role of supporting the participants and their families. such emphasis on holistic programming still presides as a foundation for all program activities, demonstrated by the formation of special spouse and child programs, as well as focused times of fellowship for whole family units to engage with one another in encouraging ways. these components emerged and remain nearly as central to the program as its educational focus. providing short-term replacement clinicians as relief for participants of the program proved difficult to coordinate and was discontinued after the first year of the conference as many participants became able to independently negotiate leave time and local relief from their settings of work. in 1979, the ad hoc committee that facilitated the first conference was formalized into a commission dedicated to education of international healthcare workers on behalf of the cmda. the second conference was held in kenya, in march 1980, and a third followed in 1982, also in kenya. the first conference held in asia (malaysia) was held in 1983. thereafter, these conferences have been held on a yearly basis, alternating between africa and asia (with the exception of 2008 when turmoil in kenya prevented the conference from proceeding). the asia conference has usually been held in thailand. since 2014, the conference routinely held in africa has been held in europe in a larger venue which has accommodated more participants in recent years and has welcomed a global audience of participants serving in any country. table 1 shows the guiding principles for the commission: two aims of the program focus on education and encouragement of international healthcare workers with the vision statement centered on the well-being of these individuals; spanning the two aims, core values are informed by scripture and give direction to the commission. 30 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. the success of this professional continuing education program is related to the commitment and quality of the commission members. a minimum of 18 members, usually serving 3 consecutive 2year terms, actualize the purposes stated in table 1 within a defined leadership and governance structure, annually reporting on activities directly to the cmda board of trustees. the commission is composed of highly qualified healthcare professionals from universities and medical centers around the world (though the majority represents the united states). in addition to being encouraged to financially support the program and contribute as faculty, commission members are central to the planning and implementation of the program, including recruitment of in-kind faculty contributors, processing registrations for participants, facilitating accreditation of program content as an independent cme accrediting agency, and ensuring appropriate venue accommodations. as such, members of the commission have been integral to the advancement of international healthcare pedagogy, support and encouragement of international healthcare workers, and development of a strong cohort and pipeline of international healthcare educators. this paper utilizes minutes from commission meetings, reports to the cmda board of trustees, and interviews of commission members to describe emerging positive impact resulting from the program. quantitative impact the professional education program described currently consists of four specialization tracks: medicine, surgery, community health, and dentistry. leaders of these tracks with expertise in their field are responsible for establishing the teaching program and recruiting faculty to present sessions at the conference within their track. there are some general sessions on common crossdisciplinary topics, but most conference periods include concurrent teaching sessions in each track. total participation (figure 1) has increased over time. please note that in figure 1 the bolded green line represents total participants and reflects trends from the y-axis scale to the right of the graph, while the y-axis scale to the left of the graph represents trends by specific categories of participants. though each venue has historically welcomed a majority of participants from either africa or asia, both conferences have been open to all countries since 2014 and have included those serving in europe, south america, and beyond. since the conference venue in europe accommodates more participants from a global range, it will be described as the africa/global 31 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. conference while the other conference that still attracts those serving primarily in asia will be referred to as the asia conference. appreciable changes in participation occurred at the turn of the century for the asia conference (an increase from ~160 to ~570 of total participants, as shown in figure 1a) and for the africa/global conferences after 2010 (an increase from ~300 to ~700 of total participants, as shown in figure 1b). tracking of participation data has not been uniform throughout 40 years of program facilitation, particularly in the reporting of nurses and other providers (ex: physician assistants, nurse practitioners, midwives, non-md physicians, physical/occupational therapists, pharmacists, phds). dentist participation has remained level at 15-30 participants each year. since 2014, the conference held in africa was offered in europe, where a larger venue accommodated more participants; this aligns with the marked increase in participation in the africa/global conference since 2014 and may account for the slight decline in participation volume in the latter years of conferences held in asia. international healthcare workers who participate in the conferences serve in approximately 30 to 60 different countries (figure 2). representation in excess of 75 countries was seen during the first conference held in europe rather than on the continent of africa since the size of the new venue allowed organizers to allow healthcare workers to participate regardless of where they were serving. acquired continuing education (figure 3) approximates 10,000 hours per conference across all participants, with the exception of 2012 and 2015 when claimed continuing education hours are nearly a third lower. the number of faculty participants has nearly doubled in the last decade (figure 1). figure 1: conference participation (note that the y-axis for total participation is to the right of each graph in green) 32 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. the continuing education program of cmda has offered at least some life support training since its inception (figure 4), tailoring the diversity and sophistication of certification to participant demand, accredited course director availability, and trends in us training requirements. these courses have included the following: bls=basic life support; acls=advanced cardiac life support; pals= pediatric advanced life support; hbb=helping babies breathe; also=advanced life support obstetrics; nrp=neonatal resuscitation program. besides continuing education and other training sessions, spouse/child programs, spiritual programming, and overall times for fellowship and interaction, research symposia have been added as a way for participants to share case reports, innovation, and original research from their settings. with 5 posters presented in 2015 and 18 posters (all related to an indigenous surgical training program) presented in 2016, this initiative will likely continue to grow, adding another educational perspective and opportunity for information sharing and collaboration among participants. 33 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. qualitative impact in addition to quantitative results about the magnitude of international healthcare workers educated and hours of educational credit provided, there have also been significantly favorable qualitative outcomes from the annual conferences. the qualitative impact of this program may be best demonstrated by participants who express their gratitude for the unique offerings of the program: i have finally found a conference with “my” people; people who understand me and my needs. since attending this conference i am better equipped to serve in my area of the world as well as refreshed, understood and encouraged. i’m so grateful i came to [this conference] (1 st time attendee). it will radically impact my ability to stay on the field long term. aim 1: supporting, educating, and resourcing international healthcare workers in offering this professional continuing education program, the cmda has maintained a consistent understanding of mission and service by requesting feedback, utilizing surveys, and implementing research (ex: the prism survey 20, 21 ) to ensure that the conference is in step with and truly meeting the educational and spiritual needs of healthcare missionaries. this holistic approach focuses on healthcare workers and their families, prioritizing encouragement in support of education. as in many faith-based endeavors, these conferences naturally take on a posture of fellowship, where biblical teaching, worship and spiritual communion add value to the educational components. this context serves as spiritual support for the attendees, as many families do not have access to as large a group of fellow believers with whom to interact in their settings of work. the program has sought to be responsive to these needs with adequate family and spiritual programming but has also emphasized the need to balance these with the functional educational purposes of the conferences. with the increase of virtual opportunities to acquire continuing education credits, the in-personal appeal of the conferences has increased the value of both the educational and spiritual components in this program, despite the associated cost of attendance. navigating these changes and needs, high-quality education has consistently been granted as the unique contribution of this program to the cause of missions. though the functional purpose of the program is providing accredited education, supporting international healthcare workers and their families is a parallel aim. the synergy of learning from peers during the conferences has reportedly contributed to an increased quality of life and a greater ability to persevere in their work. specific examples of ways the program has made adjustments towards this end include changing the venue of conferences to increase affordability and accessibility, flexibility in the way participants utilize the conference space for education, mutual support, leisure, and the appropriateness of the venue for all members of the family. special programming for non-healthcare professional female and male spouses has proven a powerful source of mutual support and encouragement. professional counseling services are also wellutilized by participants throughout the conference. child programming is often separated into 2-3 age cohorts and has focused on the spiritual and identity formation of the children, development of relationships with other children who are growing in cross-cultural settings, and includes time for leisure and entertainment with peers and family. all participants may join morning devotional/prayer meetings and evening worship services, during which peers present field reports on the work in which they are involved. a distinguished keynote lecture is also a highlight of each conference. this not only serves as an inspiration to those gathered, but it also provides an opportunity for networking, mentoring, and an exchange of information/ practices between areas of work. apart from these 34 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. formal spiritual and educational programs, informal gatherings are organized by participants between sessions or at meal times to convene according to discipline, region, sending organization, or interest (ex: community health evangelism, water sanitation, etc.). thus, the program has been effective in supporting the daily work of long-term international healthcare workers. in addition, several long-term workers report having been on the brink of abandoning their work when they went to the conference; repeatedly, missionary careers have been saved as workers obtain encouragement to carry on. this sentiment is demonstrated by the following participant quotes: it’s not easy to describe just how much [this program] has come to mean to me as i serve long-term in asia. the challenges in my assignment are not insignificant spiritual darkness, poverty, tropical heat, small numbers of like-minded people incountry, etc and plenty of joys and opportunities to grow, as well! but knowing every two years we will come together at [this conference] to be refreshed academically with state-of-theart medical education, to have fellowship with a like-minded peer group, and to benefit from informal mentoring with those more experienced than myself has enabled me to keep pressing on through the mountains and valleys! really, i am not exaggerating when i say [that this program] is an invaluable ministry and we thank god for those willing to go to all the huge effort to faithfully serve us. thank you! early in my career, i temporarily lost my medical license in the states due to the lack of documented cme. this conference rescued me… my license [in-country] depends on an active license in the usa. aim 2: developing effective international healthcare educators the consistency of high quality educational opportunities and participation, as described above, does not demonstrate the advancements in pedagogy that have taken place. a near doubling of the number of faculty participating in both the africa/global and asia conferences within the past decade (figure 1) suggests that the program is a well-established opportunity for diverse academic and clinical experts to present and develop relevancy of their content before an international forum. this stability and growth affirms the program’s commitment to educational advancements in ways that do not compromise but enhance support of international healthcare workers and also allow flexibility for innovation in pedagogy. the ten-day nature of each conference allows plentiful time for faculty to interact with participants to receive feedback on specific gaps that exist in the ability to apply presented content/practices to their settings of work. these interactions inform the nature of future course offerings. the conference has routinely offered several themed tracks, including medicine, surgery, and dentistry; upon additional feedback from those in community-based settings and in health administration roles, the community health track was added and developed with various emphases over the years actual community health, public health, administration, leadership, cultural adaptation, healthcare ethics, and faculty development. case-based discussions and consultations with faculty experts encouraged the formation of md second-opinion, a program that engages over 230 specialty clinicians that offer 3-5 virtual clinical and educational consultations to international healthcare workers per week. a commitment to presenting contemporary standardsof-care has included hands-on training with technology that may not yet be available in the settings where participants work but maintains their competence by us measures. the variety of life support training offered (figure 4) represents both the requirements of specialists in the developed 35 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. world as well as skills relevant to the needs of participants in their work settings. some program participants have been trained to be life support trainers for future programs internationally and in their places of service. a limber and committed faculty cohort has enabled quick adoption of content about high profile topics like hiv/aids in the 1980s and ebola in 2015. these examples demonstrate a commitment to high-quality standards of healthcare education as well as being responsive and relevant to the workplace needs of participants. over time, more and more conference participants have served as conference faculty, presenting lectures and leading workshops. in the new testament model of paul and timothy, educators are training participants who then go on to teach others. conference materials are available for adaptation and use in other settings. conference participants experience models of cutting-edge education and are thus equipped to educate others in these novel ways. in addition to evolving and adapting content, the way in which content is presented has continually progressed. physical slide presentations and carousel-projectors were utilized very early in the program, when such technology was not yet available in low-resource settings. initial paper binders of conference content were replaced with cd, dvd, and currently flash drive storage of all presentations for participants to reference after the conclusion of conferences. incorporation of immediate-audience-response systems into presentations has enabled participant engagement and evaluation during sessions. hands-on workshops in endoscopy, ultrasonography, casting, radiographic interpretation and other clinical techniques have been popular educational opportunities. case-based discussions and break-out sessions have also been well-attended opportunities to apply and develop interpretation and diagnostic skills. these diverse teaching techniques have been valuable to both participants and faculty who seek to respond to the unique needs of international healthcare learners. global issues such as hiv-aids, mental health, human migration, disaster relief and human trafficking present opportunities for critical contributions to vulnerable populations. the world is changing, 22 and the role of the healthcare missionary is also changing. 17 new focuses such as medical research, residency training and systematic management of chronic diseases also have opportunities for healthcare missions to support the development of strong national health care systems in developing settings. the conferences described address these issues as they arise, thus helping increase the competence of healthcare missionaries to address such concerns that frequently present more urgently in their work settings than in north america. healthcare is a highly close-knit global society, using highly uniform standards of diagnosis and care, so partnership and collegiality are not difficult to create. the discussed initiatives and developments are a small glimpse into the opportunities available in the current global health climate. the nexus of equipping international healthcare workers and developing international healthcare educators several developments have enabled the two aims of the program described to intertwine. healthcare workers in international settings have contributed in the leadership, planning, and faculty roles. their engagement has enabled shrinking of the gap that often exists between educators from the developed world and international healthcare learners in low-resource settings. this pattern has also helped to build international healthcare capacity, empowering and mobilizing for peerresourcing that is most appropriately informed and relevant to unique needs in low-resource settings. in fact, there is a rise in the number of international healthcare workers whose primary appointment is to educate in indigenous settings. engagement of national workers, such as those from the panafrican academy of christian surgeons (paacs) 36 slashcheva, strand, vanreken, sanford, phillips & halverson nov 2016. christian journal for global health, 3(2): 27-37. and other mission hospital staff, has offered opportunities for research and development projects across regions. one example is a recent article on improving diagnosis and treatment of chromoblastomycosis in rural madagascar. 23 engaging 2-4 health professionals-in-training (medical/dental school or residency) as academic assistants at conferences has not only improved the flow of conference activities, but has also presented an opportunity for young professionals interested in global health and ministry to see firsthand the complexity and reality of international healthcare, as well as consider opportunities to support this work by doing research or developing as international healthcare educators, as demonstrated by the following quote: serving as an academic assistant provided me the opportunity to interact with international healthcare workers in genuine ways beyond the glow that often comes with serving abroad to see the ordinary challenges and heartening opportunities of providing competent and compassionate care in a cross-cultural setting. as a healthcare professional still in training, i also appreciated seeing the authentic contributions of academic and clinical educators towards strengthening the global safety net. the diverse gathering of faculty, staff, volunteers, and participants at each year’s conference provides mutual inspiration and encouragement, affirming the mission of the program to advance god’s kingdom from whichever vocational setting to which we are called. through both quantitative and qualitative 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[research report]. medical missions survey working group of the cmda. 2011. 22. strand ma, paulson e, myrick t. characterizing the global context for cross-cultural healthcare work by regions of the world. christ j glob heal. 2015;2(2):2338. http://dx.doi.org/10.15566/cjgh.v2i2.78 23. santmyire a. the effectiveness of a multifocal training to improve the treatment of chromoblastomycosis in rural madagascar. j health care poor u. 2016; 27:993-1010. http://dx.doi.org/10.1353/hpu.2016.0146 peer reviewed competing interests: none declared. correspondence: lyubov d slashcheva, university of department of preventive and community dentistry, iowa, united states. lyubov-slashcheva@uiowa.edu cite this article as: slashcheva ld, strand ma, vanreken re, sanford c, phillips jd, halverson g. continuing medical and dental education on the global stage: the nexus of supporting international christian healthcare workers and developing educators. christian journal for global health (nov 2016), 3(2):27-37. © slashcheva ld, strand ma, vanreken re, sanford c, phillips jd, halverson g this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://dx.doi.org/10.1163/157338392x00072 http://dx.doi.org/10.1111/j.1600-0447.1998.tb10000.x http://dx.doi.org/10.15566/cjgh.v1i2.19 http://dx.doi.org/10.15566/cjgh.v3i1.102 https://cmda.org/about/ http://dx.doi.org/10.15566/cjgh.v2i2.78 http://dx.doi.org/10.1353/hpu.2016.0146 mailto:lyubov-slashcheva@uiowa.edu http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ commentary may 2019. christian journal for global health 6(1) the role of faith-based organizations and faith leaders in the 2014–2016 ebola epidemic in liberia perry jansena a md, dtmh, vp of strategic partnerships for medsend; executive director of the malawian non-profit health organization, partners in hope, usa abstract since the time of christ, caring for the sick and the poor has been a core distinctive of authentic christianity. the response of christians during many of the great plagues of antiquity played an important role in the spread of christianity. in modern history, response to epidemics have been professionalized and, to a certain extent, secularized. the 2014–2016 ebola outbreak in west africa offers an important illustration of the role that faith leaders and faith-based organizations still play in providing a trusted link between communities and international relief workers. during the latter half of 2018, the world was faced with another outbreak of ebola in the democratic republic of congo. it is vital to build upon the lessons of prior epidemics as we support local efforts to prepare for, detect, and respond to inevitable future outbreaks. key words: ebola, liberia, epidemic, faith leaders, faith-based organizations, public health introduction the ebola and sars outbreaks in the past decade have raised the specter of epidemics that could overtake the globe in coming years. in his book, factfulness, hans rosling lists global pandemics as one of the 10 greatest risks for our future.1 however, global epidemics (pandemics) are certainly not new to human history. ancient plagues, including yersinia pestis, influenza, smallpox, cholera, and typhus, claimed millions of lives and permanently altered civilizations. throughout the centuries, many christians and christian leaders distinguished themselves by risking their own lives, caring for the sick, and dying while others fled.2,3 christians’ sacrificial care during the time of the roman empire contrasted with prevailing culture, and their response may have been an important catalyst for the growth of early christianity.4 most early hospitals and medical schools arose from christian monasteries that played crucial roles in caring for the sick and the poor.5 christian missionaries and faith leaders played key roles in promoting the concepts of primary healthcare and health as a human right and a part of the alma ata declaration of the world health association (who) in 1979.6,7 in more recent history, some may say that christian leaders faltered in their initial response to the modern epidemics of hiv and ebola but have 71 jansen may 2019. christian journal for global health 6(1) ended up playing vital roles in the global response. david hughes, in his address to the 13th congress of the european society for evolutionary biology, said of historic christian responses to epidemics, “... the belief systems, for example, influenced whether people fled from the disease or tried to help those who were sick.” he went on to outline the importance that christian faith in malawi played in people’s likelihood to care for people with aids.8 reflections on the 2014–2016 ebola outbreak in west africa document the journey of faith leaders as they finally rose up to play an important role in implementing the social and behavioral changes necessary to decrease further transmission.9 ebola comes to west africa the index case for the west african ebola epidemic of 2014–2016 is believed to have been an 18-month old baby who died in december of 2013. in mid-march, médecins sans frontières (msf, also known as doctors without borders) confirmed a case in guinea and, subsequently, who declared an outbreak. liberia’s first confirmed case was only a week later, and by june, ebola cases had been documented in the capital city of monrovia. by july of 2014, cases had been reported in the capital cities of guinea, liberia, and sierra leone. it was not until august 8th that the world health organization (who) declared a public health emergency of international concern (pheic). this was the first time that this deadly virus had made its way from remote jungles to large urban centers, making containment a much more difficult task.10 the small west african country of liberia had several decades of political unrest marked by violent coups, counter-coups, and civil war. although there had been significant improvements in the healthcare system under the new leadership of ellen johnson sirleaf in the years before the ebola outbreak, there were still critical shortages of all cadres of health providers, and services were limited by poorly equipped facilities.11 by the time the region was declared ebola-free in june of 2016, cdc reported over 28,600 ebola cases and 11,325 deaths.13 the human and economic costs of this horrendous season in west africa’s history will leave scars for generations to come. it is estimated that over 800 health workers were infected with ebola during this period, and over 500 of them died. in liberia, 8% of its already scant number of healthcare workers died from ebola.14 while we rightly honor the heroes who risked or gave their lives to help the sick and dying, it is also important to examine the national and international responses to the epidemic and how we can improve our readiness for future outbreaks of not only ebola, but the many other emerging infectious diseases that could threaten populations in the future. ebola virus disease-epidemiology ebola virus disease (evd), formerly termed ebola hemorrhagic fever, is a rare and deadly virus that causes disease in humans and other primates. there are a number of animal reservoirs for this virus, the most significant of which may be the fruit bat.15 human-to-human transmission is through contact with any bodily fluids from a person who is sick with, or has died from, evd. caring for the sick and burial of the deceased play enormous roles in the spread of the disease in a population. the modernization of transportation and porous borders also played roles in the rapid spread from guinea to surrounding countries.16,17,18 the national and international response in addition to documenting the early cases in guinea, msf was the first organization to recognize the unprecedented danger of an outbreak in crowded, urban settings. they tried to raise the attention of international authorities, but with no timely substantial response. the book, politics of fear, recalls that during this time an unlikely partnership developed between the secular msf and the overtly 72 jansen may 2019. christian journal for global health 6(1) christian relief organization, samaritan’s purse (sp). the people at samaritan’s purse were the only ones to resolutely raise their hand and declare their willingness to help.... it was a courageous offer we could not refuse, and since then we have tried to work hand in hand, albeit with protective gloves, in the fight against ebola.19 sp had a long-standing relationship with elwa hospital, a mission hospital founded by usbased mission sim (a non-denominational christian mission organization) in the 1950s.12 msf is considered to be the world experts at managing ebola outbreaks. they provided training and support for elwa hospital as they established an ebola treatment unit in what had previously been their hospital chapel. msf worked with elwa and sp to plan and construct a second, larger ebola treatment unit (ebu) known as elwa2. this unit was run by dr. kent brantley, a physician working with sp at elwa. sim provided logistical support to get ebola supplies (especially personal protective equipment [ppe]) sent to the hospital. as additional cases of ebola were confirmed, the number of patients presenting to the hospital increased faster than their facility was able to manage. even patients admitted for other conditions, such as diabetes or labor, succumbed to co-existing with ebola and then infected a number of healthcare workers. it was clear to health personnel that this was an epidemic that was out of control, and early identification and isolation were critical to containment. the scale of death was also clear to the general public, especially around monrovia, and fear and panic set in. the un itself acknowledged that the level of trust that locals had in their state institutions was low, contributing to suspicion about the prevention messages that they were receiving, and that governmental and international agencies did not engage faith leaders early in the epidemic 9 a number of ppe-clad healthcare workers were attacked because the locals believed that msf, sp, and other western influences had intentionally brought this disease to them and that their disinfecting sprayers were actually the source of the disease.21 this out-of-the-way hospital and its dedicated staff would soon explode out from anonymity as dr. brantley and a nurse, nancy writebol, were themselves diagnosed with ebola. the world watched as news of their declining health started a frenzy of activity to save their lives. close relationships with the u.s. state department and other agencies allowed sim and sp to facilitate the services of an evacuation airplane specially equipped with a biocontainment unit to fly into liberia to evacuate brantley and writebol.22 both were showing a rapid decline in their conditions as they awaited evacuation, and the decision was made to use an untested, experimental ebola drug called zmapp first on dr. brantley and then mrs. writebol. both were successfully evacuated to the u.s., and they eventually recovered. dr. lance plyler, the medical director of samaritan’s purse’s (sp) division responsible for disaster response (world medical mission), was head of the sp team working at elwa during the epidemic and was one of two doctors caring for their team members who had become infected. dr. plyler reiterated the importance of the unlikely partnership between sp and msf. they had both been active in health system development in liberia for many years, but never worked collaboratively before the epidemic hit. the sp/elwa team did not have the expertise of msf in ebola treatment, but they did have the courage to take on treating sick patients and a resource base to rapidly expand their capacity to respond to the need. msf recognized that this team represented a valuable partner and willingly shared their experience, resources, and international spotlight to help elwa become a major ebola treatment center. similar to fellow soldiers in a war, the relationship between these two organizations is now forever changed. 73 jansen may 2019. christian journal for global health 6(1) prior strategies for responding to outbreaks of ebola often focused on preventing new infections rather than improving outcomes for those already infected.23 experienced relief organizations like msf and partners in health (pih, working in sierra leonne) also recognized that improving supportive care and reducing the delay in hospitalization could significantly reduce fatality rates.24,25 the quality work that sp did in liberia during the ebola epidemic was later expanded as they once again put themselves in harm’s way setting up a field hospital just outside of mosul, iraq. often excluded from international planning processes, sp now has a seat at the table.26 since the end of the ebola epidemic, elwa has been recognized for its contributions and has further expanded its facilities and capacities, including running one of very few ebola survivor clinics.22 response of liberian faith leaders the tear fund report describes that the early response of faith leaders in liberia did not help ease the fears of the population; rather, it created stigma that led many to refuse to let anyone know when a member of their household became ill. in july of 2014, the liberian counsel of churches released a communication unanimously warning that, “god is angry with liberia” and “ebola is god’s plague. liberians have to pray and seek god’s forgiveness over the corruption and immoral acts (such as homosexualism, etc.) that continue to penetrate our society.”9 governmental leaders and international organizations were late to recognize the important role that trusted faith leaders had in influencing community members to override stigmatization and engage in recommended ebola prevention behaviors. the lack of trust in government and “western actors” needed to be supported by more trusted voices from within their own community.27 in september, the world council of churches convened a meeting of christian leaders, aid organizations, and un agencies to highlight the importance of engaging faith leaders and faith-based organizations in this fight. this unified voice resulted in collective action from faith leaders around infection prevention activities and decreased the fear and stigma about ebola. they were able to replace messages of fear with messages of hope.9 both christian and muslim faith leaders drew lessons from their own religious texts (the bible and the quran) to support the recommended infection control and prevention measures for ebola. these included seeking medical care when sick, avoiding contact with bodily fluid, and routine hand washing after contact with the sick or with dead bodies. they emphasized the need for safe and dignified burials, as well as acceptance and appreciation of ebola workers. they validated the need for psychosocial support for those impacted by the disease, rather than stigmatizing them.9 critique of the public health response the response to the first case of ebola in lagos, nigeria, in july of 2014 can serve as an example of how rapid case detection and appropriate public health measures can limit the scale of an outbreak. a traveler had returned to nigeria after caring for an evd loved one in liberia. he became sick during the flight and was admitted to the hospital upon arrival at lagos. in total, 20 evd cases were reported in nigeria, with eight deaths. eleven of these cases were healthcare workers; nine of these were infected from the initial case before his disease was identified. within weeks, there were no new cases. evaluation of the nigerian response identified the key factors that limited further spread of the disease: 1) fast and thorough identifications of all contacts (894 individuals), 2) ongoing monitoring of all contacts, and 3) rapid isolation of all potentially infectious contacts. the global response to the ebola epidemic in guinea, liberia, and sierra leone has created another opportunity to evaluate preparedness for 74 jansen may 2019. christian journal for global health 6(1) epidemics. it is clear that these countries did not have systems for rapid identification of early cases and their contacts. despite early dire warnings from msf, the who and other international actors were slow in their response. on august 28th, 2014, the who finally declared the west africa ebola epidemic a public health emergency of international concern (pheic). an independent panel from harvard university global health institute and the london school of hygiene and tropical medicine were tasked to review the ebola response.28 the report states that “ebola exposed who as unable to meet its responsibility for responding to such situations and alerting the global community.” early in the epidemic, it was clear that these countries did not have the capacity to detect early evd cases, and none were properly trained or equipped with personal protective equipment to respond safely. this resulted in a large number of health workers becoming infected. as the disease took hold in these countries, there was a failure of political leadership to call for increased assistance. the in-country who teams were weak, and the who as a whole also failed to mobilize global assistance in a timely fashion. as funding and global attention increased, local media and police ignited fear and heightened distrust. as mentioned above, the faith community was not engaged early in the epidemic, and their initial response only increased fear and stigmatization. the 2018–2019 outbreak in the democratic republic of congo on august 1, 2018, the democratic republic of congo announced another outbreak in the mineral-rich and highly volatile province of north kivu. this came only days after declaring victory over and outbreak in the equateur province.29 responders had the advantages of lessons learned from the west african epidemic, as well as a number of experimental therapeutics and vaccines that were then available. however, responders faced additional challenges related to violence and political instability that made it complicated to deploy the workers and materials necessary to combat the epidemic. during his visit to drc in january 2019, who director-general dr. tedros adhanom ghebreyesus confirmed, “the main challenges are the security environment, pockets of mistrust among affected populations, and poor infection prevention and control in many public and private health facilities.”30 once again, msf and samaritan’s purse (sp) were on the front lines putting many of the lessons learned from west africa into action. in january 2019, sp expanded their capacity with the addition of an 18-bed treatment unit that supplemented their existing field hospital. msf had recently increased their bed capacity from 64 to 94 beds. in a recent report, msf’s roberto wright emphasized that “with ebola, treatment centers alone are not enough. connecting with the communities and building mutual trust is key to get the outbreak under control.”31 recommendations for future efforts wright’s statement echoes dr. jonathan quick’s sage advice in his book, the end of epidemics. “but counteracting panic and resistance can’t just be a top-down, government-issued effort, because trust in government is eroding everywhere. rather, trust evolves from community leaders and public-health officials working in concert.”32 quick goes on to outline seven sets of actions needed to prevent future devastating epidemics: (1) ensuring bold leadership at all levels, (2) building resilient health systems, (3) fortifying three lines of defense against disease (prevention, detection, and response), (4) ensuring timely and accurate communication, (5) investing in smart, new innovation, (6) spending wisely to prevent disease before an epidemic strikes, and (7) mobilizing citizen activism. 75 jansen may 2019. christian journal for global health 6(1) the harvard-london school of hygiene and tropical medicine independent panel cited above listed 10 major recommendations for strengthening global systems to respond to epidemics.28 however, a year before the epidemic in west africa had started, moon et al outlined a more concise list of recommendations for systematic investment to enable the global community to perform four key functions: 1) strengthen core capacities within and between countries to prevent, detect, and respond to outbreaks when and where they occur; 2) mobilize faster and more effective external assistance when countries are unable to prevent an outbreak from turning into a crisis; 3) rapidly produce and widely share relevant knowledge from community mobilization strategies to protective measures for health workers and from epidemiological information to rapid diagnostic tests; 4) provide stewardship over the whole system, entailing strong leadership, coordination, priority-setting, and robust accountability from all involved.33 had these key functions been in place, the recent ebola epidemic in west africa would certainly not have exploded as it did. however, this list of functions only hints (leadership in function 4) at creating strong relationships with community and faith leaders in preparation for epidemics and early in outbreaks and the vital role of faith-based organizations. it would certainly be easy for international humanitarian actors to work to strengthen these functions and still miss the vital role that these leaders play in actual implementation of relief efforts. the tear fund document cited above also makes a number of recommendations for engaging faith leaders and fbos in response and recovery efforts.9 salient points and additional recommendations for donors, governmental leaders and international organizations • authentic partnerships: include faith leaders and fbos, in planning for preparedness and early response to epidemics, as genuine partners who hold expertise in knowing their communities and their culture. create opportunities to engage faith leaders in doing their part to protect the health of their community and strengthen health services. avoid focusing only on outputs, and be willing to make long-term investments in building quality institutions. • faith literacy: strengthen understanding of the important role of faith and faith leaders in implementing health interventions, especially in settings where trust in government and “western influence” is low. train humanitarian staff in the religious context of the communities in which they work, and encourage them to build relationships directly with leaders. • highlight best-practices: assist fbos and faith leaders in adopting program management skills and simple and contextualized monitoring and evaluation systems to evaluate their own impact and share best-practices. this allows for pride in their work and dissemination of lessons learned. for faith-based organizations • promote excellence: help break down preconceptions and perceived barriers by producing excellent results from the work done. know humanitarian and epidemicspecific guidelines as well as any secular organization does. • promote partnership: be open to working with secular organizations, governments, and 76 jansen may 2019. christian journal for global health 6(1) other faith leaders in ways that build peace and strengthen collaboration. • build people and not just programs: the current requirements of many grants are so focused on shortand medium-term deliverables that there is not a priority (or money) for building the capacity of the people within the organization or community. seeing people as cogs in a machine will never truly build healthy communities. for faith leaders • know your faith: many of the world’s major religions and religious texts emphasize the importance of caring for the sick and building community. educate yourself about how to live out your faith in community. • know your community: look beyond the doors of your church, temple, or mosque, and know the needs of your community and how you are called to help meet those needs. building resilient communities is the sign of healthy faith. • stay connected: stay connected with what is happening in your community, district, and country, and explore how you can be leaders wherever you are. references 1. rosling h, rosling o, rosling a. factfulness: ten reasons we're wrong about the world-and why things are better than you think. flatiron books. new york, ny; 2006. 2. devaux c. small oversights that led to the great 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[cited 2018 aug 31] available from: https://www.cdc.gov/vhf/ebola/about.html 16. kramer am, pulliam jt, alexander lw, park aw, rohani p, drake jm. spatial spread of the west africa ebola epidemic. roy soc open sci. 2016;3(8):160294. http://doi.org/10.1098/rsos.160294 17. park dj, dudas g, wohl s., goba a, whitmer sl, andersen kg, et al. ebola virus epidemiology, transmission, and evolution during seven months in sierra leone. cell. 2015;161(7):1516 –26. http://doi.org/10.1016/j.cell.2015.06.007 18. ifrc.org. preventing disease from crossing borders in west-africa post-ebola [internet]. international federation of red cross and red crescent societies. 2016 march 21. available from: http://www.ifrc.org/en/news-and-media/newsstories/africa/guinea/preventing-diseases-fromcrossing-borders-in-west-africa-post-ebola--72032/ 19. hofman m, au s. the politics of fear: médecins sans frontières and the west african ebola epidemic. new york, ny: oxford university press. 2017. 20. cbs news.com. liberia clinic attack overwhelms overworked ebola aid workers [internet]. 2014 august 17. available from: https://www.cbsnews.com/news/liberia-clinic-attackoverwhelms-overworked-ebola-aid-workers/ 21. sacra d. trauma health after ebola in liberia: sociocognitive analysis of a bible-based psychoeducational approach. 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learning from experience. lancet. 2015;386(10005):e24-5. https://doi.org/10.1016/s0140-6736(15)61082-0 28. moon s, sridhar d, pate ma, jha ak, clinton c, delaunay s, et al. will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola. lancet. 2015;386(10009):2204-21. http://doi.org/10.1016/s0140-6736(15)00946-0 29. damon i, rollin p, choi m, arthur r, redfield r. new tools in the ebola arsenal. new engl j med. 2018;379(21):1981-3. https://doi.org/10.1056/nejmp1811751 30. who news release. who director-general concludes new year visit to ebola-affected areas in the democratic republic of the congo [internet]. world health organization, geneva. 2019 january 3. available from: https://www.who.int/newsroom/detail/03-01-2019-who-director-generalconcludes-new-year-visit-to-ebola-affected-areas-inthe-democratic-republic-of-the-congo 31. msf.org. ebola patient care increases amid growing tensions in north kivu-project update [internet]. médecins sans frontières.2019 january 18. available from: https://www.msf.org/ebola-patient-careincreases-amid-growing-tensions-north-kivu-drc 32. quick j, fryer b. the end of epidemics: the looming threat to humanity and how to stop it. new york, ny: st. martin's press. 2018. 33. frenck j., moon s. governance challenges in global health. new engl j med. 2013;368:936-42. https://doi.org/10.1056/nejmra1109339 https://www.cdc.gov/vhf/ebola/about.html http://doi.org/10.1098/rsos.160294 http://doi.org/10.1016/j.cell.2015.06.007 http://www.ifrc.org/en/news-and-media/news-stories/africa/guinea/preventing-diseases-from-crossing-borders-in-west-africa-post-ebola--72032/ http://www.ifrc.org/en/news-and-media/news-stories/africa/guinea/preventing-diseases-from-crossing-borders-in-west-africa-post-ebola--72032/ http://www.ifrc.org/en/news-and-media/news-stories/africa/guinea/preventing-diseases-from-crossing-borders-in-west-africa-post-ebola--72032/ https://www.cbsnews.com/news/liberia-clinic-attack-overwhelms-overworked-ebola-aid-workers/ https://www.cbsnews.com/news/liberia-clinic-attack-overwhelms-overworked-ebola-aid-workers/ https://doi.org/10.1093/infdis/jiw345 https://doi.org/10.1093/infdis/jiw345 https://doi.org/10.1056/nejmp1411310 https://doi.org/10.1164/rccm.201408-1514cp https://doi.org/10.1016/s0140-6736(15)61082-0 http://doi.org/10.1016/s0140-6736(15)00946-0 https://doi.org/10.1056/nejmp1811751 https://www.who.int/news-room/detail/03-01-2019-who-director-general-concludes-new-year-visit-to-ebola-affected-areas-in-the-democratic-republic-of-the-congo https://www.who.int/news-room/detail/03-01-2019-who-director-general-concludes-new-year-visit-to-ebola-affected-areas-in-the-democratic-republic-of-the-congo https://www.who.int/news-room/detail/03-01-2019-who-director-general-concludes-new-year-visit-to-ebola-affected-areas-in-the-democratic-republic-of-the-congo https://www.who.int/news-room/detail/03-01-2019-who-director-general-concludes-new-year-visit-to-ebola-affected-areas-in-the-democratic-republic-of-the-congo https://www.msf.org/ebola-patient-care-increases-amid-growing-tensions-north-kivu-drc https://www.msf.org/ebola-patient-care-increases-amid-growing-tensions-north-kivu-drc https://doi.org/10.1056/nejmra1109339 78 jansen may 2019. christian journal for global health 6(1) peer reviewed: submitted 17 nov 2018, accepted 31 jan 2019, published 31 may 2019 competing interests: none declared. correspondence: perry jansen, vp of strategic partnerships for medsend; executive director of the malawian non-profit health organization, partners in hope, usa. perry@medsend.org cite this article as: jansen p. role of faith-based organizations and faith leaders in the 2014– 2016 ebola epidemic in liberia. christian journal for global health. april 2019; 6(1):70-78. https://doi.org/10.15566/cjgh.v6i1.265 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ original article july 2017. christian journal for global health 4(2):30-42. increasing access to family planning services through a nonhealth sector: technical integration coverage and access (tica) in nepal ghanshyam k bhattaa, josue orellanab, bidya mahatb, ishwar nath mishrab, chandeshwari tamrakarb, sujit kumar sahb a team leader, adventist development and relief agency (adra), nepal b adventist development and relief agency (adra), nepal abstract background: family planning (fp) is a key developmental focus for the government of nepal. use of modern contraceptives has stagnated at 43.2% since 2011. unmet need for family planning (fp) in nepal remains high at 27%. despite relatively high unmet need, a factor contributing to this levelling of contraceptive use is the limited range of methods available to most clients at most sites. to address the fp need among married women of reproductive age (wra), we tested integration of fp into agricultural programs. aim: to assess the effectiveness of a fp program integrated into an agriculture (e.g., non-health) sector program. methods: a descriptive cross-sectional (post interventional) study was conducted november 2015 to february 2016 among 525 wra participating in an agriculture program. results: the contraceptives commonly used by women in the study location were depo provera and minilap. after technical integration coverage and access (tica) interventions, almost all of the respondents (99.6%) had heard about fp of which 67.8% correctly understood fp as a method to prevent unwanted pregnancy. about 50% of the respondents were found currently using fp. the percentage of wra aware of longacting and permanent fp methods increased from 49.0% to 62.0% and 39.0% to 52.0% respectively. decisions on using a fp method were predominantly made by the husband (68.0%). however, 68.4% women reported that they were accompanied by their husband. the proportion of men willing to use fp increased from 5.2% to 15.5% after tica activities implementation. the main reason identified for not currently using fp devices was that the husband and wife were not living together (88.8%). most of the women (98.0%) reported that fp utilization improved their quality of life. conclusion: tica activities were very successful in both increasing fp knowledge level as well as utilizing fp services among the targeted beneficiaries. the use of fp increased 31 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. among agriculture program beneficiaries after the integration of tica activities with a gradual shift from short-acting fp methods to long-acting and permanent fp methods. for easy integration, fp projects should also utilize existing community structures such as cooperatives, women’s groups, men’s groups, and youth clubs. key words: family planning, nepal, development, agriculture sector, contraceptives introduction and problem statement overview of family planning context in nepal based on global evidence, maternal and child health outcomes could be substantially improved by meeting family planning (fp) needs of women in developing countries. provision of fp services contributes to a reduction in maternal mortality by lowering the risk of maternal death per birth hence preventing high-risk and high-parity births.1,2 according to the nepal demographic and health survey (ndhs 2011) and nepal mdg progress report 2010, despite significant progress toward achieving millennium development goal (mdg) 5, “improve maternal health” (decreasing maternal mortality from 539 in 1996 to 229 in 2011), nepal was unlikely to meet the 2015 mdg 5 modern contraceptive prevalence rate (mcpr) target of 67%. nepal’s early success in family planning (increasing the mcpr from 2.6% in 1976 to 44% in 2006) had plateaued, and use of modern contraceptives had stagnated at 43.2% since 2011. unmet need for fp in nepal remains high: 27% of married women reported unmet need in 2011, up from 25% in 2006. the government of nepal’s family planning goal is to achieve replacement level fertility (2.1) by 2020.3,4 pregnancies at an early age whether planned or not and unwanted pregnancies increase reproductive health risk including exposure to unsafe abortion and maternal mortality. over half (55.0%) of nepali women are married by the age of 18 which increases their chance of pregnancy at an early age. nearly half (47.0%) of girls who had their sexual debut before age 15 are forced against their will. a quarter (25.0%) of wra in nepal experience unplanned pregnancies.3 disparities in contraceptive use important disparities in contraceptive use exist. while the overall national mcpr among married women is 50.0%, it is only 19.0% among muslims, 25.8% among youth (married and unmarried), 37.0% among hill dalits, and 41.0% among hill janajatis (indigenous). both dalit and janajatis are groups that are traditionally disadvantaged/marginalized. the mcpr of spouses of migrant labourers is also extremely low: 20.0% among women whose husbands live elsewhere for at least one year, with even lower rates in the mountains and the hills (11.0% and 14.0%).3 high unmet need among groups with low mcpr, unmet need for contraception is considerably higher than the national average of 27.0%: 39.0% among muslims, 38.0% among youth, 35.0% among hill dalits, and 34.0% among hill janajati. unmet need is also high among migrants, at more than double the national average, and among the poor: 31.0% in the lowest wealth quintile compared to 22.0% in the highest. unmet need is higher in rural than in urban areas and highest in the western hill sub-region (36.0%) and western region (34.0%). it is similar in mountain and terai areas (26.0% in both). compared to 2006, levels of unmet need in 2011 declined in mountain and hill areas but increased in terai areas.5,6 choice in fp another factor contributing to the levelling off of contraceptive use despite relatively high unmet need is the limited range of methods available to most clients at most sites. in addition, poor quality counselling may be hindering clients’ understanding 32 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. and choice when selecting a contraceptive method. since 2001, female sterilization has been the most common modern method of contraception in nepal accounting for 35.3% of all fp users, mostly postchild bearing, followed by male sterilization at 18.1%. 15.0% of married women report using surgical contraception, followed by 9.0% using injectable contraceptives. all other modern methods are at negligible levels, with only 2.8% using implants and 1.3% using intra-uterine contraceptive devices (iucds).3 limited contact with fp providers and outreach workers limited services in hard-to-reach areas and insufficient community-based fp outreach to hardto-reach groups has resulted in insufficient contact between fp non-users and fp service providers. among all women who are not currently using fp methods, only 9.0% were visited by female community health volunteers (fchvs) who discussed fp, and only 6.0% visited a health facility where they discussed fp. overall, 88.0% of nonusers did not discuss fp with any health worker.3 key gaps in fp service delivery system the government of nepal’s fp program aims to have all fp methods (condoms, oral contraceptive pills, injectables, and long acting reversible contraception (larc)) available at service delivery sites from district hospitals down to the health post (hp) and outreach clinic level. it also aims to have district hospitals provide voluntary surgical contraception (vsc) services year-round, and mobile services provide comprehensive fp services, including vsc and the full range of temporary methods. despite this goal of providing district wide comprehensive fp services, poor functioning of institutionalized family planning service centres has been identified as a key issue in fp service delivery. the majority of health posts and primary health care/outreach (phc/orc), particularly in hard-toreach areas, do not provide voluntary larc services; many district hospitals do not provide vsc services year-round; and historically, mobile services have been focussed only on vsc and have not offered other methods. factors contributing to these gaps include limited trained and skilled human resources, and supply issues. there is also insufficient systemic focus on the provision of quality, client friendly, and comprehensive fp services, including comprehensive fp counselling, as assessed by the national health training center quality improvement tools. larc services auxiliary nurse midwives (anms) are the only service providers eligible to offer iucds at health posts and birthing centers; however, many have never received training, and those that have may not actually deliver services at their posts due to stock-outs of commodities, lack of equipment, and low client flow. a very limited number of eligible providers (including doctors, nurses, and anms) have received iucd and voluntary implant insertion training. tica overview improving access to contraception has largely remained an effort contained within the health sector. integration is a powerful way to reach women, men, and youth who may not otherwise seek reproductive health (rh)/fp care, but whose rh/fp needs may be especially great. when health and non-health agencies include rh/fp services and/or information in their programs, the resulting increase in the number of service delivery points leads to fewer missed opportunities, greater continuity of care, increased rh/fp access, and the sense on the part of clients that services are responsive to and respectful of their needs. integrating fp into non-health-sector development projects, private institutions, cooperatives, and recently the ministry of health (moh) test of introducing fp in the immunization programme could be effective ways to facilitate access to fp and other health services and information for women and communities. more evidence is needed on whether and how such efforts can work, and what types of models might be replicated and scaled up. the described study provides an early and unique look at the 33 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. effectiveness of tica in a non-health sector program for increasing fp utilization. the study examines fp utilization in fifteen village development committees (vdcs) of three districts: rupandehi, palpa, and kapilvastu of the western development region of nepal, where an agriculture program was being implemented. tica was designed to leverage community access points and resources of the localized agriculture program to address fp needs and challenges in the targeted areas. the tica activities were concentrated in five of the vdcs in each of the three districts. the tica activities focused on increasing access to and demand for fp services through enhancing fp knowledge and demand generation activities such as: • social and behavior change communication; • raising fp awareness of community group members, cooperatives and women’s groups trainings/meetings, offices of cooperatives, and women’s groups where condom boxes and drop boxes were placed; • providing fp competency-based training to health workers; • increasing service provision by conducting fp camps at outreach sites, and • increasing the capacity of facilities through training and basic equipment.7 moreover, tica utilized existing health and non-health structures, including health facilities, female community health volunteers, cooperatives, women’s groups, and adolescent groups. building on the women’s groups, cooperatives, and market centers established and strengthened through the current develop local economy to eradicate poverty (deep) project, tica delivered fp education and services through peer education. specifically, tica delivered fp training directly to women’s groups after training group leaders. cooperatives were engaged in managing mobile fp service camps in hard-to-reach areas, and also hosting and managing condom distribution boxes and question drop boxes, both of which were anonymously accessible by all community members. tica also supported the upgrade of a selected number of health facilities through service provider training and material provision. it was anticipated that improving utilization of fp would considerably increase couple year of protection (cyp), and contribute to decreasing unwanted pregnancies and ultimately the maternal mortality rate (mmr). tica could also contribute to nepal’s sustainable development goals (sdgs) by supporting the private sector and moh to increase availability of fp services and percentage of wra utilizing fp methods. the objective of this evaluation was to assess 1) the effectiveness of a fp program focusing on increasing the utilization of larc integrated into an agriculture (e.g., nonhealth) sector program, 2) the characteristics of clients visiting public health facilities in selected districts and their perspectives on the quality of fp services offered to them, 3) the level of awareness among clients on fp methods, and 4) knowledge and practice on access to and utilization of family planning methods. materials and methods study design, setting, and population the study design was descriptive cross-sectional (post intervention of the tica project). the study was carried out from november 2015 to february 2016 in five vdcs in each of three districts where an agricultural program was being implemented. settings: palpa district is a mid-hill district in western nepal with a total population of 261,180 (male: 115,840; female: 145,340). its cpr is 35.3%, slightly higher than the average regional cpr of 31.0%. rupandehi district is in the terai of western nepal with a population of 880,196 (male: 432,193; female: 448,003), and cpr is 31.6%. kapilvastu district, also in the terai, has a total population of 571,936 (male: 285,599; female: 286,337). its cpr is 33.4%.8 the study population: the study population included married wra, all of whom participated in the agriculture program (tica project beneficiaries). we did not include the same women groups 34 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. in the baseline to minimize the bias. women already sterilized before the implementation of tica project were excluded from this study. the size of the sample was calculated as 25% of total agriculture program participants and 25% of the 60 existing women’s groups, i.e., 25% from 1800 (n) = 450 (n) among 15 women’s groups. however, the actual sample size was calculated as 525 from 21 women groups which included the 17% non-response rate. samples were distributed according to the number of target beneficiaries that participated in the program of the 21 selected women groups. sampling technique there was a total of 60 women’s groups within the agriculture program catchment area. a two-stage sampling technique was used to select respondents for participation in the study. in the first stage, of the 60 women groups a total of 21 groups were selected randomly from three agriculture program intervention districts. in the second stage, respondents within each group were selected by using a census method, i.e., all women from the 21 groups were included in the study. the study included 179 women from 7 women’s groups in kapilvastu; 228 women from 9 women’s groups in palpa, and 118 women from 4 women’s groups in rupandehi (figure 1). data were collected through face-to-face interviews of the women (agricultural program beneficiaries) using semi-structured questionnaires during 18-30 november 2015. figure 1: diagram for sampling and sample size data analysis and presentation data processing included data entry program development, data entry, and data cleaning. epidata software was used for data entry and analysis (version 3.1 for entry and version 2.2.2.183 for analysis, epidata association, odense, denmark) and validated before undertaking analysis. the data entered in epidata was exported to spss and checked for inconsistencies. spss descriptive was used for data analysis as per requirements. for multiple response data, where the respondents could choose or provide more than one response, multiple response analysis was done. the multiple responses were organized using multiple dichotomy (i.e., 1=yes and 0= no). the crosstab option was used to obtain frequencies or percentages according to the number of respondents/responses. for all continuous variables, the shapiro-wilk test for normality was used to check the distribution of data. when the test was significant (p value < 0.05) and suggested nonnormal distribution of variable, a non-parametric test was used. the analyzed data was presented in tabular and graphical forms. approach for presenting comparative findings the baseline study was already accomplished in 2014/15 following same study design, crosssectional descriptive. the sample size in the baseline study was 493 from 16 women groups, but the same women groups were not included in endline, e.g., women sterilized prior to implementation of the tica project, to minimize the bias. similarly, the same data collection tools were used for baseline and endline, i.e., data were collected from interviews, using semi-structured interview guidelines. baseline data was collected before the intervention, whereas endline data were collected after the intervention. this report presents the comparative findings of both data collection points. ethical consideration the research protocol was submitted to the institutional review committee of adra international for ethical review and approval. field works were commenced after obtaining approval from adra-i. a copy of the approval documentation was 35 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. provided to all study sites. the consultancy team monitored for adherence to the research protocol and research norms and standards of adra international and nepal. informed consent was obtained for participation in the survey. all the participants intending to take part in the survey signed a written consent form. all the participants’ related information was decoded and personal information was kept confidential and secured in the respective selected sites. results socio-demographic information from the total of 525 wra respondents, the average age was 32 years with a minimum age of 15 years and a maximum of 50 years. nearly 25.0% of the sampled women did not live with their husbands as men commonly worked outside of nepal. more than two-fifths (44.8%) of the women had informal education. nuclear and joint (several households sharing a common kitchen) families were the predominant family systems. agriculture was the main occupation, although some had been educated. nearly 50.0% of women had income sufficient to feed their family for the whole year as shown in table 1. “disadvantaged” meant those who had been forced to fall backward politically, economically, and socially; those who had been unable to avail services because of discrimination and harassment and because of geographical disconnection; and those communities whose standard of living had been below the legal standard as specified in the human development indicators. table 1: sociodemographic characteristics of respondents in the three agriculture program intervention districts characteristics n % ethnicity dalit 60 11.4 disadvantaged janajatis 307 58.5 disadvantaged non-dalit terai caste 5 1.0 relatively advantaged janajatis 5 1.0 upper caste groups 145 27.6 religious minorities 3 0.6 total 525 100.0 religion hindu 514 97.9 buddhist 6 1.1 muslim 3 0.6 christian 2 0.4 total 525 100 educational status illiterate 4 0.8 informal education 235 44.8 primary (1-8) 115 21.9 secondary (9-12) 89 17.0 higher (12 above) 82 15.6 total 525 100.0 main occupation professional/technical/managerial 8 1.5 business 9 1.7 labor (skilled and unskilled) 13 2.5 agriculture 485 92.4 household worker 6 1.1 foreign employment 4 0.8 total 525 100.0 family type nuclear 272 51.8 joint 248 47.2 extended 5 1.0 total 525 100.0 duration of income in one year 3 months 32 6.1 6 months 44 8.4 9 months 46 8.8 1 year 262 49.9 some saving 137 26.1 unknown status 4 0.8 total 525 100.0 knowledge related to fp services table 2 shows that almost all of the respondents (99.6%) had heard about fp. this means they were able to explain how to use fp methods, their side effects, and where to access them. of these, more than two thirds (67.8%) correctly understood fp benefits as, among others, a method to prevent unwanted pregnancy. a sizeable number (other) understood fp to reduce unsafe abortion, limit family size, improve quality of life, and reduce the fertility rate. most sources where respondents got information that was considered accurate about fp services were women’s literacy groups, female community health volunteers (fchvs), school teachers, and health workers. women also sought information from relatives/neighbors/friends. study findings show that print material about fp was less 36 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. effective in reaching the study participants as shown in table 3. table 2: women having knowledge of family planning heard about fp n % yes 521 99.6 no 2 0.4 total 523 100 women who correctly understand about family planning yes 356 67.8 no 169 32.2 total 525 100 women understanding on family planning method to avoid unwanted pregnancy 326 62.1 methods to prevent sti 30 5.7 method to protect from serious illnesses 27 5.1 no response 17 3.2 others 125 23.8 total 525 100 table 3: main source of information for family planning related messages source of information n % friends/neighbors 89 17.1 school/ teacher 94 18.1 fchvs 106 20.4 women's literacy group 128 24.7 health institution/ health worker 43 8.3 family members 20 3.9 husband 14 2.7 media (tv radio/ newspaper/pamphlets) 2 0.4 pharmacy 22 4.2 cooperatives 1 0.2 total 519 100 table 4 shows the percentage of women aware of various fp methods. the level of awareness for short-acting methods was higher compared to long-acting and permanent methods. the majority of respondents agreed that the upgrade of health facilities as fp sites, and the use of the drop boxes for fp questions and suggestions contributed to their increased awareness and knowledge of fp. approximately three fourths (72.3%) of respondents said that government health institutions had been providing fp services to reach marginalized and disadvantaged groups as shown in table 5. table 4: women who have heard about different types of family planning methods types of fp methods n % condom 469 89.3 pills (oral contraceptives) 474 90.3 depo (sangini) 500 95.2 intra-uterine contraceptive device (iucd) 304 57.9 implant 337 64.2 non-scalpel vasectomy (nsv) 199 37.9 minilap 345 65.7 emergency contraception 424 80.8 table 5: women who know where to obtain family planning services place of getting family planning services n % government health institution 373 72.3 fchvs 55 10.7 private health institutions 30 5.8 pharmacy 42 8.1 non-governmental health institutions 9 1.7 cooperatives 7 1.4 total 516 100.0 fp methods and services used the main fp methods used by the participants are presented in figure 2. about half (47.6%) of the respondents reported using fp methods at the time of data collection. the contraceptives commonly used were depo provera and minilap. the study found a significant decline in the proportion of women using short-acting methods from ever used to currently using, while, as expected, long lasting and permanent methods were found to have no significant difference. for example, the proportion of women using depo provera reduced drastically from 30.7% ever used to 10.3% currently using while the percentage of women ever used and currently using minilap remained almost constant (13.0%). 37 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. tables 6 and 7 show uptake of fp services by couples, as reported by respondents, stratified by age categories and educational level. there is low uptake of all methods of fp below age 20. vasectomy was the most commonly used contraceptive method among couples with lower educational levels (nonschooled/informal, primary, secondary only) while depo provera for women was commonly used by couples with higher educational status (beyond secondary education). table 6: status of currently using family planning methods by age categories age categories in years fp users fp non-users n % n % 15-19 1 0.2 8 1.6 20-24 24 4.8 31 6.2 25-29 43 8.6 42 8.4 30-34 60 12.0 57 11.4 35-39 51 10.2 51 10.2 40-44 43 8.6 34 6.8 45-49 28 5.6 26 5.2 total 250 50.1 249 49.9 table 7: fp method used by couples stratified by education (n=165) fp methods illiterate informal education primary education secondary education higher education nsv 0.6 10.9 10.3 6.1 0.0 minilap 0.6 29.1 6.1 1.8 1.8 depo provera 0.6 13.9 6.1 5.5 6.7 figure 3: decision made on using fp methods (n=250) figure 4: pay status for using fp methods (n=250) 13.5 26.1 32.5 3.8 4.2 6.1 13.7 8.4 12.8 21.6 4.8 8.0 18.4 26.0 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 condom pills (oral contraceptives) depo (sangini) intra-uterine contraceptive device (iucd) implant non-scalpel vascetomy (nsv) minilap figure 2: comparative chart of status of ever used and current users of fp method by spouses (%) ever used current users 68% 32% husband self + husband 20% 80% yes no 38 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. figure 3 shows that decisions on participating in fp and the choice of fp methods were predominantly made by the husband (68.0%) while men accompanied by women in making fp decisions is 32%. about a fifth (20.0%) of women reported that they were paying for fp services as shown in figure 4. “no pay” status means that transportation costs and wage compensation were provided while utilizing services from health facilities. table 8 shows that 68.4% of respondents reported that they were motivated by their husbands to use fp. also, the study found that although the percentage of wives willing to utilize fp was higher than husbands (54.9% vs. 15.6%), the proportion of husbands willing to use fp saw an increasing trend after tica interventions as indicated in figure 5. table 8: motivators for using family planning services motivators n % husband 143 68.4 family members 21 10.0 friends/ neighbors 2 1.0 health worker 9 4.3 fchvs 30 14.4 social mobilizers 4 1.9 total 209 100.0 figure 5: willingness to use fp methods (n=406) the reasons for not using fp devices were explored among the respondents who were not using any types of fp devices at the time of the study. the main reason identified (88.8%) was that their husbands were not living with them. moreover, in nepal, when women lived with their husband, they use fp methods. after husbands left to work outside of nepal, then, the majority of women stopped using fp methods. table 9 shows that in a smaller proportion of woman, lack of awareness, shyness about using the device, and/or lack of availability at the proximity were identified as the main reasons for not using fp devices. table 9: reasons for not using family planning services reasons n % husband not living together 151 88.8 device not available 5 2.9 lack of awareness 5 2.9 due to shyness 1 0.6 health facilities too far 8 4.7 total 170 100.0 perceptions of fp use on quality of life after tica activities women perceived the optimal gap between births to be 48 months/4 years. most of the women (98%) reported that fp helped to enhance their quality of life. most of the women agreed 54.9% 15.6% 18.7% 10.8% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% wives husband both husband and wives no one willing to use fp 39 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. that establishment of fp counselling and implant service rooms at local health facilities increased the quality of the fp services they received. nearly all (97.0%) were satisfied with the fp services provided at the fp camps as shown in figure 6 and table 10. figure 6: perception that family planning has increased quality of life table 10: satisfaction towards health facility and health workers (n=525) categories responses n % waiting time perceived too long no 323 61.5 satisfaction with the cleanliness of the institute yes 416 79.2 satisfaction with the privacy during examinations/ checkup yes 399 76.0 satisfaction with the time provided by the health workers yes 414 78.9 behavior of health workers was polite and respectful yes 385 73.3 health workers forced to accept any family planning methods no 371 70.7 comparative findings showing effectiveness of integrating fp into agricultural programs a summary of findings comparing endline and baseline is shown in tables 11 and 12. overall, there has been an augmentation in knowledge of fp among study participants. almost all of the participants had heard about fp at both baseline and endline. a statistically significant proportion (p=0.03) of endline participants had a correct understanding about fp. there has been a statistically significant increase in the proportion of women who had heard about at least four types of contraceptives by the endline compared to the baseline. a statistically significant improvement (p= 0 .001) in the practice of fp was achieved by the endline in terms of the proportion of couples ever using any fp methods. the willingness among husbands to use fp methods substantially increased from 5.2% to 15.6% compared to baseline: the difference was statistically significant (p<0.001). in both baseline and endline, the majority of the respondents discussed fp with their husbands with the proportion being slightly increased over baseline. the percentage of respondents aware of shortacting fp methods increased from 86.0% to 92.3% post-intervention. the percentage aware of longacting and permanent fp methods increased from 48.7% to 61.5% and 39.0% to 52.2%, before and after the intervention, respectively. the trend towards increased awareness of all three types of methods was significant. the proportion using permanent methods increased from 31.1% before the intervention to 44.4% after the intervention. there was no statistically significant difference (p= 0.10) in women between baseline and endline in terms of their opinion that fp methods helped to improve their quality of life. there was statistically no difference among respondents on their satisfaction with various health facilities as well as health workers. almost all of the respondents expressed that the overall behavior of the health worker towards them as the client appeared satisfactory at both baseline and endline. however, a statistically significant proportion of women at the endline (p< 0.001) expressed that more comprehensive counselling was given by health workers while providing fp methods.9 more specific evidence that improved knowledge translated into behavior is seen in table 12. if the methods of contraception are grouped into temporary (condom, pill), long term/reversible (depo, iud, implant), and permanent (vasectomy, minilap), there is a significant trend (p<0.001) towards employment of permanent methods. 98% 2% yes no original article july 2017. christian journal for global health 4(2):30-42. table 11: comparison of endline features vs. baseline feature measured baseline (n=493) baseline (%) endline (n=525) endline (%) p value knowledge of fp (no response=2) 490 99.8 521 99.6 women who correctly understand about family planning 301 61.4 356 67.8 p=0.03 heard of four types of contraception 296 60.0 420 80.0 p<0.001 spouse ever used any family planning 360 73.0 426 81.1 p<0.001 spouse currently using any family planning method 256 51.9 263 50.1 husbands willing to use fp 17 5.2 63 15.5 p<0.001 discussion about family planning with husband 414 84.0 457 87.0 women aware of short-acting fp methods 424 86.0 485 92.3 p=0.016* women aware of long-acting fp methods 240 48.7 323 61.5 women aware of permanent fp methods 192 39.0 274 52.2 spouse using permanent methods 74 31.1 111 44.4 satisfaction with the overall behavior of the health workers (baseline n=322 and endline n=420) 316 98.1 415 98.8 comprehensive counselling not practiced by hws while providing fp methods 241 48.9 154 29.3 p<0.001 *chi square of three rows with data on awareness of short, long and permanent methods table 12: family planning methods currently being used by couples (%) types of fp methods baseline (n=238) endline (n=250) condom 10.1 8.4 pills (oral contraceptives) 18.1 12.8 depo (sangini) 25.6 21.6 intra-uterine contraceptive device (iucd) 2.9 4.8 implant 12.2 8.0 non-scalpel vasectomy (nsv) 8.0 18.4 minilap 23.1 26.0 total 100.0 100.0 discussion the study of tica activities demonstrates the feasibility of integrating fp into agricultural and potentially other non-health sectors. evidence from the study suggests that tica activities helped augment the knowledge of fp among the project population. the use of fp increased among agricultural program participants as a result of tica, with a gradual shift from short-acting fp methods to long-acting and permanent fp methods. this was particularly true for the number of couples that used vasectomy as a fp method, which more than doubled at the end of the study period and was the most common fp method among the least educated couples. also, this research showed that utilization of fp services could be increased through increased fp knowledge diffusion and awareness creation, with a high probability of encouraging husbands to use fp and be actively involved in fp decisions. overall, the tica activities were very successful in increasing fp knowledge level as well as promoting the use of fp among the targeted women. findings from a similar study show that integration was effective at increasing beneficiaries’ understanding and appreciation of the benefits of voluntary family planning. further, beneficiaries 41 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. perceived the program positively and reported an increase in acceptance of family planning as well as a decrease in myths and misconceptions about family planning.10 another similar study revealed that about four of five women (81%) were currently using a modern contraceptive method. the most popular methods being used were injectables (38%) and pills (17%), followed by the intrauterine device (9%). within the intervention group of 800 women, fp use for all methods increased significantly from 40% at baseline to 69% at endline, with a majority of new users.11 there is, however, room for improvement. the proportion of women who could not correctly explain fp and used short-acting fp methods, although substantially reduced at the study endline, remained quite high and emphasized the need for more awareness creation and fp sensitization. limitations the findings and conclusions are limited to the intervention group only and may not reflect the fp behaviors of the entire district population. according to tica program reports, nearly 25% of the sampled women’s husbands were working outside of nepal. this may have impacted and most likely reduced the proportion of women currently using fp as well as limited the potential for women to discuss fp with their husbands. follow up questions were not asked among those women who said that the main reason they did not use fp methods was that they were not living with their husbands; if their husbands return intermittently, this data may not be accurate. conclusions integrating fp activities with non-health sector interventions is acceptable to communities, engages males and youth, and tends to increase community goodwill toward other aspects of the project that may not originate as community priorities. including fp activities in livelihoods interventions can increase community support for programming whose benefits are longer-term and increase resonance among men, women, and youth, potentially increasing their involvement and support for activities. it was discouraging to see that the willingness among husbands to use the fp method was still low (15.5%). thus, males should also be encouraged to participate in family planning issues. male involvement in fp should be the area of action and research in future. it is recommended that similarly integrated fp programming be replicated in the study districts as well as other districts in nepal. since this community approach worked, it could be tested for implementation through other community structures in addition to cooperatives, women’s groups, men’s groups, and youth clubs. references 1. un. contraceptive commodities for women’s health, in key data and findings. new york: united nations commission on life-saving commodities for women and children; 2012. p. 1-29. 2. unfpa. united nations high level meeting on reproductive health commodity security. new york: united nations; 2011. p. 1-40. 3. mohp, new era, and icf international inc. nepal demographic and health survey 2011. kathmandu: ministry of health and population, new era, and icf international; 2012. 4. heart. nepal health sector programme-ii, mid term review. kathmandu: health and education advice and resource team; 2013. 5. khanal mn, shrestha dr, panta pd, mehata s. impact of male migration on contraceptive use, unmet need and fertility in nepal. further analysis of the 2011 nepal demographic and health survey. calverton, maryland, usa: nepal ministry of health and population, new era, and icf international; 2013. 6. cbs. nepal multiple indicator cluster survey (nmics), 2014: key findings. kathmandu: central bureau of statistics; 2015. 7. adventist development and relief agency (adra) international. technical proposal: develop local economy to eradicate poverty (deep); technical integration for coverage and access (tica). silver spring, md: adra international; 2013. 42 bhatta, orellana, mahat, mishra, tamrakar & sah july 2017. christian journal for global health 4(2):30-42. 8. department of health services. annual progress report of nepal: ministry of health; 2010/11. available from: http://www.dohs.gov.np 9. adventist development and relief agency (adra). baseline survey report. study on effectiveness of integration of family planning into agriculture and economic empowerment program for access and coverage. adra; 2014. 10. yavinsky wr, lamere c, patterson kp, bremner j. the impact of population, health, and environment projects: a synthesis of evidence. [working paper]. washington, dc: population council, the evidence project; 2015. 11. fhi 360/progress project. integrating family planning into other development sectors. durham, nc: fhi 360; 2013. available from: https://www.fhi360.org/sites/default/files/media/doc uments/integrating-family-planning-developmentsectors.pdf peer reviewed competing interests: none declared. correspondence: ghanshyam bhatta, adventist development and relief agency, nepal. http://www.adranepal.org/about-nepal g.bhatta@adranepal.org cite this article as: bhatta n, et al. increasing access to family planning services through a non-health sector: technical integration coverage and access (tica) in nepal. christian journal for global health. july 2017; 4(2):30-42. https://doi.org/10.15566/cjgh.v4i2.170 © bhatta n. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.dohs.gov.np/ https://www.fhi360.org/sites/default/files/media/documents/integrating-family-planning-development-sectors.pdf https://www.fhi360.org/sites/default/files/media/documents/integrating-family-planning-development-sectors.pdf https://www.fhi360.org/sites/default/files/media/documents/integrating-family-planning-development-sectors.pdf http://www.adranepal.org/about-nepal mailto:g.bhatta@adranepal.org https://doi.org/10.15566/cjgh.v4i2.170 http://creativecommons.org/licenses/by/4.0/ book review may 2019. christian journal for global health 6(1) one step at a time: the birth of the christian medical college, vellore, by reena george. roli press, 2018 gareth david tuckwella a mb bs, mrcs, lrcp, dip pall med (univ. of wales), mrcgp, chairman of friends of vellore, 2009-2013; chairman of sanctuary care, 2013current, uk introduction one step at a time was written to mark the centenary of the founding of one of the foremost medical colleges in india. behind so many remarkable institutions there lies a hidden story relating to its founding, its struggles to become established, and its challenges faced while growing to maturity in our rapidly changing world. as we journey through the second millennium with many well-established organisations, straining at the leash of tradition and seeking fresh vitality and vision, it is important to look back to the founders and reflect on the lives of those who have been pioneers and teachers in the preceding decades. to be radical in moving forward, organisations benefit from drawing from their roots (radix: latin) and allowing their strategies to be enriched through them. hence, this amazing book deserves to have a wider readership than just those many thousands who have passed through the christian medical college (cmc), vellore. today, when time seems at such a premium, it would be easy to decide that giving precious hours to reading over 300 pages centred on the birth and development of cmc would be a poor investment. for those with this mindset, there is very helpful guidance inserted indicating the chapters not to be missed because their content is key to the message of this book. overview outline following a forward by philip yancey, the subsequent chapters take the reader chronologically through the events of the last one hundred years that lead up to cmc as it is today. the content of each chapter draws on college minutes, speeches, and personal correspondence, and these are coloured by reminiscences, photographs, and fascinating biographies. weaving these together, the gifted author’s narrative adds depth, insight, and meaning. review of content writing that this book is a comprehensive record of the development of cmc is almost an understatement. the reader is even treated to a copy of ida scudder’s 1911 paper on vesicovaginal fistulae and perineorrhaphy along with a list of the operations performed in 1906. the book concludes with an excellent 8-page bibliography. this is an indication of how thoroughly the contents for this book have been researched. with much of the content drawn from archival material, this book is filled with facts rather than sentiment. this is particularly refreshing because delving into the life and call of someone as remarkable and revered as dr ida scudder could so easily allow sentiment to rule the day. for those who have lived on the residential campus as part of the cmc community, this is an unsurpassed and fascinating record of the development of both the college and the hospital, from minute beginnings to the educational and 92 tuckwell may 2019. christian journal for global health 6(1) research institute of today that is of national and international renown. for others who, like myself, were not students at cmc but are ready to learn from history and to integrate that learning into transformational healthcare strategies for their own situations, there is a depth and richness in the material here. the evidence-based, thoroughly researched text is filled with insights that are surprisingly relevant for today despite the technological advances that are currently transforming both medical education and treatment. it is encouraging to read how certain core values and beliefs that were so evident in the life and work of ida scudder (such as learning, ever-advancing skills, and a focus on reaching out to poor and marginalised people) remain close to the heart of cmc today. cmc, as is so evident within the text of this book, is refreshingly unashamed of how it holds to its christian heritage and how this is lived out today despite increasing pressures to dilute this. obedience to god’s call has consistently been the heartbeat of its success. those reading this book with no such faith are unlikely to find the christian thread off-putting as the accounts of people’s lives and the development of training and care are not embellished with words that focus unnecessarily on god’s provision over the past century. dr reena george is a gifted writer, such that even potentially lengthy historical text is an easy read peppered with wisdom, insight, and an indepth understanding along the way. what stands out that makes this book an important and rewarding read? cmc was not born out of ambition but in obedience to a call from god. that ‘call’ was born during a time of great distress when 20-year-old ida scudder was caught up in the grief surrounding the deaths of three women in childbirth because there were no female doctors to attend to their obstructed labours. it was the anger in her compassion that became a compelling force for a complete change of course for her life as dr george has described in calling and consecration.2 she was subsequently shown the way forward ‘one step at a time’. similarly, many see the birth of the modern hospice movement in the uk as being born out of an anger within compassion that became a powerful force for change.3 until fifty years ago, many people were dying in pain and distress with clinicians and carers watching helplessly at their bedsides. today selfish ambition, greed, and the desire for power are too often the motivators for change, a change that rarely benefits the wider community that often remains in great need. a ‘call’ that determines the choice of a career is rare today. it is fascinating to read the story behind how the training of women to become doctors became established—the impossible became possible and eventually normative. today, in the uk and india, a little over 50% of those in medical training are women, something inconceivable just fifty years ago.4 ida scudder’s exhaustion and probable “burn out” in 1913, from overwork and enhanced by unmet need led to fresh vision and the realisation that there just had to be a medical school founded to enable more women to access medical training. yes, this took a decade to come about due to a long gestation and a protracted labour exacerbated by the first world war, but there was no giving up; determination won through. there are interesting insights into student life that would be hard to recreate today. training as an undergraduate at cmc offered an experience that “nourished the heart and soul.” students, whatever their faith position, said how they felt loved and cared for despite their founder’s expectation of good results. any significant success was celebrated, and this spurred them on to further achievements. for many, dr ida scudder’s compassion for and overflowing love of humanity was caught rather than taught. in this context, her address to the first college graduates (pp 110-115) makes for such an inspiring read that, if lived out today, still has the potential to transform healthcare across the globe. this address deserves reading and reflecting on time and again. 93 tuckwell may 2019. christian journal for global health 6(1) conclusion reading this book will be time well spent whether you are part of the worldwide cmc community or someone keen to learn from history and see breakthroughs today that lead to the transformation of treatment and care in their situation. even if you are involved in fundraising, and wondering how a one-bedded clinic-comedispensary in 1900 has become an educational and research institute of national and international fame, including a network of primary, secondary, tertiary, and quaternary care hospitals with over 3000 inpatient beds across six campuses (with the seventh under construction), there is real learning embedded here. having a compelling cause and building key relationships with the energy of a committed community alongside wins through. references 1. george rm. one step at a time: the birth of the christian medical college vellore. roli press, isbn: 978-81-937501-7-9. available from: http://cmykbookstore.com/one-step-at-a-time.html 2. george, rm. calling, conflict and consecration: the testament of ida scudder of vellore. christian journal for global health. august 2014;1(1):26-33. https://doi.org/10.15566/cjgh.v1i1.10 3. clark d. religion, medicine, and community in the early origins of st christopher’s hospice. journal of palliative medicine. 2001;4(3):353-360. https://doi.org/10.1089/109662101753123977 4. jefferson l, bloor k, maynard a. women in medicine: historical perspectives and recent trends. british medical bulletin. june 2015;114(1):5–15. https://doi.org/10.1093/bmb/ldv007 peer reviewed: submitted 19 dec 2018, accepted 25 dec 2018, published 31 may 2019 competing interests: none declared. correspondence: gareth david tuckwell, chairman of friends of vellore, 2009-2013; chairman of sanctuary care, 2013-current, uk. garethdtuckwell@yahoo.co.uk cite this article as: tuckwell gd. one step at a time: the birth of the christian medical college, vellore, by reena george. roli press, 2018. christian journal for global health. may 2019; 6(1):91-93. https://doi.org/10.15566/cjgh.v6i1.271 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://cmykbookstore.com/one-step-at-a-time.html https://doi.org/10.15566/cjgh.v1i1.10 https://doi.org/10.1089/109662101753123977 https://doi.org/10.1093/bmb/ldv007 http://creativecommons.org/licenses/by/4.0/ review article may 2019. christian journal for global health, 6(1) critical thinking in medical education missions j. dwight phillipsa, mary hermizb, laura smelterc, and james smithd a md, professor, department of pediatric and adolescent medicine, mayo clinic, minnesota, usa b rn, msn, edd, missionary emeritus, world gospel mission, ohio, usa c md, director of training, christian health service corps, texas, usa d md, professor emeritus, oregon health and science university, portland, oregon, usa critical thinking, an essential skill for the transformation of medical knowledge into practice, should be a key component of medical education, even in cross-cultural training situations. critical thinking is the use of purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference as well as the explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment was based. critical thinking is important because the healthcare workplace and the science on which healthcare is based continue to advance and evolve. those who teach healthcare cross-culturally may experience challenges in teaching critical thinking to crosscultural learners, challenges in the areas of language/communication, cultural differences, customary education approach, and educator factors. the challenges may be identified, addressed, and overcome. tangible means of implementing training in critical thinking include the use of questions and discussions during educational sessions as well as structured systems for reflecting on causes and treatment of medical conditions. key words: medical education, critical thinking, cross-cultural training introduction christians often provide cross-cultural patient care around the world, an activity referred to as “medical missions.” now, many christians are involved in cross-cultural trans-national education of health care professionals, “medical education missions.” in many settings, medical education can be a key component of international service, missions, and outreach. however, preferences for and styles of learning vary between cultures. in areas where professionals have tended to learn by rote memory, medical education missionaries can struggle to implement training that is based on critical thinking. in many cultures, though, there is acknowledgement that basing medical practice on evidence leads to interventions that work, help people, and are associated with good outcomes. determining how to apply scientific evidence in different settings requires a process of critical thinking. how, then, might evidence-based critical thinking appropriately be taught and implemented cross-culturally? the comments in this article both informed and were informed by a workshop on critical thinking in medical education missions that involved approximately 80 medical missions personnel at the global missions health conference in louisville, kentucky, usa in november 2018. this article is presented now in an effort to foster ongoing discussion of the important topic of critical thinking in medical education missions. 80 phillips, hermiz, smelter and smith may 2019. christian journal for global health, 6(1) what is critical thinking? there are numerous definitions of critical thinking that have been presented over the years. each definition has its own emphasis. simplistically, alfaro-lefevre1 defines critical thinking as controlled and purposeful, using wellreasoned strategies to get the results you need. critical thinking is not something new, and a review of the term and definitions can be helpful. critical thinking can be traced to the thinking of socrates (469-399 bc), the great greek philosopher 2,500 years ago. socrates is known for his deep questioning that probed into thinking before accepting ideas. more recently, albert einstein (1879-1955), a german-born theoretical physicist, is quoted as saying “education is not the learning of facts but training the mind to think.” einstein also reportedly claimed that, “it’s not that i’m smarter than other people, it’s just that i stick with problems longer.”1 the term “critical thinking” has its roots in the mid to late 20th century. the american philosophical association obtained a consensus statement from 46 experts on critical thinking in 1987. we understand critical thinking to be purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference as well as the explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment was based.2,3,4 critical thinking in health care in 1992, schools of nursing were required to define critical thinking and to produce outcome assessments of students’ increased competence in this skill for accreditation purposes. in 2000, a consensus statement on critical thinking was developed by a panel of 55 nursing experts.5 in 2013, another survey was done with 65 expert nurses that showed agreement that the critical thinking indicators were behaviors often seen in nurses that are critical thinkers.1 the 2013 survey1 identified 22 characteristics and behaviors often seen in critical thinkers: selfaware, genuine/authentic, effective communicator, curious and inquisitive, alert to context, reflective and self-corrective, analytical and insightful, logical and intuitive, confident and resilient, honest and upright, autonomous/responsible, careful and prudent, open and fair-minded, sensitive to diversity, creative, realistic and practical, proactive courageous, patient and persistent, flexible, healthoriented, and oriented toward improvement (of self, patients, and systems). this list of characteristics of critical thinkers is the ideal. no one is perfect. characteristics vary depending on the specific circumstances and setting, such as comfort and familiarity with the people and situation at hand. an ability to think critically is a combination of these characteristics, along with intellectual skills, interpersonal and self-management skills, and technical skills.1 why is critical thinking important in health care? critical thinking is important because the healthcare workplace and the science on which healthcare is based continue to advance and evolve. no one can be expected to know, or even to rapidly access, all medical knowledge; care providers must be able to reason as they consider patient presentations, differential diagnoses, and treatment plans. awareness of and access to information is vitally important, but care providers must be able to act upon that information in ways that are adapted to and appropriate for specific clinical situations. each patient is unique, and care plans must also be unique. checklists and algorithms can guide thought processes, but they are incapable of always fitting each complex patient’s specific situation. with high patient acuity and demands on time, care providers need to be able to think through plans when it is not possible to consult sources of information. 81 phillips, hermiz, smelter and smith may 2019. christian journal for global health, 6(1) challenges in teaching critical thinking cross-culturally those who teach healthcare cross-culturally may experience challenges in teaching critical thinking. classifying these challenges can help educators to identify and address them in order to achieve effective cross-cultural teaching. the challenges may roughly be categorized into the areas of language/communication, cultural differences, customary pedagogy, and educator factors. language/communication teaching involves communicating thoughts and concepts. in looking at the importance of language to teaching, baydak et. al. state that “language is how people think.”6 teaching critical thinking involves examining ways of thinking. awareness of nuances of language and communication is thus important in teaching critical thinking cross-culturally. challenges may arise when the teacher and the learner have different primary languages. the technical language of medicine adds a third layer of complexity. if a common language has been elected as the educational language that is not the primary language of a learner, the learner not only has to learn the concepts but has the added challenge of interpreting the language used.7 in sharing or testing situations, the learner may fully understand but be hesitant to answer due to perceived language proficiency difficulties. these challenges extend to the language of the educational literature being used; there is a sparsity of healthcare professional educational literature in some languages. finally, communication also involves nonverbal communication such as body language, gestures, intonation, and the use of silence. all of these may be used differently and have different meanings in different cultural contexts; effectively teaching healthcare cross-culturally includes an awareness of these differences. cultural differences to identify and address the challenges posed by cultural differences, all parties involved must evaluate underlying assumptions, preconceptions, and expectations. cross-cultural teachers and learners approach each other with preconceived ideas based on literature, previous similar experiences, societal stereotypes, and even outdated television programs.8 effective translation of ideas can occur when these preconceived notions are replaced by genuine relational knowledge in an educational exchange. this requires humility on the part of both teacher and learner to identify and examine their own and each other’s preconceived notions. introducing a different teaching or thinking style, such as critical thinking, may initially challenge culturally-held belief and value systems. take, for example, one of the critical thinking indicators mentioned earlier, autonomous. initially, this descriptor may challenge someone from a collectivist society. however, upon further examination, seemingly dichotomous characteristics such as autonomy/individualism/responsibility and collectivism/consensus/teamwork can be viewed as two sides of a coin, both necessary for thinking critically and providing healthcare. a seeming difference in values may actually be a difference in prioritization, with the same value being held by both cultures but at a higher or lower priority than other values. customary pedagogy the third category of challenges to teaching critical thinking cross-culturally is the customary educational approach. in many areas of the world, customary educational approaches rely heavily on methods such as oral learning and rote memorization for reasons beyond the scope of this article but related to culture and language factors. oral learning and memorization are both quite helpful and useful ways to learn and retain a large volume of information, such as when studying something like anatomy. however, introduction of the creative thinking and problem-solving skills necessary for the 82 phillips, hermiz, smelter and smith may 2019. christian journal for global health, 6(1) interpretative, analytical, and evaluative aspects of critical thinking may initially challenge the conventionally held educational paradigm. crosscultural learners may also be accustomed to a structured learning environment where the teacher is an expert authority who is not to be questioned and there is a single “right” answer.9 critical thinking in healthcare entails identifying and reasoning between multiple possible answers, for example when developing a differential diagnosis. effective teaching and learning in healthcare utilizes the strengths of both a pedagogical approach focused on knowledge and information retention and a critical thinking approach focused on considered application of information. educator factors finally, factors related to the cross-cultural educator himself may pose challenges to teaching critical thinking cross-culturally. educator factors include the teacher’s motivation for teaching in a cross-cultural environment, preconceived assumptions as discussed earlier, and preparation. teachers may elect to work in a cross-cultural setting for a variety of reasons, such as a service orientation, a desire to grow personally and professionally, and even a desire to enhance one’s resume. responsible teachers utilize self-reflection to identify their motivations and ascertain they are aligned with the purposes of their sending and receiving organizations. teachers are accustomed to the responsibility of preparation. however, as bovill et. al. note, there is a sparsity of training and support for transnational, intercultural teaching.8 gopal suggests preparation for teaching cross-culturally should address attitudes, knowledge including cultural self-awareness, and skills such as effective cross-cultural communication and contextualization.10 cross-cultural educators may need to be creative in seeking preparatory opportunities. identifying challenges in teaching critical thinking cross-culturally the above classification can help educators identify and address challenges in teaching critical thinking cross-culturally. the first step in identifying any of the challenges is asking. ask educators from within the culture how verbal and nonverbal communication is used and interpreted. ask translators for insight into methods of communication and cultural nuances. ask educators and learners from within the culture what the customary educational approach is, and ask oneself about motivation, preconceived assumptions, and preparation. the next step is observing and discussing: observe how learners interact with the communication and approach being used; discuss with learners and other educators how the educational approach being used may be different from one they are accustomed to and why. other activities that aid in identification of challenges include orientation and seeking a cultural mentor. finally, continue asking throughout the process of teaching critical thinking cross-culturally: ask for advice and feedback from peers, supervisors, and students. practical ways to teach critical thinking cross-culturally teaching critical thinking in a cross-cultural setting is an important part of effective global healthcare education. in many global settings, the primary method of learning is by rote memory. one colleague who did medical school studies in an asian country, but then came to the united states and did an internal medicine residency, reported that the biggest difference for her in the residency program in the us was that she could make the correct diagnosis, but she could not tell you how or why she made the diagnosis. this points out why memorization of medical facts alone does not help a trainee apply the information in a day-to-day clinical setting. 83 phillips, hermiz, smelter and smith may 2019. christian journal for global health, 6(1) participatory approaches to education encourage critical thinking and foster comprehension.11 one of the ways we can encourage a trainee to use critical thinking is to start with a question. tofade et. al. use bloom’s taxonomy pyramid of learning to help create questions appropriate for the learner’s level of training.12 the sometimes dreaded “why” question is a good one. other ways are to ask open ended questions, get group participation, and have the participants do problem solving. try to think of ways to stimulate their curiosity. when asking questions, be patient, pause, and wait for an answer. there may be many reasons an audience will be reluctant to answer questions in a cross-cultural setting. culturally, it may not be polite to answer quickly as it is perceived by peers that you are showing off or you consider yourself superior. if you are a visitor, senior professor or lecturer, the culture would be that a student would never ask you a question. there may be the concern that if the answer given is wrong, they would “lose face.” finally, if english is not the group’s first language, it may be difficult or take them time to format an answer. in a clinical setting, the skills required to do critical thinking include the ability to observe (history and physical), analyze, interpret, and evaluate the findings (differential diagnosis), so one can problem solve (select the correct diagnosis). the learner then has to make a decision on further workup (lab tests and x-rays, for instance) and treatment. the final step is for the trainee to be able to explain to the patient why he or she thinks the chosen diagnosis is the most likely and why the recommended therapy was selected. in applying these skills, we want to help the trainee learn how to organize the information, so a presentation will be coherent and easy to follow. we want to encourage trainees to appropriately evaluate the data so they can come to the appropriate conclusion or diagnosis. encouraging them to ask for help from their preceptor or peers will help them recognize their own limitations and teach a sense of humility and integrity. as they recognize their own lack of knowledge, they should be encouraged to go away and look up information (self-learning) which will help them learn the importance of life-long learning. one method to practice critical thinking skills in clinical situations is a presentation technique called snapps.13 it will help the learner to integrate experience and learning in the clinical setting and encourage shared responsibility between teacher and learner. it will help the teacher to focus on ‘teachable moments”. the acrostic snapps stands for: 1) summarize the case, 2) narrow the differential to two or three relevant possibilities, 3) analyze by comparing and contrasting the differential diagnosis orally, 4) probe the preceptor by asking questions for more information, 5) plan jointly with the preceptor for treatment of the patient, and, 6) select an issue for self-directed learning. a second method to teach critical thinking would be to use small group participation. an example of this is described by mclaughlin and pfister in teaching african medical students ethical decision-making skills using case-based small groups.14 the course started with a two-hour, interactive didactic lecture on ethical principles and application. they then developed 10 case studies relevant to the local rural african context. groups of 4-5 students were assigned a scenario and then given several days to evaluate and analyze the case. the groups reconvened, and each group was given 15 minutes to present their findings and conclusions, followed by 15 minutes for questions from their peers and the faculty. the process was student-led, but faculty facilitated the case discussion. an example of one scenario used to bring out the ethical aspects of autonomy and beneficence is as follows: “who decides?” a mother of 8 children is hospitalized for a cesarean section for baby #9 while baby #8 is hospitalized for severe, acute malnutrition due to an inadequate food supply at home. the mother agrees to have a tubal ligation, but the father refuses not for religious reasons, but because he says 84 phillips, hermiz, smelter and smith may 2019. christian journal for global health, 6(1) that “a large family is the truest blessing.” the mother asks you secretly to do the tubal ligation anyway and to not inform the father. what do you do?14 by using scenarios from the local cultural context, the course is made relevant to the students’ life experiences and their future practice as physicians. in contrast to western culture, the african culture is patriarchal, collectivistic, and has a different view of the often-cited pillars of medical ethics autonomy, beneficence, non-malfeasance, and justice. there would also be resource limitations, varied levels of professional expertise, and a different christian worldview even though it may be in a predominately “christian” country. what the authors found was that the students had lively and interactive discussions but could still discuss their disagreements. it helped them improve their ability to think critically about ethical principles in their local context. the expatriate faculty found they needed to construct scenarios which would force the students to make a difficult decision. it was important that the faculty facilitated the discussion to allow for disagreement to occur. sometimes, it was necessary to propose slight permutations to see if this would change the group’s opinions. there are also special challenges when teaching cross-culturally, especially if the teachers and learners do not share the same primary language. one needs to speak clearly and slowly, using more basic or straight forward, not nuanced, words. we must learn to understand the silence and absence of questions, or discussion may reflect respect and the local learning style. also as mentioned earlier, answering in a non-primary language can add to a trainee’s complexity and anxiety. frequently, “less can be more” by focusing on one to three critical learning points.15 finally, we need to adapt to the local educational culture.16 when it comes to rote memory versus critical thinking, we have to be careful not to “throw out the baby with the bathwater.” cultures with oral traditions have a better ability to memorize. in medicine there are certain things that require memorization, so we need to be careful and not denigrate or diminish these skills. we need to figure out ways to add critical thinking to learners’ skill sets, as mclaughlin and pfister did in the previous example14 by helping trainees apply their learning in a practical clinical setting and making them better health care professionals. learning points for all of us rote memory is not bad. in fact, it is commendable and valuable when one can amass and recall a wealth of factual information. good thinking, though, is multi-faceted. good thinking involves gathering a knowledge base, thoughtfully using intellectual skills, demonstrating an ability to communicate, and implementing technical skills. critical thinking might complement mobilization of many aspects of intellectual life to better serve patients and populations. in the current era, in order to deal with nuanced clinical situations as medical knowledge is expanding to dizzying degrees, there is great value in supplementing rote memory and other learning techniques with critical thinking. it is challenging to teach critical thinking in areas where the technique is new, and good educators will face and overcome those challenges. good teachers will explore their own obstacles as they teach critical thinking. they will see if they, too, suffer from challenges of culture (what one thinks) and language (how one thinks). frustrated teachers need to explore the sources of their frustrations rather than merely blaming the learners for not learning well. good teachers are humble, and they learn along with their students. good teachers model good learning by letting their students know what and how they are thinking and what and how they are learning. questions, especially “why” and “how” questions, can stimulate thought. the use of programmed techniques and discussion of scenarios can also be useful. educators will find that their trainees learn to better practice medicine when 85 phillips, hermiz, smelter and smith may 2019. christian journal for global health, 6(1) educators can think about the value, challenges, and techniques of critical thinking while implementing specific strategies to help learners think critically. references 1. alfaro-lefevre r. critical thinking, clinical reasoning, and clinical judgment: a practical approach, 6th ed. philadelphia: elsevier; 2017. 2. facione pa. critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. research findings and recommendations. millbrae, ca: the california academic press (eric doc. no. ed 315 423); 1990. p. 2. 3. jacobs p, ott b, ulrich y, short l. an approach to defining and operationalizing critical thinking. j nurs educ. 1997;36:19-22. https://doi.org/10.1097/00003465-199711000-00013 4. facione nc. critical thinking and clinical judgment: goals 2000 for nursing science [ paper presented at the annual meeting of the western institute of nursing]. san diego: ca; 1995. 5. scheffer bk, rubenfeld mg. a consensus statement on critical thinking in nursing. j nurs educ. 2000;39:352-9. https://doi.org/10.3928/0148-483420001101-06 6. baydak a, scharioth c, il’yashenko ia. interaction of language and culture in the process of international education. soc behavr sci. 2015;215:14-8. https://doi.org/10.1016/j.sbspro.2015.11.567 7. dhaliwal g. teaching medicine to non-english speaking background learners in a foreign country. j gen intern med. 2009;24(6):771-3. https://doi.org/10.1007/s11606-009-0967-z 8. bovill c, jordan l, watters n. transnational approaches to teaching and learning in higher education: challenges and possible guiding principles. teach high educ. 2015;20(1):12-23. https://doi.org/10.1080/13562517.2014.945162 9. strand m. teaching creative-thinking skills in a confucist context. colorado springs: csof med mg. 1998. 10. gopal a. internationalization of higher education: preparing faculty to teach cross-culturally. int j teach learn higher educ. 2011;23(3):373-81. 11. shah v, larson he, grills n, o’neill d, soderling m. “exporting” medical education. christ j glob health. 2016;3(2):3-5. https://doi.org/10.15566/cjgh.v3i2.150 12. tofade t, elsner j, haines st. best practice strategies for effective use of questions as a teaching tool. am j pharm educ. 2013 sep 12;77(7):155. https://doi.org/10.5688/ajpe777155 13. wolpaw d, papp k. snapps: a learner-centered model for outpatient education. acad med. 2003;78:893-8. https://doi.org/10.1097/00001888200309000-00010 14. mclaughlin e, pfister a. equipping african medical students with ethical decision-making skills: a casebased method. christ j glob health. 2018;5(3):23-8. https://doi.org/10.15566/cjgh.v5i3.229 15. gurpreet d. teaching medicine to non-english speaking background learners in a foreign country. j gen intern med. 2009;24(6):771–3. https://doi.org/10.1007/s11606-009-0967-z 16. gosselin k, norris jl, ho mj. beyond homogenization discourse: reconsidering the cultural consequences of globalized medical education. med teach. 2016;38(7):691-9. https://doi.org/10.3109/0142159x.2015.1105941 peer reviewed: submitted 1 march, accepted 14 may, published 31 may 2019 comp interests: none declared. correspondence: j dwight phillips (pseudonym used for security purposes), mayo clinic, rochester, minnesota, usa jdwightphillips@gmail.com cite this article as: phillips jd, hermiz m, smelter l, and smith j critical thinking in medical education missions. christian journal for global health. may 2019;6(1):79-85. https://doi.org/10.15566/cjgh.v6i1.289 ©authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, if the original author and source are properly cited. http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1097/00003465-199711000-00013 https://doi.org/10.3928/0148-4834-20001101-06 https://doi.org/10.3928/0148-4834-20001101-06 https://doi.org/10.1016/j.sbspro.2015.11.567 https://doi.org/10.1007/s11606-009-0967-z https://doi.org/10.1080/13562517.2014.945162 https://doi.org/10.15566/cjgh.v3i2.150 https://www.ncbi.nlm.nih.gov/pubmed/?term=tofade%20t%5bauthor%5d&cauthor=true&cauthor_uid=24052658 https://www.ncbi.nlm.nih.gov/pubmed/?term=elsner%20j%5bauthor%5d&cauthor=true&cauthor_uid=24052658 https://www.ncbi.nlm.nih.gov/pubmed/?term=haines%20st%5bauthor%5d&cauthor=true&cauthor_uid=24052658 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3776909/ https://doi.org/10.5688/ajpe777155 https://doi.org/10.1097/00001888-200309000-00010 https://doi.org/10.1097/00001888-200309000-00010 https://doi.org/10.15566/cjgh.v5i3.229 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2686769/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2686769/ https://doi.org/10.1007/s11606-009-0967-z https://doi.org/10.3109/0142159x.2015.1105941 mailto:jdwightphillips@gmail.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ case study nov 2017. christian journal for global health 4(3): 40-46 building nursing capacity for palliative care at a jesuit catholic university: a model program eileen r. o’shea a , robin bennett kanarek b , meredith wallace kazer c , patrick w.kelley d , tomi thomas e a dnp, aprn, pcns-bc, chppn, associate professor, egan school of nursing and health studies, fairfield university, usa b bsn, rn, president, kanarek family foundation, usa c phd, aprn, faan, dean & professor, egan school of nursing and health studies, fairfield university, usa d md, drph, distinguished professor, egan school of nursing and health studies, fairfield university, usa e phd, msw, former director general, catholic health association of india, director, healing hands for india, usa abstract the average life span is increasing, due to vast advancements in social conditions, public health, and medical care. globally, those living with chronic and serious medical conditions can benefit from palliative care services. yet, the workforce is insufficient to support the demand. this case study describes efforts made by one jesuit catholic university to build nursing capacity and to promote access to high quality, compassionate palliative healthcare. the growing need for palliative care a dramatic trend in global health has been the shift from short life spans due to high levels of infant and maternal mortality and fatal infectious diseases to longer life-spans with a proportionately greater burden of chronic diseases. 1 for many persons with single or multiple chronic diseases, years may be spent in need of palliative care to address symptoms such as: pain, dyspnea, depression, anxiety, delirium, agitation, confusion, anorexia, constipation, nausea/vomiting, dry mouth, fatigue, insomnia, and seizures. 2 palliative care utilizes a team approach to support patients and their families faced with serious medical conditions, beginning from the point of diagnosis and continuing throughout the trajectory of illness. the focus of palliative care is not one in the same as hospice care; rather, palliative care aims to improve quality of life by preventing and relieving suffering, through early identification and assessment and treatment of various symptoms, whether physical, psychosocial, or spiritual. 3 the advancing epidemic of chronic diseases that includes diverse cancers, cardiovascular disease, strokes, and diabetes is now dominant in all but the most undeveloped countries and drives the need for palliative care. according to the world health organization (who), 40 million people need palliative care every year, but only 14% of them receive it. 3 in many countries, palliative care services are simply unavailable. researchers, seya, gelders, achara, milani, and scholten (2011), suggest that 83% of the world population lack access to pain relief. 4 opioids, a mainstay of severe pain control, are not available in many countries 41 o’shea, kanarek, kazer, kelley & thomas nov 2017. christian journal for global health 4(3): 40-46 due to lack of the political will to put into place the legal structures needed for their use. for palliative care to be delivered, a workforce needs to be educated to provide high quality patient centric services. few countries, including high-income nations, have a palliative care ready workforce. according to the most recent report conducted by the worldwide palliative care alliance (wpca), most health professionals worldwide have sparse knowledge of the principles and practices of palliative care; the lack of knowledge further hinders the development and implementation of palliative care globally. 5 specifically, concerning the lack of knowledge of the principles and practices of palliative care education, the wpca recommended: “basic palliative care training for all health professionals; intermediate training for those routinely working with patients with life-threatening illnesses; and specialist palliative care training to manage patients with more than routine symptom management needs,” (p.28). 5 the leading role of nursing in palliative care the delivery of palliative care is a team-based endeavor and nurses are prepared to play a leading role on that team. by definition, the professional nurse: . . . encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. 6 in regards to care for the dying, the international council of nursing describes nurses as “uniquely prepared to offer compassionate and skilled care,” and views the nurses’ role as, “fundamental to a palliative approach that aims to reduce suffering and improve the quality of life for dying patients and their families through early assessment, identification, and management of pain and physical, social, psychological, spiritual, and cultural needs.” 7 nursing as a profession explicitly acknowledges the spiritual dimension of health, an integral consideration as patients face serious illness. the international council of nurses' code for nurses highlights the need to address spirituality and health, and the american association of colleges of nursing calls for nursing education to include spirituality as it relates to a patient’s health, healing, and well-being. 8 in the u.s., nursing education at the baccalaureate level ideally inculcates not only a sensitivity to the holistic needs of patients as persons, but also provides a foundation grounded in liberal education that includes the physical, social, mathematical, and life sciences, as well as the arts and humanities (aacn, 2008). 9 thus, nurses can support patients from widely different ethnic and religious backgrounds and may facilitate connection with spiritual leaders, if desired, to an individual or family member. while transcendent beliefs are common in many cultures, attitudes about the meaning of life and its end can be significantly different. 10, 11, 12 in circumstances where aggressive, life-extending treatments are an option, different religions can advance different considerations based on how they view the concept of an afterlife. 13 in diverse multicultural settings and among believers and those who do not adhere to a belief system, it often falls to the nurse to recognize and react in a culturally and spiritually competent manner when patients nearing the end-of-life and their families are at peace, angry, confused, scared, or depressed. faith-based institutions and palliative care faith-based institutions play an immense role in the delivery of health care services. one example 42 o’shea, kanarek, kazer, kelley & thomas nov 2017. christian journal for global health 4(3): 40-46 of this outreach is by the catholic church. managing 26% of health care facilities in the world, the catholic church oversees “117,000 health care facilities, including hospitals, clinics, orphanages,” in addition to “18,000 pharmacies and 512 centers for the care of those with leprosy.” 14 the salvation army is another example of an international organization that has made end of life care one of its priorities. 15 extending into 127 countries, salvationists respond to heath care concerns through more than 15,000 churches. 15 many other faith traditions sponsor high visibility health care programs in high, middle, and low-income countries. a commitment to palliative care services in catholic facilities comes from the highest levels of the church. in may 2015, pope francis addressed the pontifical academy for life and stated that palliative care “is an expression of the properly human attitude of taking care of one another, especially of those who suffer. it bears witness that the human person is always precious, even if marked by age and sickness.” 16 he spoke of “the duty of honoring the elderly,” which he related to the commandment to honor one’s mother and father and described it “as the duty to have extreme respect and to take care of those who, because of their physical or social condition, could be left to die, or ‘made to die.’” 16 reflective of the broad resonance of this concern for palliative care, on 30 march 2017, in rome, an interfaith charter was put forth entitled religions of the world charter — palliative care for older people. 17 palliative care and christian higher education the judeo-christian philosophy behind the delivery of health care services also inspires what should be a serious commitment of faith-based academic institutions to the education of practitioners of palliative care. while some countries have moved away from religious centric nursing programs in favor of more modern humanistic approaches, the us reports approximately one third of the four-year colleges offer nursing programs that are religiously based. 8, 18 increasingly, nursing education takes place at four-year colleges and that allows the student nurse to benefit from complementary education in theology, philosophy, culture, social sciences, and communication. the juxtaposition of these disciplines fosters in the student an intellectually grounded perspective that reflects the sanctity of life at all of its stages and professional practices that respect a patient’s dignity while minimizing suffering. in the u.s., preparing nurses to provide high quality palliative care has been widely supported by several leading healthcare professional organizations. 19, 20, 21, 22 specifically, the american association of colleges of nursing has recommended the incorporation of essential palliative nursing concepts, learning objectives, content, and competencies within curricula of all undergraduate nursing programs. 23 the goal of this undergraduate focus is to prepare future nursing professionals with the knowledge and skills to provide general palliative care to those with a serious illness, as the present numbers of palliative healthcare professionals available cannot meet the present needs. 24 additionally, the american nurses association (ana) issued a call to action for all registered nurses and advance practice nurses to support and advance primary palliative nursing care. 25 the ana recommendations have educational implications to enhance graduate level curricula with palliative care education. while these recommendations were written with an american audience in mind, they are similar to international trends. 26, 27, 28 faith-based academic institutions should be in the forefront of the response to this call for building up the capacity for palliative care. as institutions that share a common sense of mission and attachments to global institutional networks, (e.g., catholic church and salvation army) they are particularly well suited to work together to achieve palliative care progress globally. 43 o’shea, kanarek, kazer, kelley & thomas nov 2017. christian journal for global health 4(3): 40-46 genesis of the kanarek center for palliative care nursing education in response to the growing need to develop a general palliative care ready nursing workforce and in an effort to address the lack of education, one jesuit school of nursing located in fairfield, connecticut in the united states has taken action to meet these demands. the marion peckham egan school of nursing and health studies at fairfield university strives to: develop nursing professionals who are morally reflective providers, working to deliver evidenced-based holistic care to patients and families with consistent sensitivity to cultural differences and issues of social justice. 29 the strong core curriculum steeped in ethics, communication, philosophy, theology, humanities, math, and science prepares fairfield nursing students with comprehensive education necessary to become excellent nursing professionals. 29 integrating palliative care education into the fairfield curriculum became a priority goal to respond to local and national workforce needs. through a generous donation, the egan school of nursing and health studies established an innovative center of nursing excellence for evidence-based palliative and end-of-life care education, named the kanarek center for palliative care nursing education (kcpc). this center of nursing education seeks to transform palliative care by developing the next generation of specialized leaders in the field by integrating high quality palliative nursing education into clinical practice. specifically, the center utilizes the end-of-life nursing education consortium (elenc) curricula to enhance both the undergraduate and graduate curricula. 30 the elnec program was chosen as the curricula model as it continues to be revised by national palliative care experts and incorporates evidence-based practices and research on a regular basis, which allows for easy adoption into nursing curricula inside and outside of the us. 30 additionally, the kcpc center offers the elnec program to community clinical agencies, so that practicing licensed nurses have the opportunity to engage in continuing education concerning palliative care. extending this education to practicing nurses will further generate consumer and provider driven communication that serves as a regional and national resource to inspire understanding of best practices in palliative and end-oflife care. the kanarek center for palliative care nursing education has several notable aspects. first, the focus is to advance nursing leadership and foster inter-professional collaboration that will enhance the lives of patients with serious illness and families through education, administration, practice, research, and policy. 31 second, because the palliative care nursing education center is based within the nursing school of a faith-based liberal arts-oriented university, it has some advantages over other palliative programs based in tertiary care academic medical centers. these advantages include close relationships with community-based agencies, the faith-based community, and various outpatient settings. 29 the comprehensive university setting also facilitates multi-disciplinary engagement with fields as diverse as counseling, communication, applied ethics, theology, the social sciences, engineering, and business. 32 third, the core values of this palliative care nursing education center were developed purposefully to align closely with the holistic, judeo-christian values that underpin the entire university mission. 29, 32 of note, the idea of having a palliative care nursing education center at the egan school of nursing was conceived by the kanarek family 15 years after their son’s death following a five year battle with cancer. this family’s commitment stemmed from the judeo-christian values that they hold in common with the university. their recognition of the desperate need for better palliative care nursing education was born out of the lack of psycho-social, spiritual support during their son’s final months of life. as a nurse and alumna of fairfield university, mrs. kanarek, was motivated to show leadership by establishing the 44 o’shea, kanarek, kazer, kelley & thomas nov 2017. christian journal for global health 4(3): 40-46 center. admittedly, without the philanthropic support, a center of this magnitude may not have been feasible. leading the way: palliative care in christian higher education to meet the global need to provide high quality compassionate care for patients with serious and life threatening medical conditions, a palliative care nursing workforce must be cultivated. all nursing students should graduate ready to deliver primary level palliative care. this education should address not only clinical topics such as pain and symptom management but also ethical issues, communications, spirituality, and leadership. nurses also should fill a leading role in educating the larger lay population in what palliative care offers and in preparing all to make informed choices around palliative care and end-of-life decisions. developing a center of palliative care nursing education within faith-based schools of nursing may be an innovative solution to address the growing need. measuring outcomes for this new program is needed and, if successful, may offer opportunities for replication within the u.s. and in other countries. cooperation among faith-based nursing schools can be based on shared values and may facilitate the spread of palliative care capacity. references 1. world health organization [internet]. geneva. ncd surveillance. 2017. available from: 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[internet]. vatican. pope francis: we must not abandon the elderly. 2015. available from: http://en.radiovaticana.va/news/2015/03/05/pope_fra ncis_we_must_not_abandon_the_elderly/1127144 17. baykov a, bernabei r, bhikshuni t, blanchard t, brown b, busch cj, et al [internet]. rome. religions of the world charter — palliative care for older people. 2017. available from: http://olderpeoplereligionsworldcharter.maruzza.org 18. tveit b, karvinen i, damsma-bakker a, ylonen m, oosterhoff-zielman m, fanuelsen o et al. balancing identity and diversity in faith-based nursing education: a case study from northern europe. christ higher ed. 2015;14:283-97. 19. national consensus project for quality palliative care. clinical practice guidelines for quality palliative care. 3rd ed. pittsburgh, pa: national consensus project; 2013. 20. hospice and palliative nurses association [internet]. position statement: palliative nursing leadership. pittsburgh, pa. hpna; 2015. available from: http://hpna.advancingexpertcare.org/wpcontent/uploa ds/2015/02/position-statement-on-palliativenursing-leadership.pdf 21. institute of medicine. dying in america: improving quality and honoring individual preferences near the end of life. washington, dc: the national academies press; 2015. 22. american nurses association and hospice and palliative nurses association. palliative nursing: scope and standards of practice — an essential resource for hospice and palliative nurses. 5th ed. silver spring, md: the association; 2013. 23. american association of colleges of nursing [internet]. cares: competencies and recommendations for educating undergraduate nursing students — preparing nurses to care for the seriously ill and their families. washington, dc: aacn; 2016. available from: http://www.aacn.nche.edu/elnec/new-palliativecare-competencies.pdf 24. coyle n. introduction to palliative nursing care. in: ferrell br, coyle n, paice j, editors. oxford textbook of palliative nursing. 4th ed. new york, ny: oxford university press; 2015:3-10. 25. american nurses association [internet]. professional issues panel report. call for action: nurses lead and transform palliative care. silver spring, md: ana; 2017. available from: http://nursingworld.org/mainmenucategories/thepr acticeofprofessionalnursing/palliative-care-callfor-action/draft-palliativecareprofessionalissuespanel-callforaction.pdf 26. gamondi, c, larkin p, payne s. core competencies in palliative care: an eapc white paper on palliative care education — parts 1 & 2. eur j palliative care [internet]. 2013;20(2). available from: http://www.eapcnet.eu/linkclick.aspx?fileticket=xp rm1lnasbo%3d&tabid=38 27. doyle d, woodruff r. education and training for service staff. in: the iahpc manual of palliative care. 3 rd edition. houston, texas: iahpc; 2013. p.112-3. 28. pastrana t, wenk r, delima l. consensus-based palliative care competencies for undergraduate nurses and physicians: a demonstrative process with colombian universities. j palliat med. 2016;19(1):76-82. available from: http://dx.doi.org/10.1089/jpm.2015.0202 29. fairfield.edu [internet]. fairfield, ct: egan school of nursing and health studies. available from: https://www.fairfield.edu/undergraduate/academics/s chools-and-colleges/egan-school-of-nursing-andhealth-studies/administration-and-faculty 30. american association of colleges of nursing (aacn): end-of-life nursing education consortium (elnec) fact sheet [updated 2016]. duarte, ca. the consortium; 2003. available from: http://www.aacnnursing.org/portals/42/elnec/pdf /factsheet.pdf 31. fairfield.edu [internet]. fairfield, ct: kanarek center for palliative care education. available from: https://www.fairfield.edu/undergraduate/academics/s chools-and-colleges/egan-school-of-nursing-andhealth-studies/kanarek-center-for-palliative-care 32. fairfield.edu [internet]. fairfield, ct: mission, values and history. available from: https://www.fairfield.edu/about-fairfield/missionvalues-history http://www.catholicnewsagency.com/news/catholic_hospitals_represent_26_percent_of_worlds_health_facilities_reports_pontifical_council http://www.catholicnewsagency.com/news/catholic_hospitals_represent_26_percent_of_worlds_health_facilities_reports_pontifical_council http://www.salvationarmy.org/ihq/health http://en.radiovaticana.va/news/2015/03/05/pope_francis_we_must_not_abandon_the_elderly/1127144 http://en.radiovaticana.va/news/2015/03/05/pope_francis_we_must_not_abandon_the_elderly/1127144 http://olderpeoplereligionsworldcharter.maruzza.org/ http://hpna.advancingexpertcare.org/wpcontent/uploads/2015/02/position-statement-on-palliative-nursing-leadership.pdf http://hpna.advancingexpertcare.org/wpcontent/uploads/2015/02/position-statement-on-palliative-nursing-leadership.pdf http://hpna.advancingexpertcare.org/wpcontent/uploads/2015/02/position-statement-on-palliative-nursing-leadership.pdf http://www.aacn.nche.edu/elnec/new-palliative-care-competencies.pdf http://www.aacn.nche.edu/elnec/new-palliative-care-competencies.pdf http://nursingworld.org/mainmenucategories/thepracticeofprofessionalnursing/palliative-care-call-for-action/draft-palliativecare-professionalissuespanel-callforaction.pdf http://nursingworld.org/mainmenucategories/thepracticeofprofessionalnursing/palliative-care-call-for-action/draft-palliativecare-professionalissuespanel-callforaction.pdf http://nursingworld.org/mainmenucategories/thepracticeofprofessionalnursing/palliative-care-call-for-action/draft-palliativecare-professionalissuespanel-callforaction.pdf http://nursingworld.org/mainmenucategories/thepracticeofprofessionalnursing/palliative-care-call-for-action/draft-palliativecare-professionalissuespanel-callforaction.pdf http://www.eapcnet.eu/linkclick.aspx?fileticket=xprm1lnasbo%3d&tabid=38 http://www.eapcnet.eu/linkclick.aspx?fileticket=xprm1lnasbo%3d&tabid=38 http://dx.doi.org/10.1089/jpm.2015.0202 https://www.fairfield.edu/undergraduate/academics/schools-and-colleges/egan-school-of-nursing-and-health-studies/administration-and-faculty https://www.fairfield.edu/undergraduate/academics/schools-and-colleges/egan-school-of-nursing-and-health-studies/administration-and-faculty https://www.fairfield.edu/undergraduate/academics/schools-and-colleges/egan-school-of-nursing-and-health-studies/administration-and-faculty http://www.aacnnursing.org/portals/42/elnec/pdf/factsheet.pdf http://www.aacnnursing.org/portals/42/elnec/pdf/factsheet.pdf https://www.fairfield.edu/undergraduate/academics/schools-and-colleges/egan-school-of-nursing-and-health-studies/kanarek-center-for-palliative-care https://www.fairfield.edu/undergraduate/academics/schools-and-colleges/egan-school-of-nursing-and-health-studies/kanarek-center-for-palliative-care https://www.fairfield.edu/undergraduate/academics/schools-and-colleges/egan-school-of-nursing-and-health-studies/kanarek-center-for-palliative-care https://www.fairfield.edu/about-fairfield/mission-values-history https://www.fairfield.edu/about-fairfield/mission-values-history 46 o’shea, kanarek, kazer, kelley & thomas nov 2017. christian journal for global health 4(3): 40-46 peer reviewed competing interests: none declared. correspondence: eileen r. o’shea, fairfield university, usa. eoshea@fairfield.edu cite this article as: o’shea er, kanarek rb, kazer mw, kelley pw, thomas t. building nursing capacity for palliative care at a jesuit catholic university: a model program. christian journal for global health. nov 2017; 4(3):40-46. https://doi.org/10.15566/cjgh.v4i3.192 © o’shea er, kanarek rb, kazer mw, kelley pw, thomas t. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:eoshea@fairfield.edu https://doi.org/10.15566/cjgh.v4i3.192 http://creativecommons.org/licenses/by/4.0/ commentary nov 2017. christian journal for global health 4(3):21-39. should evangelical christian organizations support international family planning? monique c. wubbenhorst a and jeffrey k. wubbenhorst b a md, mph, assistant professor, division(s) of duke specialists in benign gynecology & community outreach and education, department of obstetrics & gynecology, duke university medical center, usa b dmin, gordon-conwell theological seminary, south hamilton, ma abstract the evangelical christian church and christian international organizations today face considerable pressure to promote family planning in the course of their activities overseas. this pressure can be subtle or overt; the need to provide family planning is often couched in terms of biblical compassion, justice, improvement in women’s health, poverty alleviation or development. it is evident from even a superficial glance at the internet that the concept of “family planning” is heavily laden with negative associations due to the bitter legacy of eugenics and population control. does family planning include just contraception? or is there a mentality or implicit agenda behind the use of contraceptive technology? what are the possible results of promoting family planning as part of the church’s international activities? is there a mandate, scriptural or otherwise, for christians and international christian organizations to promote pregnancy prevention? more important to the practicing christian, what are the assumptions behind the “need” for family planning in the context of christian global health? we discuss ethical and theological frameworks as well as scientific and epidemiologic data from an evangelical christian perspective that might help inform discourse and decision-making on this controversial subject. introduction evangelical churches and international organizations today face considerable pressure to promote family planning overseas, for reasons including improved maternal health and child health, population control, poverty alleviation, and development. some proposed ventures such as christian connections for international health (ccih) involve working with non-christian entities that promote abortion worldwide, while eschewing abortion in their cooperative ventures with christian organizations. although the promised benefits of such cooperation can be attractive, there are serious issues to consider before evangelical christians “sign on” to such initiatives. these include the wisdom of the bible, christian history, and theology; the effects of contraception where it has been widely practiced; the close connection between contraception and abortion; alternative solutions to the problems contraception and abortion purport to solve; and the possible pitfalls of alliances with non-christian organizations. to begin, an “evangelical by belief” may be defined as someone who agrees with the following four statements: “the bible is the highest authority for what i believe; it is very important for me 22 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. personally to encourage non-christians to trust jesus christ as their savior; jesus christ’s death on the cross is the only sacrifice that could remove the penalty of my sin; only those who trust in jesus christ alone as their savior receive god's free gift of eternal salvation.” 1 this definition was specifically formulated for purposes of research by the national association of evangelicals. of greater importance, each person engaging in christian work should test their beliefs against historic christian orthodoxy and scripture to see if they and their work are in fact “in the faith” (2 cor 5:8-12). family planning may include contraceptive technologies, pregnancy prevention, induced abortion, birth spacing, birth limiting or the ambiguous terms “reproductive health care” and “sexual health care.” it is vitally important for christians to consider what christian family planning consists of, and to precisely and scripturally define this term. scriptural foundations the bible provides a framework for understanding family planning by describing the origin and sanctity of human life. as the crowning act of his creation, god created humankind (male and female) uniquely in his own image. he further dignified human life through the incarnation of jesus christ as a man and promised the resurrection of the physical body at the end of time. thus, all human life should be treated as a gift from god and worthy of respect. in old testament times, god’s people were forbidden upon penalty of death to practice child sacrifice as the surrounding nations did (lev 18:21; 20:5). this is the context for considering the ethics of abortion, which old testament judaism always forbade: life is a gift of god. the preciousness of an unborn human life is celebrated in psalm 139, where david writes, “for you formed my inward parts; you knitted me together in my mother’s womb... i am fearfully and wonderfully made... your eyes beheld my unformed substance; in your book were written, every one of them, the days that were formed for me, when as yet there was none of them.” (psalm 139: 13-14, 16). even in utero at the earliest stages of development, god recognizes the humanity of the embryo (see genesis 20:18, 29:31, 30:2, 30:22; judges 13:2-3; ruth 4:13; 1 samuel 1:6; jeremiah 1:5; luke 1: 13-15 and 1:24-25, 1:44). in other words, life is sacred from the moment of conception. given this biblical evidence, it is clear that christian family planning should have nothing to do with elective abortion, including “safe abortion.” surprisingly, however, even some leaders among professedly christian organizations may condone “safe abortion” where it is “legal” despite the fact that abortion destroys human life. 2 however, the historic position of the church has always been emphatically against abortion. not only this, but the church has viewed contraception in a similar light. a brief history of the church’s position on contraception and abortion illustrates this. historical views contraception and abortion are nothing new; the earliest known mention of contraception was in the egyptian petrie papyrus from 1850 b.c. 3 the hippocratic oath (5th century b.c.) explicitly prohibited abortion by physicians, but abortion was nonetheless widely accepted in greek culture. in his republic, plato (424-347 bc) advocated mandatory abortion for any women over the age of 40. 4 in his politics, aristotle (384–322 bc) stated, “there must be a limit fixed to the procreation of offspring, and if any people have a child as a result of intercourse in contravention of these regulations, abortion must be practiced.” 5 in the 4 th century b.c., aristotle mentioned contraceptive methods, and many other cultures worldwide practiced contraception, abortion or both. abortion and contraception were very common in the grecoroman culture in which christianity emerged, being approved at the highest levels of society even 23 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. though induced abortion was often fatal for the mother. 6,7 however, the church departed from the societal norms of the time and radically cherished life at all stages and conditions. contraception and abortion were condemned, along with the widespread practice of infanticide. for example, the didache, a first-century church manual, stated, “thou shalt not murder a child by abortion nor kill them when born.” 8 athenagoras (mid-2 nd century ad) wrote: “... women who use drugs to bring on an abortion commit murder, and will have to give an account to god for the abortion... [for we] regard the very foetus in the womb as a created being, and therefore an object of god’s care...” 9 epiphanius of salamis (c. 375 a.d.) denounced those who, “prevent(ed) the conceiving of children” as did others including st. hippolytus, jerome, chrysostom, minucius felix, origen, ambrose, basil, clement of alexandria, tertullian, and augustine. 10,11 the rejection of contraception and abortion transcended the rift of the protestant reformation. martin luther, the father of the reformation, said, “how great, therefore, the wickedness of human nature is! how many girls there are who prevent conception and kill and expel tender fetuses, although procreation is the work of god!” 12 such protestant leaders as john calvin, cotton mather, and john wesley also held this view. 13, 14 in fact, up until the 20 th century, the three major branches of christianity (orthodoxy, roman catholicism, and protestantism) all condemned contraception. 15 the birth control movement this unified christian ethic across millennia was broken largely through the work of the birth control movement, led by margaret sanger and her allies, in the first three decades of the 20 th century (though its roots go back to the 18 th century). sanger and others exploited christian disunity and anti-catholic sentiment by asserting that birth control was “prohibited... by an alien, halfamericanized roman catholicism,” 16 even though at the time all protestant denominations condemned birth control. 17 she also appealed to the eugenics sentiment by pitching birth control as a method to guide the evolution of the race by suppressing the reproduction of the “unfit.” 18 sanger’s strategy worked: as one historian noted, “eugenics gained popular support in large part through the endorsement of mainstream and progressive protestant spokespersons,” including african american leaders and clergy. 19, 20 these efforts led to a breakthrough at the 1930 lambeth conference, where, in marked contrast to previous lambeth conferences, a resolution passed approving the “cautious” use of contraceptives in extreme cases within marriage. 21 other protestant groups soon began to follow. in the same year, pope pius xi defended the historic christian opposition to contraception with his encyclical casti connubii, but by the end of the 1930’s nearly all protestant denominations in the united states had abandoned 1,800 years of christian consensus on contraception. many later abandoned their condemnation of abortion as well. 22 the issue of modern contraception exploded to significance in the 1960s with the introduction of the birth control pill, and the subsequent united states supreme court 1967 ruling in griswold v. connecticut upholding the “reproductive rights” of married people to use contraception, though the right of privacy was not explicitly included in the constitution. this ruling essentially agreed with the lambeth conference resolution of 1930. in 1968, pope paul vi’s encyclical, humanae vitae, reiterated the historic christian opposition to contraception but protestant leaders attacked the encyclical as trying to impose “catholic views” on the world. in 1972, the supreme court expanded the right of privacy to include unmarried people in eisenstadt v. baird, setting the stage for roe v. wade (1973) that declared abortion a “right”. with some exceptions, this elicited little protest from protestants, both evangelical and nonevangelical, since they had already conceded 24 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. contraception and abortion as compatible with christian ethics by the end of the 1960s. 22 for example, one month after the pope issued his encyclical, an evangelical symposium sponsored by christianity today and the christian medical society came to the defense of contraception and, in some cases, abortion: “the christian physician will advise induced abortion only to safeguard greater values sanctioned by scripture. the values should include individual health, family values, and social responsibility... ” 23 five years later, some southern baptist voices even defended the 1973 roe v. wade decision that legalized abortion. prominent evangelical pastor w.a. criswell, for example, claimed, “i have always felt that it was only after the child was born and had life separate from its mother that it became an individual person.” 23 this widespread acceptance among protestant churches was cited by the supreme court in roe v. wade: the view that life does not begin until live birth... may be taken to represent also the position of a large segment of the protestant community, insofar as that can be ascertained; organized groups that have taken a formal position on the abortion issue have in general regarded abortion as a matter for the conscience of the individual and her family. 24 in saying this, the court underlined the connection between contraception and abortion, and acceptance of these effectively left the catholic church alone to uphold the ancient christian tradition of condemning contraception. and, although these attitudes toward abortion and contraception among western evangelicals likely differed greatly from those of christians outside the u.s. and western europe, the outsized impact of western international policy (and funding) made it inevitable that there would be pressure on the church (especially in the global south) to embrace contraception and abortion. contemporary christian approaches since 1973, many evangelicals have reconsidered their position on abortion, and some are rethinking their position on contraception. for example, albert mohler, president of the southeastern baptist theological seminary, noted that “in an ironic turn, american evangelicals are rethinking birth control even as a majority of the nation’s roman catholics indicate a rejection of their church’s teaching.” 25 in a later interview, he stated, “i cannot imagine any development in human history, after the fall, that has had a greater impact on human beings than the pill... the entire horizon of the sex act changes... the pill gave incredible license to everything from adultery and affairs to premarital sex, and within marriage, to a separation of the sex act and procreation.” 26 these were, of course, among the four outcomes predicted by humane vitae in 1968: a lowering of moral standards, an increase in infidelity, decreased respect for women by men, and the coercive use of contraceptive technology by governments. in her book, adam and eve after the pill, mary eberstadt examines empirical evidence largely derived from secular social scientists and notes that all of these predictions have come true. 27 jesus declared, “… you will know a tree by its fruit” (matthew 12:33). have the wide-scale use of contraceptives borne good fruit? has it been an aggregate good to societies that have adopted it? if not, should it be exported to other societies? the push to bring contraceptives to other countries appears to be driven by ideology and not by the targeted nations’ own perceived needs. for example, nigerian writer and women’s advocate obianuju ekeocha declares, “many countries in the west... have decided... to raise millions of dollars that they are dedicating to the so-called ‘safe abortion’... [but] have not even thought of asking the africans what they want!” 28 she cites a 2014 pew research survey showing that upwards of 80% of people in african countries found abortion to be “morally unacceptable.” 29 ekeocha speaks of this 25 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. as “the new colonialism,” “cultural imperialism,” and “the dictatorship of the wealthy donor.” one might even call this “sexual colonialism” or “sexual imperialism.” the contraceptive mentality this ideology may originate in “the contraceptive mentality” which is deeply rooted in american and western european culture. dr. donald demarco, drawing upon writings by carl jung, describes a mentality as a notion existing in a society: “when enough people react automatically to a situation without thinking of the long-range consequences.” 30 jesuit sociologist stanislas de lestapis was the first to draw attention to the “contraceptive mentality.” dr. demarco states the following: in his book, la limitation des naissances, published in 1960, de lestapis provided sociological data that indicated the presence of what he termed a “contraceptive state of mind.” in england, for example, the royal commission on population noted that in 1949 the number of procured abortions was 8.7 times higher among couples who habitually practiced contraception than among those who did not. in sweden, after contraception had been fully sanctioned by law, legal abortions increased from 703 in 1943 to 6,328 in 1951. in switzerland, where contraception was almost unrestricted, abortions were alleged to equal or outnumber live births by 1955, and so on. such figures offered compelling evidence for the claim that more contraception does not reduce the incidence of abortion. in fact, the figures suggested that more contraception tends to establish a “contraceptive state of mind” which leads to absolving responsibility for children conceived which, in turn, leads to more abortion... malcolm potts, the former medical director of the international planned parenthood federation, accurately predicted in 1973, “as people turn to contraception, there will be a rise, not a fall, in the abortion rate.” 30 lawrence lader, a champion for abortion and contraception whose influential 1966 book, abortion, provided much of the scientific foundation for roe, ratified this concept, lamenting that contraception, ... [has not] been scientifically perfected to meet every requirement of dependability, cost, and esthetic preference... until medical research discovers the final solution, abortion is the essential emergency measure, the inalienable right of all women in a free society... as long as a reasonable chance of contraceptive failure persists... abortion must be included as a part of birth control to insure every child’s becoming a wanted child. 31 he quotes garrett hardin, professor of biology at university of california-santa barbara, as saying, “no matter how good a method of contraception is, we can never expect it to be perfect ... even one with a 1 percent failure rate produces a quarter of a million unwanted children a year [based on the us population at the time] ... abortion is the much-needed backstop in the system of birth control.” 31 this explicit connection between contraception and induced abortion shows the fruit of the contraceptive mentality. operationally, recent research by nguyen and budiharsana has shown that high contraceptive prevalence and receipt of family planning services paradoxically were associated with high rates of abortion in vietnam. 32 this study was especially noteworthy because even though the majority of women were using the iud, a “modern, highly effective” type of contraceptive technology, abortion rates were high. existing as it does in a 26 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. materialist and utilitarian ethical framework, the contraceptive mentality cannot help but lead couples to turn to abortion when contraception fails. george and tollefson make the point that within any such utilitarian ethic, there will always be human beings who are dispensable, who must be sacrificed for the greater good. utilitarianism... treats the greater good, a mere aggregate of all the interests or pleasures or preferences of individuals, as the good of supreme worth and value, and demands that nothing stand in the way of its pursuit. 33 beyond ideology, we question what is behind the impetus for evangelical organizations to promote contraception internationally. there is a clear economic incentive; contraceptive drugs and devices are manufactured and marketed by drug companies whose goal is profit for their shareholders. certainly, the use of “safe abortion,” or abortion as family planning or as a backup to contraception, is contrary to christian morality as noted above. some christian organizations respond to this by renouncing the promotion of abortion while advancing the use of contraceptives. however, by forming partnerships with proabortion organizations, the latter may be further empowered in their pro-abortion activities. since the mexico city policy has been reinstated, it would not be surprising if pro-abortion organizations seek support and/or legitimacy from christian international organizations or offer them training, educational materials, etc. for pro-abortion organizations, legitimacy, credibility, and access are important benefits. churches and organizations overseas, which might otherwise reject such partnerships, could be encouraged to do so based on relationships with evangelical churches or organizations in the u.s. further, if christian organizations in the u.s. or overseas become dependent on funding from pro-abortion organizations, they may not be able to serve christ without compromise. the question should be asked: are we entering into an “unholy alliance” with nonchristian, pro-abortion organizations? in the bible, amos 3:3 states, “can two walk together, unless they are agreed?” christian organizations should consider not supporting or entering into a partnership with any organization that performs or promotes abortion, or which is associated with organizations that do so. by extension, when considering international fp programs, some fundamental questions need to be asked from a christian perspective and their theological basis examined carefully. this does not mean that christians should withdraw from working with proabortion governments. rather, we must obey the new testament command to not be unequally yoked together with unbelievers (2 cor 6:14). this scripture refers to a close relationship between believers and unbelievers which is not pleasing to god and which always leads to negative consequences. the bible gives examples of the dangers of such alliances such as those between joshua and the gibeonites, jehosaphat and ahab and joram and ahaziah (joshua, 1 kings 20:32, 42; 1 kings 22; 2 kings 9:21-24). toward a christian definition of family planning the definition and purposes of “family planning” should be explicitly stated and examined carefully. for example, one christian group describes family planning as enabling “couples to determine the number and timing of pregnancies, including the voluntary use of methods for preventing pregnancy—not including abortion— that are harmonious with their values and beliefs.” 34 this definition is problematic from a christian perspective. first, it is an overstatement to say that with “family planning” couples can determine the number and timing of pregnancies. at most, they can try to prevent or space pregnancies (birth spacing). but what happens when a woman becomes pregnant while using contraception? in the 27 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. context of the contraceptive mentality, could abortion (birth limiting) become the “backup,” as stated earlier? couples can also hope when they stop contraception and try to become pregnant that they will succeed. but prolonged contraceptive effect and delayed return of fertility is well known with depoprovera. 35-37 sadly, it is also well-documented that many women have contracepted past the limits of their own natural fertility (for an especially poignant discussion of this modern dilemma, see creating a life: professional women and the quest for children by sylvia ann hewlett). 38-41 human beings cannot decide infallibly that they will or will not become pregnant when they want to. “family planning” is a mirage which promotes the illusion that we have a degree of control over life that, as humans, we simply do not have. the bible states that god has the ultimate power to open and shut the womb (genesis 20:18, 29:31, 30:2, 30:22; judges 13:2-3; ruth 4:13; 1 samuel 1:6; luke 1:1315, 1:24-25). second, the methods used to prevent pregnancy matter. most contraceptives have preovulatory, pre-fertilization, post-ovulatory or postimplantation effects (or a combination of these). while a complete discussion of this topic is beyond the scope of this paper, briefly, contraceptives with pre-ovulatory and/or pre-fertilization effects may prevent the union of sperm and egg (such as barrier methods and some hormonal methods); may be gametocidal (such as spermicides); or may act to suppress ovulation (many hormonal methods). contraceptives with post-fertilization effects may prevent the embryo from implanting. these distinctions are extremely important, because whether or not the use of a specific contraceptive method is acceptable to evangelical christians worldwide may depend on when they believe human life begins. physicians and scientists have long stated that human life begins at conception. 42-44 in contrast, the pragmatic recent view that life begins with implantation is based on the discovery that upon implantation, the embryo sends out a hormonal signal (hcg)—which can be detected in the mother’s urine and blood. but defining pregnancy and life as beginning at implantation does not accord with newer scientific evidence and may concede to views that make the embryo less than human. fertilization triggers a detectable calcium wave in vitro. 45-46 further, at the same time as intracellular activity begins in the new embryo, a zinc “spark” is released into the extracellular space within the mother’s body, distinct from the newly formed human organism. 47 there is also evidence that maternal recognition of pregnancy is prompted by a signal from the preimplantation embryo. 48 for christians who believe that life begins at implantation, methods that disrupt an implanted pregnancy are abortifacient and, therefore, not acceptable. these may include the drug ulipristal (ella, which blocks the action of progesterone) and mifepristone (part of medical abortion protocols). the mechanism of action of both drugs appears to be embryocidal, but they are recommended as emergency contraception (ec). ec is universally promoted alongside other types of contraception. 49,50,51 conversely, for christians who believe that life begins at conception, contraceptive methods that prevent or interfere with implantation and therefore indirectly embryocidal are unacceptable. a third problem with the above definition is that organizations that promote the involvement of christians and christian organizations with “family planning,” do not appear to encourage health workers or educators to pray with couples and seek god as to the number and timing of pregnancies. couples also may not be encouraged to pray about god’s will for themselves, their marriage, and families. god requires of us that we seek him for even the seemingly unimportant decisions in our lives. biblical examples where people of god did not do this include abraham, whose attempt to have a son based on his human understanding resulted in the birth of ishmael, and hezekiah, whose request that god save his life made possible the birth of 28 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. manasseh, who brought judgment on the nation of judah (2 kings 20:1-7, genesis 16). in contrast, christ’s life models a complete dependence on god for everything (john 5:19). fourth, “family planning” often mentions neither god nor marriage. “couples” mentioned could be unmarried couples including adolescents, or those in adultery, in which case family planning facilitates sex outside of marriage without the (perceived) risk of pregnancy. such relationships are explicitly prohibited and described as sin in scripture (1 corinthians 6:9-10). the vague mention of couples’ “values and beliefs” in the brochure quoted above means that a couple could have beliefs that might not be christian or could even be anti-christian. should christians support such values and beliefs, as some have done? here we should be aware that even good intentions, when not employed in the context of biblical values, can and often do hurt the people we are trying to help. effects one common motive for “family planning” is to control population growth. though this is widely accepted as a present danger, the forecasts of catastrophic overpopulation have not occurred. for example, the dire predictions of paul ehrlich’s famous book, the population bomb, have spectacularly failed to materialize. 52 in fact, nations now face the opposite danger, a “demographic winter” where declining birth rates (often influenced by government efforts at family planning) lead to population decline below a sustainable level. if family planning leads to “demographic winter,” it is actually hurting, not helping, a society. the present disastrous results of china’s one-child policy, attributed to coercive population control policies, include skewed sex ratios (since many more girls than boys are aborted), social instability, increased crime and sexual trafficking, and an impending crisis in couples’ ability to support an aging parent. 53, 54 contraceptives are routinely stated to be very safe. but as with any drug or medical device, they may have adverse health effects. these include blood clots and increased risk of stroke and heart attack, especially in smokers and older women with cardiovascular disease (oral contraceptives, the vaginal ring, the contraceptive patch, depoprovera). adverse effects also include weight gain and changes in carbohydrate metabolism (oral contraceptives, depo-provera, the vaginal ring, the contraceptive patch); anabolic steroid-type effects (depo-provera); mood changes including depression (depo-provera, some implants, the levonorgestrel iud); infection with resultant infertility (iuds); decreased bone density (depoprovera); and increased risk for breast cancer (depo-provera, oral contraceptive pills) 55-60 . these effects are unpredictable and in developed countries medical care is available to manage potential complications. such care is often limited or unavailable in developing countries. when promoting contraception outside the u.s. and western europe, are women adequately counseled regarding these risks? do they have access to health care in case of side effects or complications? meeting unmet need? the push for international christian organizations’ involvement in “family planning” is also made based on perceived “unmet need” for contraception. it is stated that “family planning saves lives” because if this “unmet need” is addressed by increasing contraceptive prevalence, there would be a substantial reduction in abortion, and maternal and infant deaths. the concept of unmet need has received recent scrutiny (see, for example, dr. rebecca oas’ excellent articles in the new atlantis and an earlier edition of this journal). 61, 62 “contraception saves lives,” we are told, by reducing maternal and child mortality and abortion. while a full discussion of this topic is beyond the scope of this commentary, we agree with oas that the concept of unmet need is, “deeply 29 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. flawed and frequently mischaracterized,” especially with regards to the impact of contraception on maternal mortality. we further agree with dr. oas that not using contraception is not the same as needing contraception. it is intuitively obvious that women’s intentions regarding pregnancy are dynamic, as are their life circumstances, and not all women who want to avoid pregnancy and are not using a modern method want modern contraception. nor does the concept of unmet need speak to the question of whether women would be disappointed or seek abortion if they became pregnant, or whether they even want contraception. similarly, to state that a person “needs” something implies that they feel the lack of it in their lives. once again, the concept of “unmet need” might be seen as paternalistic, an imposition of western contraceptive mentality upon women in developing countries. saving lives? population reference bureau’s document, family planning saves lives (2009), states that “family planning saves lives” because it, could prevent as many as one in every three maternal deaths by allowing women to delay motherhood, space births, avoid unintended pregnancies and abortions, and stop childbearing when they have reached their desired family size. 63 the document cites collumbien et al, who used models based on the demographic and health survey to analyze the attributable burden of morbidity and mortality from abortion and childbirth associated with contraception use or nonuse. 64 these authors state that “avoiding unwanted pregnancies will reduce maternal mortality in two ways: by reducing the number of pregnancies and by reducing obstetric risk...,” and, “it is estimated that worldwide 415,000 women die each year from obstetric causes,” but, “only a minority of these pregnancies are unwanted.” they estimate that about 23.7% of obstetric deaths, “could be prevent(ed) each year if all women who desire no more children were to use modern contraceptives.” however, they go on to write: a reduction in unintended pregnancies is not the only pathway to lower levels of disease burden. in industrialized countries, there are still high levels of unintended pregnancies and abortions, but the disease burden... is minimal because of the high quality of obstetric and abortion services. indeed, the avoidable burden in absolute numbers [of maternal deaths] may change more through... improvements in quality and provision of safe obstetric and abortion services—than through a decline in unintended pregnancies resulting from the use of effective contraception. 64 these authors also note “reducing mistimed births by contraceptive practice will have little influence on the incidence of pregnancies as the births will merely be delayed rather than averted. such delay... will not reduce the burden of delivery complications.” family planning saves lives states, “after giving birth, family planning can help women wait at least two years before trying to get pregnant again, thereby reducing newborn, infant and child deaths significantly.” there is evidence that both short and long intervals are associated with adverse perinatal, infant, and child outcomes. in one of the few studies to assess the relationship between contraceptive use and maternal and infant health outcomes, merali noted that users of modern contraception had longer birth intervals (adjusted or 2.4 (ci 2.0-2.8) but not lower levels of infant mortality (adjusted or 1.4, ci 0.9-2.0) and “modern contraceptive use was not associated with infant mortality.” 68 family planning saves lives states that interpregnancy interval of less than 5 months is associated with increased risk for maternal death and cites conde-agudelo and belizan’s study on birth spacing and maternal mortality. 69 in contrast, collumbien et al note, “it is uncertain whether 30 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. shorter birth intervals are associated with an increased risk of maternal morbidity or mortality. the only two published studies give conflicting results. it is therefore not justified to regard short intervals as a risk factor for obstetric complications.” 64 ronsmans and campbell make the point that “the statement that short birth intervals increase the risk of maternal mortality has never been confirmed empirically. instead, it seems to arise from the unproved assumption that maternal and infant mortality behave in the same way, and from the desire to exhort more women to use contraceptives.” based on a literature search and data from matlab, bangladesh, they found that there was “little support for an association between the length of intervals between births and the risk of maternal death.” they further state that, “although preventing [higher risk] pregnancies at the extremes of the reproductive ages will have some effects on reducing maternal mortality... prolonging spacing will not.” 67 other evidence challenges the assumption that younger or older maternal age, parity, and interpregnancy duration are associated with maternal mortality. ganatra and faundes reviewed the evidence for maternal mortality risk factors. they found that large studies, analyzing data from many countries... have reported that while there is a markedly higher risk of maternal death after age 30, the high risk among adolescents is either of a much lower magnitude than is generally assumed or that there is no increased risk of maternal adverse outcomes among adolescents compared with adults... the risk associated with younger age is more related to socioeconomic than to physiological factors... the association of older maternal age with higher mmr is probably the result of the higher incidence of other coincidental clinical conditions among older women. this suggests that screening for medical comorbidities could reduce maternal risk in this age group. these authors go on to state, the association between parity and maternal mortality, although identified in several studies and frequently underestimated by a number of authors, is not as clearly documented as the association with maternal age... [and] appears to be biased by a number of other determinants of maternal morbidity and mortality. finally, the authors state that conflicting results in various studies, “do not confirm the common assumption that very short inter-pregnancy intervals carry a higher risk of maternal mortality, and that by increasing such interval, it is possible to reduce mmr.” 68 the most frequently cited mechanism for reduction of maternal and child mortality with increased contraceptive prevalence is that there are fewer pregnancies and births and, therefore, fewer “opportunities” for poor outcomes. but statistically speaking, decreasing the number of pregnancies and live births does not decrease maternal mortality rate, since in the absence of good maternity care, the ratio of deaths remains the same even though the number of births (the denominator of the calculated mmr) may be decreased. fortney states, the maternal mortality ratio is likely to show significant improvement only with improvements in obstetrical care. family planning reduces the maternal mortality rate only to the extent that it reduces the proportion of pregnancies to high-risk women. 69 ronsman and campbell also note that reductions in maternal mortality with increasing contraceptive prevalence are only likely to occur if births among women at higher risk for adverse outcomes are avoided. however, all these models are built on the premise that, eliminating all births to women under 20 and over 39 can reduce maternal mortality by 34%, and eliminating births above parity 5 can reduce maternal 31 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. deaths by 58%. thus by eliminating births in developing countries in the ‘ages of reproductive inefficiency’ and confining them to ages 18-35, it would be possible to reduce maternal mortality by 20%. 70 collumbien et al also note that averting high risk births based on maternal age and parity can decrease maternal mortality, though “the effect is relatively small.” 64 following this logic, eliminating high-risk pregnancies and births in a population would prevent most maternal deaths. however, 100% pregnancy prevention is not possible with any contraceptive method. as noted above, even with high rates of “modern” contraceptive utilization, contraceptive “failures” will occur resulting in “unintended pregnancies” (outside the united states and western europe, where male fertility appears to be declining, this may be especially true). 71 with “unintended pregnancies,” birth limiting—not just pregnancy prevention—would be needed, and birth limiting is not possible without abortion. as ganatra et al state, “... not all unintended pregnancies can be prevented through increase in contraceptive use... [so] access to abortion is needed...” 68 implications thus, the goal of reducing maternal mortality cannot be achieved using contraception alone; birth limiting—through abortion—is also required. “eliminating all births” to women in the developing world at the ages of “reproductive inefficiency” would be nearly impossible without coercive contraception programs for birth limiting, including abortion. such contraception programs would not just eliminate births—they would eliminate human beings for whom christ died. this again demonstrates the inevitable progression of the contraceptive mentality—from preventing pregnancies with contraception to limiting or preventing births with abortion. if family planning programs do not succeed at first, there will be pressure to use the latter to reach their goals. “unless family planning services are offered alongside improved access to and quality of obstetric services,” ronsman and campbell state, “the risks associated with each pregnancy will remain unacceptably high.” 76 the underlying problem remains: even if increased uptake of contraception decreases the number of pregnancies and births, neither childbirth nor childhood would be safe. fortney succinctly summs up the frustrations many feel regarding the problem of maternal mortality in the developing world: “while implementing family planning programs is not easy, it is more feasible than the implementation of significant improvements in the quality and availability of obstetric care.” 69 we would counter this by stating that the rapid deployment and scaleup of such interventions is entirely possible with appropriate will. this has been demonstrated with many pediatric and infectious disease control programs. motivation will certainly be lacking, though, if it is felt that the fertility of women in developing countries is the problem and not poor living standards, low maternal literacy and a lack of available health services. finally, and most important, quoting ms. ekeocha above, have women in developing countries been asked whether they want modern contraception? “unmet need” assumes, without considering women’s desires or wishes, that they need western people to tell them how to control their fertility. the wording used—women “are considered to be in need”—shows clearly that the decision is being made by someone other than themselves. indeed, the language used above that high-risk births in the developing world must be “eliminated” and/or “confined” to certain age groups is eerily reminiscent of the language of eugenics. is this a form of “sexual colonialism” or “sexual imperialism?” 32 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. more than preventing pregnancy another point to be made here is that family planning is mentioned exclusively in reference to limiting or preventing pregnancy. but true family planning would also include helping people who want more children, who wish to achieve pregnancy and childbearing but for whatever reason have been unsuccessful. does this project also include helping such couples? while who’s definition of fp includes treatment of infertility, in practice this is not a programmatic emphasis. along these lines, it should be noted that emotional, physical, economic, and psychological benefits accrue more to married couples, and children raised in an intact family with a married father and mother. is this also part of the teaching and care given? is marriage affirmed and are sexual relationships outside of marriage explicitly discouraged? this is an important aspect of christian ethics that should be emphasized. poverty reduction an often-cited rationale for promoting family planning is to combat poverty with the assumption that a family with fewer members will be able to give more to each individual member. usaid is “the lead u.s. government agency that works to end extreme global poverty and enable resilient, democratic societies to realize their potential.” 72 as one of four strategic priorities to prevent child and maternal deaths, family planning is funded to help end extreme global poverty. but how is it accomplished? if contraception is made widely available, how will that help eliminate extreme poverty? couldn’t a large number of children actually help families come out of poverty by having more working members in the family? the document also implies that making family planning available will enable resilient, democratic societies to realize their potential. but what does this mean? what is our yardstick as christians for a godly society? does fp contribute to a more godly society or detract from it? should this strategy be employed only in democratic societies? if family planning is employed in non-democratic societies, is there a danger that those governments will use such programs coercively? how does family planning enable resilient, democratic societies to realize their potential? how is realizing potential measured? is it solely in material, economic terms or in certain health outcomes? while these questions are beyond the scope of this paper, they require consideration. the econometric evidence that smaller families may lead to increased prosperity may be only a short-term phenomenon. the possible longterm effects of demographic decline are just beginning to be appreciated, most strikingly in japan, germany, and china. this is especially remarkable for japan, whose booming post-wwii economy set a standard for economic development. not only are birth rates rapidly declining in japan, poverty is increasing, especially among young single women. 73,74 similarly, china’s impending demographic winter (noted above) and its potential economic and social problems should cause christians to pause and consider the long-term effects of promoting smaller families through increased contraceptive prevalence. 75 biblical justification various biblical rationales are sometimes given for family planning such as the call to take dominion, provide for family, and promote abundant life. adam’s naming of the animals with no stated participation by god is sometimes cited as evidence that man is a “co-creator” with god. 76 it is inferred that there are some things that god has left to humanity to decide on their own, and this includes the number and spacing of children. god spoke clearly to adam and eve, “be fruitful and multiply: fill the earth and subdue it; have dominion over the fish of the sea, over the birds of the air, and over every living thing that moves on the earth” (genesis 1:28). this is a clear command to procreate. there is no opposite command to prevent procreation. dependence upon god, seeking god’s counsel for every important decision (which surely 33 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. includes decisions around childbearing) is more the scriptural norm than independence. in fact, as our example, christ’s life models a complete dependence on god for every-thing. this is true “family planning.” avoiding the contraceptive mentality we have seen that the contraceptive mentality has been associated with increased likelihood of acceptance of abortion. so, the argument can be made that the contraceptive mentality moves individuals and societies incrementally toward acceptance of induced abortion. this link was recognized by the supreme court in planned parenthood v. casey (1992), which stated: ... [the roe v. wade decision] could not be repudiated without serious inequity to people who, for two decades of economic and social developments, have organized intimate relationships and made choices that define their views of themselves and their places in society, in reliance on the availability of abortion in the event that contraception should fail... it should be recognized, moreover, that in some critical respects, the abortion decision is of the same character as the decision to use contraception, to which griswold v. connecticut, eisenstadt v. baird, and carey v. population services international afford constitutional protection. we have no doubt as to the correctness of those decisions. they support the reasoning in roe relating to the woman’s liberty, because they involve personal decisions concerning not only the meaning of procreation but also human responsibility and respect for it [emphasis ours]. 78 personally and societally, people have tried to draw a strict boundary between contraception and abortion but it can easily collapse. a further case can be made that the acceptance of contraception leads to other things that the christian church has traditionally denounced. as eberstadt notes, “if a church cannot tell its flock ‘what to do with my body’... with regard to contraception, then other uses of that body will quickly prove to be similarly off-limits to ecclesiastical authority.” 27 she quotes the philosopher g.e.m. anscombe: if contraceptive intercourse is permissible, then what objection could there be after all to mutual masturbation, or copulation in vitae indebito, sodomy, buggery [anal intercourse] when normal copulation is impossible or inadvisable (or in any case, according to taste)? it can’t be the mere pattern of bodily behavior in which the stimulation is procured that makes all the difference! but if such things are all right, it becomes perfectly impossible to see anything wrong with homosexual intercourse for example... you will have no answer to someone who proclaims as many do that they are good too. you cannot point to the known fact that christianity drew people out of the pagan world, always saying no to these things. because, if you are defending contraception, you will have rejected christian tradition. 27 like the “firewall” between contraception and abortion, the wall between contraception and sexual sin collapses because it is built on a rejection of god’s authority. likewise, christian efforts to bring family planning to other countries, even with the intent of excluding abortion, are likely to unleash the same forces as have been released in the united states and western europe, starting with the contraceptive mentality and ultimately leading to the acceptance and widespread use of abortion and other moral problems. recommendations here are some possible guidelines as well as questions that can be asked to help inform decisionmaking by evangelical christian international 34 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. organizations and churches regarding the promotion of pregnancy prevention and contraception. we believe that such decisions ultimately need to be made by brothers and sisters in the nations we are called to serve. to attempt to dissuade them of their scripturally-based convictions—especially with financial or other incentives—is paternalistic at best and defiles their consciences at worst. 1. decide whether or not to make pregnancy prevention a strategic or operational focus, by seeking god through fasting and prayer on the part of the leadership and workers in the organization. a. recognize that the pervasive nature of the contraceptive mentality makes it difficult to see this issue through the lens of scripture. b. identify potential biases and inconsistencies in thought and practice. c. ask, “is this something that the target country wants or is asking for, or is it reproductive imperialism assuming ‘the west knows best?’” 2. if god’s leading is for the organization to make this a focus: a. work in agreement with the people the organization serves. b. do not be unequally yoked or form unholy alliances. c. formulate a pro-marriage, pro-pregnancy, pro-children orientation based on the scripture in agreement with the brothers and sisters in the nations you are called to serve. d. acknowledge that god’s plans for humans may begin before conception and/or during pregnancy, under unlikely circumstances. for example, the prophet samuel, john the baptist, and jesus christ, all were born to women in the “ages of reproductive inefficiency.” perez, an ancestor of christ, was born of an illicit liaison between judah and tamar which was considered incestuous under the mosaic law (genesis 38; leviticus 18:15). e. celebrate premarital purity and holiness, and marriage as covenantal and ordained by god between one man and one woman; conception as one of god’s mysteries; fertility as a blessing; children as the product of the covenant; family as the cornerstone of society. f. dignify women, men, and unborn children as being created in the image of god. g. dignify motherhood and fatherhood. h. do not promote any contraceptive technology that is life-destroying. i. encourage the use of free or very lowcost, low-tech methods (such as fertility awareness) which do not require outside inputs, have low or no side effects, require shared responsibility, and for which there is no financial incentive or profit motive. ii. be explicit in counseling women that all contraceptive technologies have risks, side effects, and failure rates, and ensure the availability of health services to manage adverse outcomes that might reasonably occur with specific contraceptive technologies. i. carefully scrutinize teaching materials to ensure that they fully conform to biblical teaching—that they do not just use passages from scripture to mix truth and untruth. j. avoid financial and other incentives which might encourage the use of contraception. k. use christian wisdom; direct scarce resources to proven interventions to reduce maternal mortality, increase child survival, and alleviate poverty. where funds are limited and maternal mortality is high, focus on these needs. 3. if god’s leading is for the organization to not make this a focus: an emphasis on proven interventions to reduce maternal mortality, increase maternal education, improve child survival, and alleviate 35 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. poverty could assist societies in the developing world to substantially improve the lives of women and children in developing countries with measurable effects. 4. in either case, focus on education to counter harmful messages and promote biblical messages, including the following: a. abstinence and chastity are normative for adolescents and unmarried couples. b. the goal of sexual purity (holiness) is to please god, not to avoid bad consequences. c. sex is a gift from god that he gave us for his pleasure, not just our own. d. resources and teaching are available for couples who want more children or who wish to achieve pregnancy and childbearing, but for whatever reason have been unsuccessful. conclusion a reflection on the incarnation could help illuminate our thinking on this contentious subject. jesus, the second member of the trinity, could have come to earth as the savior in any form he chose— as a spirit or as a fully-grown man—and bypassed the process of pregnancy. as god, he had the power to do so. but not only did he lay aside his position through the kenosis (κένωσις), jesus himself became an embryo. as an embryo, he implanted himself in mary’s uterus and gestated. like every other fetus, he grew and developed to the end of pregnancy at which time mary gave birth to him. was god’s decision to send his son to become flesh and dwell among us in the ultimate humility of conception, gestation and birth random? no. through the beauty of the incarnation, god showed us that human reproduction was different from animal reproduction. god values and esteems human reproduction because, in his wisdom, he deemed the human frame, made from dust, as worthy to contain christ, the fullness of the godhead, the glory of god. in turn, jesus submitted to the will of his father and in so doing dignified conception, gestation, pregnancy, and women and motherhood. further, god gave human beings the power, through the act of marriage (sex) to procreate immortal human life in his image and likeness. this blessing and responsibility was given to us before the fall. our understanding of how to prevent pregnancy came to us after the fall and was tainted by our fallen nature. in light of this, as fallen creatures, we need to exert the greatest caution in promoting the use of technology in a context that could not only damage or destroy the image of god in other human beings, but ultimately undermine their societies and cultures. instead, together with those we are called to serve, we should approach and embrace god’s gifts of sex and procreation with the greatest reverence and the greatest care. references 1. smietana b, what is an evangelical? four questions offer new definition. christianity today. 19 nov 2015. available from: http://www.christianitytoday.com/news/2015/nove mber/what-is-evangelical-new-definition-naelifeway-research.html. 2. a discussion with henry mosley, professor emeritus at johns hopkins bloomberg school of public health. berkley center for religion, peace and world affairs. 16 sept 2013. available from: https://berkleycenter.georgetown.edu/interviews/adiscussion-with-henry-mosley-professor-emeritusat-johns-hopkins-bloomberg-school-of-publichealth transcript reads: “but if we are working in this area, we can’t talk about birth limiting. we talk instead about birth spacing, but that is largely because of the politics and sensitivity of the issue at the political level. just to clarify my own view, as a public health professional, i do not promote abortion as a means of family planning but i recognize that it is a reality. and as health professionals, we need to prevent deaths of women and thus, in that context, need to make safe abortion accessible to those who want it to prevent risky, back-alley procedures.” 3. tone a, devices and desires: a history of contraception in america. new york: hill and wang; 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http://www.ibtimes.com/japans-demographic-doom-214188 http://www.economist.com/node/21553056 http://www.ccih.org/cpt_resources/scriptural-support-for-family-planning http://www.ccih.org/cpt_resources/scriptural-support-for-family-planning 39 wubbenhorst & wubbenhorst nov 2017. christian journal for global health 4(3):21-39. 77. planned parenthood of southeastern pa. vs. casey 505 u.s. 833 (1992) justia us supreme court. available from: https://supreme.justia.com/cases/federal/us/505/833 /case.html. peer reviewed competing interests: none declared. correspondence: monique c.wubbenhorst, monique.chireau@duke.edu cite this article as: wubbenhorst mc, wubbenhorst jk. should evangelical christian organizations support international family planning? christian journal for global health. nov 2017; 4(3): 21-39. https://doi.org/10.15566/cjgh.v4i3.184 © wubbenhorst mc, wubbenhorst jk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://supreme.justia.com/cases/federal/us/505/833/case.html https://supreme.justia.com/cases/federal/us/505/833/case.html mailto:monique.chireau@duke.edu https://doi.org/10.15566/cjgh.v4i3.184 http://creativecommons.org/licenses/by/4.0/ original article dec 2019. christian journal for global health 6(2) impact of an interprofessional training session on student spirituality and faith integration in the workplace felisha l younkina, emily laswellb, kristi coec, joy hansond, robert snydere, aleda chenf a phd, imft, professor, dept of psychology, cedarville university, ohio, usa b pharmd, bcps, professor, school of pharmacy, cedarville university, ohio, usa c ms, mlis, rn, professor, cedarville university school of nursing, ohio, usa d student, department of psychology, cedarville university, ohio, usa e md, president, his global, pennsylvania, usa f pharmd, phd, professor, school of pharmacy, cedarville university, ohio, usa abstract providing spiritual care to patients can result in improved health outcomes and healthrelated quality of life. however, healthcare professionals feel largely unprepared to address spiritual health. the objective of this study was to determine the impact of an interprofessional training session on student spiritual health and perceived confidence and competence in sharing their faith with patients. an all-day, interprofessional workshop to assist students in assessing their own spiritual health, identifying opportunities to address patient spiritual health, and sharing their faith ethically was incorporated. nursing, pharmacy, allied health/kinesiology, psychology, and pre-med students attended and completed assessments related to the student outcomes preworkshop, post-workshop, and at 3, 6, and 9 months post-workshop. significant improvements in perceived confidence and competence were documented initially and longitudinally. baseline student spiritual health was high; only participation in christian activities significantly improved in the assessment of their spiritual health. further study is necessary to fully understand the impact of this training on student spiritual health. nonetheless, incorporation of this training can better prepare students to engage in spiritual care of patients and share their own faith with others ethically as opportunities arise. key words: spiritual vital signs, training, healthcare workers. introduction when experiencing a chronic or acute illness, patients face a variety of concerns that go beyond physical aspects. providing unidimensional care instead of holistic care leaves an unfulfilled gap for these patients, as spirituality enhances health-related quality of life in chronic disease.1 maclean et al. surveyed patients in a primary care setting and found that 66% of them thought that their physicians should be aware of their religious or spiritual 4 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) beliefs.2 in a survey of 54 studies, best, butow, & olver found that a majority of patients express interest in discussing religion and spirituality in medical consultations.3 patients perceive that spirituality discussions may assist in positive religious-based coping, greater collaboration, and increased faith.4 although including spiritual care in consultations has been shown to reduce medical costs5, improve quality of life6, and lead to less aggressive care at the end of life,7 many healthcare professionals feel uncomfortable addressing spiritual care directly and refer patients instead to clergy or chaplains.8 this is likely due to factors such as confusion about the differences between spirituality and religion and about how religion is regarded in the healthcare setting.8 in a study of family medicine residents, saguil, fitzpatrick, and clark found that as few as 12% of them have received training in spiritual care and indicated that they would be more likely to provide spiritual care or initiate discussions with further training, particularly if the training provides evidence on the importance of it.9 it may be important that healthcare providers build and cultivate their own spiritual health to address their own challenges (burnout, attrition, etc.), improve resilience, and increase career satisfaction.10 vanderweele et al. suggest that accessing their own spiritual resources can build resilience in healthcare workers. they also note the reciprocal relationship between providing medical care and accessing spiritual resources—that through providing care, clinicians can better access their spiritual resources.10 given the lack of training in school and the importance of addressing one’s own spiritual health as well as the patient’s, it is important that health profession schools determine ways to prepare their students for this aspect of practice. very few approaches exist in the literature that address both personal spiritual health and how to provide patient spiritual care. thus, the objective of this study was to determine the impact of an interprofessional training session on students’ spiritual vital signs and their perceived confidence and competence in sharing their faith with patients. materials and methods this study received institutional review board (irb) approval from cedarville university exempt status. saline process educational session the saline process, which was named so because it relates to the medical iv solution that is often used for patient treatment but also refers to christians being “salt” and “light”, was offered by ihs global. it is an educational endeavor to prepare christian healthcare workers to care for the spiritual needs of their patients while also caring for their physical needs11. the saline process also encourages christians to examine, cultivate, and strengthen their own personal faith journey and is focused on equipping healthcare professionals to share their faith in the healthcare setting while adhering to commonly accepted ethical standards as well as workplace rules and regulations. the training addresses five main questions: “1) why is faith important in healthcare?; 2) what are the opportunities for and barriers to fulfilling god’s call?; 3) what is my part?; 4) what tools will help me cultivate, sow, and harvest?; and 5) where do i go from here?”11 the training includes a didactic portion, as well as integrated learning activities (i.e., reflection questions about personal spiritual vital signs, opportunities for sharing faith, etc.) for students or healthcare professionals to complete both individually and in groups over the course of 6–8 hours. students/healthcare professionals also follow the entire healthcare journey from the beginning of healthcare because of an auto collision until the end of care of a patient as part of the learning experience, with opportunities to practice their patient interactions and learned skills with role play during the training. the ihs curriculum includes 5 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) instructions on how one of the trainers of the saline process training should act as a patient and then allows time for the students in the training to “interact” with the patient. time also is spent ensuring students understand the ethics of this approach in the midst of workplace rules and regulations as well as respect for patient preferences and values. as part of the training that students received for addressing spirituality in patients, they were instructed to consider their own spiritual vital signs, which include characteristics such as their competence and compassion for patients.11 implementation of training this saline process training was provided at no charge (including the presentation of material, the material, and the facilitation of activities and discussions related to the training) for a group of health profession students at a christian university to prepare them to provide spiritual care in their future practice as well as address their own spiritual health. all students who attend the university are asked to make a declaration of their christian faith as part of the admissions process. similar requirements are present for faculty and staff. full-time faculty from pharmacy, nursing, kinesiology/allied health, and psychology underwent training in the saline process and became certified trainers. these faculty members all had practiced or currently practice in their disciplines. two cohorts of students completed the saline process training in an eight-hour, one-day training period during the 2017–2018 (n=179) and 2018–2019 (n=134) academic years. students were excused from class to attend the training. in august 2017, first professional year doctor of pharmacy (pharmd) students and sophomore nursing students were required to attend the training session. students from other health profession majors (allied health/kinesiology, psychology, and pre-medicine) could elect to attend. on the day of the event, students were broken up into groups of 7– 8 per table across 4 rooms of faculty trainers. each table had at least one pharmacy student, one nursing student, and one other health profession student. rooms held no more than 50 students each to maximize opportunities for student participation in the large group setting. after reviewing student feedback and discussion amongst trainers and faculty, it was decided to offer the training to students with a higher level of clinical experience in august 2018. senior nursing students were required to attend. students from other health profession majors (pharmacy, allied health/kinesiology, psychology, and premedicine) could elect to attend. for the second training, the students who attended had not attended the first training. students were again broken up to allow as much diversity in their majors at each table as possible. assessments to assess the study objectives, surveys were administered pre-training, immediately after the training and at 3 longitudinal intervals (3, 6, and 9 months) (see figure 1). figure 1. timing of assesments the surveys were modified from ones utilized by ihs global.11 demographic information was obtained along with survey information in 3 areas: 1) self-assessment of spiritual vital signs (7 items: 2 items about belief in christ, 5 items about frequency of faith activities); 2) agreement about the 6 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) importance of different aspects of biblical witness (5 items: 5-point likert-type agreement scale, 1=strongly disagree, 5=strongly agree); and 3) confidence in biblical witness (5 items: 5-point likert-type confidence scale, 1=not at all confident, 5=extremely confident). agreement and confidence questions included the same concepts with differences in whether they were confident in performing the item or agreed with the importance of or preparedness to perform an item. data analysis spss v. 25.0 was used to analyze the data. variables were described using frequencies, medians with an interquartile range (non-parametric data), and means with a standard deviation (parametric data). changes in spiritual vital signs between the pre-assessment and the first post-assessment were examined using a wilcoxon test and changes across all assessments with a friedman’s anova. results as shown in table 1, demographic data were collected on the cohort. most students were in pharmacy or nursing, female, sophomores, and had limited patient experience. only 5 participants (2.9%) were not from the united states. table 1. demographics demographic item n (%) or mean ± sd major pharmacy 46 (27.7%) nursing 96 (57.8%) pre-med 6 (3.6%) allied health 7 (4.2%) exercise science 1 (0.6%) psychology 10 (6.0%) year in school freshman 2 (1.2%) sophomore 98 (58.0%) junior 8 (4.7%) senior 14 (8.3%) p1 47 (27.8%) gender: male 29 (17.2%) years interacting with patients no experience 31 (18.5%) less than 1 year 93 (55.4%) less than 2 years 27 (16.1%) less than 3 years 9 (5.4%) 4 or more years 8 (4.8%) age 20.5±3.1 when comparing the pre-saline training results to that of 3 months post-training, only question 5 (participation in christian activities/ ministries) was statistically significantly higher than pre-training assessment in participation in christian activities/ministries, with students indicating greater frequency of participation (p<0.05, see table 2). when changes were assessed longitudinally at 3, 6, and 9 months related to spiritual vital signs, only question 5 (how often do you participate in christian or church-based activities/ministries?) was significant (p=0.008). no statistically significant differences were found for the other survey questions (see table 2). 7 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) table 2. changes in svs items item preassessment median (iqr) 3 month assessment median (iqr) 6 month assessment median (iqr) 9 month asmnt median (iqr) pre-post asmnt 1 p-value longitudi nal p-value q1: are you a christian? 1 (1-1) 1 (1-1) 1 (1-1) 1 (1-1) 0.317 0.392 q2: for how long? 5 (4-6) 5 (4-6) 5 (4-6) 5 (4-6) 0.621 0.711 q3: how often do you attend church or small group? 3 (3-3) 3 (2-3.25) 3 (3-3) 3 (3-3) 0.077 0.97 q4: how often do you pray? 5 (4-5) 4 (4-5) 5 (4-5) 5 (4-5) 0.317 0.632 q5: how often do you participate in christian or church-based activities/ministries? 4 (3-4) 4 (3-4) 4 (3-4) 4 (3-4) 0.019 0.008 q6: how often do you read your bible? 5 (4-5) 4 (4-5) 5 (4-5) 5 (4-5) 0.196 0.557 q7: how often do you engage others in conversation which results in you witnessing and sharing about christ? 2 (2-3) 3 (2-3) 3 (2-4) 3 (2-4) 0.291 0.062 a number of changes were statistically significant in the survey items related to the importance of and preparedness for sharing faith in the clinical setting immediately after the training session (see table 3). longitudinal changes across all assessments were significant (p<0.001) for all statements measuring level of agreement with the importance of biblical witness, with the exception of two. both the importance of sharing faith with patients (p=0.146) and the importance of sharing faith with other professionals (p=0.442) did not have a statistically significant change. longitudinal changes across all assessments were significant (p<0.001) for all statements measuring level of confidence with respect to biblical witness. table 3. changes in witnessing items item pre assessmnt median (iqr) immediate post-asmnt median (iqr) 3 month assessmnt median (iqr) 6 month assessmnt median (iqr) 9 month assessmnt median (iqr) preimmediate post pvalue longitudi nal p-value i feel that i know how to initiate spiritual conversations with my patients.a 3 (2-4) 4 (4-5) 4 (4-5) 4 (4-4) 4 (3-4) <0.001 <0.001 i feel prepared to share my faith in the workplace in accordance with legal restrictions/regulations.a 2 (2-3) 4 (3-4) 4 (3-4) 4 (3-4) 4 (3-4) <0.001 <0.001 i feel it is important for me to share my faith at work with my patients.a 5 (4-5) 5 (4-5) 5 (4-5) 5 (4-5) 5 (4-5) 0.002 0.146 8 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) table 3. changes in witnessing items (continued) item pre assessmnt median (iqr) immediate post-asmnt median (iqr) 3 month assessmnt median (iqr) 6 month assessmnt median (iqr) 9 month assessmnt median (iqr) preimmediate post pvalue longitudi nal p-value i feel it is important for me to share my faith at work with other healthcare professionals.a 5 (4-5) 5 (4-5) 5 (4-5) 5 (4-5) 5 (4-5) 0.031 0.442 i feel prepared to use tools to help me share my faith with permission, sensitivity, and respect.a 3 (2-4) 4 (4-5) 4 (4-4) 4 (4-5) 4 (4-5) <0.001 <0.001 i can initiate spiritual conversations with my patients.b 3 (2-3) 4 (3-4) 3 (3-4) 3 (3-4) 3 (3-4) <0.001 <0.001 i can share my personal faith in the workplace in accordance with legal restrictions/regulations.b 2 (2-3) 4 (3-4) 3 (3-4) 3 (3-4) 3 (3-4) <0.001 <0.001 i can share my personal faith at work with my patients.b 3 (2-4) 4 (3-4) 3 (3-4) 4 (3-4) 3 (3-4) <0.001 <0.001 i can share my personal faith at work with other healthcare professionals.b 3 (2.5-4) 4 (3-4) 4 (3-4) 4 (3-4) 4 (3-4) <0.001 <0.001 i can use tools to help me share my personal faith with permission, sensitivity, and respect.b 3 (2-3.5) 4 (3.75-5) 4 (3-4) 4 (3-4) 4 (3-4) <0.001 <0.001 discussion this study presents a first step in preparing students to approach spiritual care and provides an assessment of students’ spiritual health as it relates to their confidence in approaching spiritual care in professional practice. our findings show that students had a midpoint level of confidence and preparedness for having spiritual conversations with patients prior to the saline process training with median responses at neutral or below, despite believing in the importance of doing so. we also found that students who attended the saline process training reported increased participation in christian activities/ministries after the training. these findings are of importance because they may indicate that training related to integrating faith in clinical practice encourages students to increase activities that can enhance their own spiritual health. assessing a patient’s spiritual need and responding to prompts that a patient may be interested in having a conversation can be challenging for health professional students as well as practicing professionals.8,12,9 yet, it is important to prepare students to have conversations with patients about spiritual care, as patients with many 9 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) different chronic diseases indicate spiritual care as an unmet need.13 failure to address this need can be linked to poorer health outcomes.1,14,15,4 intentional integration in the curriculum with role models and the opportunity to practice and apply skills in an ethical manner can be an effective tool in meeting this need.12 indeed, healthcare providers indicate a need for evidence-based training to break barriers in providing spiritual care.13,8,9 this training addressed these key needs by providing an evidence-based approach for spiritual care. training for healthcare professionals, and students, also can incorporate how to listen actively and follow the patient’s leading for opportunity identification and provision of ethical spiritual care.12,16 our training provided interprofessional, faculty role models with practice experience, an opportunity to practice and apply skills with each other and the faculty, and a discussion of how to approach spiritual care legally and ethically. these elements, along with providing training on patient spiritual care, likely resulted in the significant initial and longitudinal improvements of student perceived importance as well as confidence in approaching spiritual care and sharing their own faith. a training for nurses regarding the spiritual care of patients also resulted in similar increases in knowledge and selfperceptions of preparedness.17 healthcare providers may benefit from attending to their own spiritual health.10 throughout their careers, healthcare professionals may face burdens and challenges as part of patient care as they help patients navigate through acute and chronic diseases. spirituality also may be a key component in a healthcare professional’s job satisfaction.18,10 thus, it may be important to train students in how to best support and share their faith with other healthcare professionals. further, cone and giske interviewed nursing students and faculty and found that their ability to care for their patients spiritually depended on their maturity and especially on how secure they felt in their own faith. as they matured in their faith, they were better able to remain relaxed with their patients when spiritual issues were discussed.12 how do we determine if someone is ready to provide spiritual care? one example of readiness assessment is similar to an apgar (appearance, pulse, grimace, activity, and respiration) score for newborns, wherein a healthcare provider’s spiritual well-being or vitality may be assessed by looking at their circulation (connection to the head and body of christ), ventilation (prayer), muscle tone (participation in activities and ministry), nutrition (receiving biblical teaching, reading, and study), and reproduction (making of disciples).11 one way to measure these spiritual vital signs is to reflect on each of these areas as an individual and adjust, if needed. our training provided students with an opportunity for such an assessment as part of active learning during the training sessions. students in our study were able to gain confidence in providing spiritual care which also significantly increased their involvement in faith-based activities. given that these students were at the mid-point of their college years and had high baseline scores in their spiritual vital signs, it is not unexpected to see limited improvement with the ceiling effect of a 5-point likert-type scale. it is our hope that these students have the preparation they need for future practice. limitations this study was done at a single christian institution. thus, it will not be generalizable to all settings. the survey instruments were not validated, although they were modified from previously utilized but not validated surveys from ihs global. further, there may be social desirability bias present in this study. students may choose responses related to their spiritual vital signs to provide spiritual care based on the perceived “correct” choices. we attempted to minimize this by making the surveys voluntary and anonymous. further, the group was fairly homogenous and had a high interest in spiritual issues. these types of issues have been commonly reported in spirituality training studies.19 self 10 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) assessment also is limited in its scope and applicability19; it would be beneficial to consider a competency-based assessment in the future to substantiate the findings. there also was some attrition in completing the surveys over time, so this may impact findings from the research. implications for future practice incorporating a training for future christian healthcare professionals may result in improved confidence and knowledge in providing patients’ spiritual care. students’ own spiritual vital signs changed little, but baseline assessments had high scores. given the generally positive impact of providing spiritual care for patients on health outcomes and quality of life as well as personal spiritual care on resilience, it is hoped that these students are better prepared for future practice. suggestions for further research future research in christian institutions should look at a comprehensive curricular approach, where the concepts are reinforced throughout the curriculum and students are given additional opportunities to apply and practice. the impact of using these skills in clinical, experiential settings should also be assessed to determine how the classroom components and practice translate into the workplace. triangulation of the data with qualitative perspectives may also provide further insight into the development of students. references 1. megari k. quality of life in chronic disease patients. health psychol res. 2013;1(3):e27-e27. https://doi.org/10.4081/hpr.2013.e27 2. maclean cd, susi b, phifer n, schultz l, bynum d, franco m, et al. patient preference for physician discussion and practice of spirituality. j gen intern med. 2003;18(1), 38-43. https://doi.org/10.1046/j.1525-1497.2003.20403.x 3. best m, butow p, olver i. do patients want doctors to talk about spirituality? a systematic literature review. patient educ couns. 2015;98(11):1320-8. https://doi.org/10.1016/j.pec.2015.04.017 4. stanley ma, bush al, camp me, jameson jp, phillips ll, barber cr, et al. older adults' preferences for religion/spirituality in treatment for anxiety and depression. aging ment health. 2011;15(3):334-43. https://doi.org/10.1080/13607863.2010.519326 5. balboni t, balboni m, paulk me, phelps a, wright a, peteet j, et al. support of cancer patients’ spiritual needs and associations with medical care costs at the end of life. cancer. 2011;117:5383e5391. https://doi.org/10.1002/cncr.26221 6. tracy ab, paulk me, balboni mj phelps ac, loggers et, wright aa, et al. spirituality and religion in oncology. ca cancer j clin. 2013;63(4):280-7. https://doi.org/10.3322/caac.21187 7. balboni ta, paulk me, balboni mj, phelps ac, loggers et, 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educators. j clin nurs. 2013;22(13-14):1951-60. https://doi.org/10.1111/j.1365-2702.2012.04203.x 13. balboni ta, paulk me, balboni mj, phelps ac, loggers et, wright aa, et al. provision of spiritual care to patients with advanced cancer: associations https://doi.org/10.4081/hpr.2013.e27 https://doi.org/10.1046/j.1525-1497.2003.20403.x https://doi.org/10.1016/j.pec.2015.04.017 https://doi.org/10.1080/13607863.2010.519326 https://doi.org/10.1002/cncr.26221 https://doi.org/10.3322/caac.21187 https://doi.org/10.1200/jco.2009.24.8005 https://doi.org/10.1177/0269216315600912 https://doi.org/10.1007/s10943-010-9452-6 https://doi.org/10.1001/jama.2017.8136 https://www.ihsglobal.org/board-of-reference https://www.ihsglobal.org/board-of-reference https://doi.org/10.1111/j.1365-2702.2012.04203.x 11 younkin, laswell, coe, et al. dec 2019. christian journal for global health 6(2) with medical care and quality of life near death. j clin oncol. 2010;28:445e452. https://doi.org/10.1200/jco.2009.24.8005 14. park cl, sacco sj. heart failure patients' desires for spiritual care, perceived constraints, and unmet spiritual needs: relations with well-being and healthrelated quality of life. psychol health med. 2017;22(9):1011-20. https://doi.org/10.1080/13548506.2016.1257813 15. pearce mj, coan ad, herndon je 2nd, koenig hg, abernethy ap. unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients. support care cancer. 2012;20(10): 2269-76. https://doi.org/10.1007/s00520-011-1335-1 16. selby d, seccaraccia d, huth j, kurppa k, fitch m. patient versus health care provider perspectives on spirituality and spiritual care: the potential to miss the moment. ann palliat med. 2017;6(2):143-52. https://doi.org/10.21037/apm.2016.12.03 17. murray rp, dunn ks. assessing nurses' knowledge of spiritual care practices before and after an educational workshop. j contin educ nurs. 2017;48(3):115-22. https://doi.org/10.3928/00220124-20170220-07 18. puchalski cm, guenther m. restoration and recreation: spirituality in the lives of healthcare professionals. curr opin support palliat care. 2012;6(2):254-8. https://doi.org/10.1097/spc.0b013e3283522223 19. paal p, helo y, frick e. spiritual care training provided to healthcare professionals: a systematic review. j pastoral care counsel. 2015;69(1):19-30. https://doi.org/10.1177%2f1542305015572955 peer reviewed: submitted 8 april 2019, accepted 15 oct 2019, published 20 dec 2019 competing interests: none declared. correspondence: felisha l younkin, cedarville university, usa. flyounkin@cedarville.edu cite this article as: younkin fl, laswell e, coe k, hanson j, snyder r, chen a. impact of an interprofessional training session on student spirituality and faith integration in the workplace. christian journal for global health. dec 2019; 6(2):3-11. https://doi.org/10.15566/cjgh.v6i2.301 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1200/jco.2009.24.8005 https://doi.org/10.1080/13548506.2016.1257813 https://doi.org/10.1007/s00520-011-1335-1 https://doi.org/10.21037/apm.2016.12.03 https://doi.org/10.3928/00220124-20170220-07 https://doi.org/10.1097/spc.0b013e3283522223 https://doi.org/10.1177%2f1542305015572955 mailto:flyounkin@cedarville.edu https://doi.org/10.15566/cjgh.v6i2.301 http://creativecommons.org/licenses/by/4.0/ clinical care april 2020. christian journal for global health, 7(1) hospital readiness for covid-19: the scenario from india with suggestions for the world mandalam s. seshadria and t. jacob johnb a md, phd, frcp, former professor of medicine & endocrinology, department of endocrinology diabetes & metabolism, christian medical college & hospital, vellore; consultant physician & endocrinologist, honorary medical director, thirumalai mission hospital, vanapadi road, ranipet, india b phd (virology), frcp (paediatrics), former professor& head, department of clinical virology, christian medical college & hospital, vellore, india abstract lessons learned from italy regarding hospitals and health care facilities as important sources of disease spread for covid-19, and ways to mitigate this in india and other countries. key words: covid-19, hospitals, mitigation, low income countries. we have learned that recently, in two hospitals in india, emergency surgical procedures were performed on patients and healthcare personnel got infected with sars-cov-2. these surgical patients developed covid-19 pneumonia in the postoperative period, and succumbed. in these hospitals, a large number of health care professionals got infected. this had led to a lock down and containment situation of these hospitals. these incidents have provided many important lessons for the medical profession, other healthcare workers, administrators, and health ministries. if asymptomatic individuals during the incubation period develop covid-19 in the postoperative period, there are only 2 possibilities: 1. their infection was nosocomial; or 2. they were already infected on presentation. in either situation community level spread is occurring. in option one it would represent silent infection in medical staff or other admitted patients. the experience in italy italian doctors, after their heart-rending experiences with covid-19, made a plea in nejm catalyst; their article carries the following messages for the rest of the world in the approach to covid-19 pandemic1: 1. the virus is exploiting centralized health care systems of the current era in a large number of countries. 2. once you keep admitting very sick patients with high viral load, the hospital becomes a reservoir of the virus. health care personnel acquire infection and unwittingly become vectors, who spread the infection to their patients and this leads on to further 34 seshadri & john april 2020. christian journal for global health, 7(1) community spread. so, hospitals become hotbeds of sars-cov-2 infection. 3. a good number of health care professionals contract and some succumb to the infection they contracted in the hospital. 4. physicians generally are skilled in treating individual patients and often make decisions in the interest of the patient as a whole rather than one symptom or abnormality. for example, in a difficult to control diabetic the physician may accept suboptimal control of blood sugars in order to avoid hypoglycaemia which can be life threatening. similarly, in a pandemic, the way the medical profession should respond is to do their level best to consider the population as a whole and keep the population healthy. they need to think differently in order to achieve this. this approach is likely to reduce overall spread of covid-19 and reduce overall mortality. 5. if you do not follow this approach, the human toll becomes huge as in italy, spain, and the us. 6. they recommend home based care as far as possible (mild and moderate covid 19 cases, including those who have early covid-19 pneumonia who need oxygen with home oxygen if needed, under the care and supervision of the family physician. this will minimize potential for contamination of hospitals. 7. there is a place for a fully isolated, wellequipped covid-19 centres with all tertiary facilities manned by a committed team to take care of those who need positive pressure ventilation. an approach to hospital-based mitigation there is an old saying originating from the bible (luke 4:23) “physician, heal thyself!” in the current covid-19 context, this can be rephrased as “healthcare worker, protect thyself.” if healthcare professionals are depleted because of covid-19 or if the health-care force is demoralised because of personal risk and fear, the situation can become extremely difficult to handle. how can we handle a catastrophe of this magnitude? how would a humane, caring person in the interest of community justice approach this problem? 1. ensure alternative avenues of management for chronic non-communicable diseases (ncds) and restrict regular out-patient department (opds). patients with ncds are vulnerable people who should not be coming to hospitals potentially contaminated with the virus — for their own safety – but need ongoing management to prevent other causes of morbidity and mortality. reduce crowding in the hospital, and limit avoidable workload of an already stressed group of healthcare staff. 2. mobile telephone/telemedicine-based counselling for patients with chronic illness through their usual caregiver with the understanding that if there is a medical emergency, they will have to access a safe hospital not frequented by covid-19 patients. 3. home delivery of medications to avoid elderly coming out of their homes. they should be cocooned (reverse quarantined). when necessary, physicians wearing personal protective equipment should undertake home visits — instead of patients coming to hospitals when their illness is of low/moderate severity and not lifethreatening. for example, utilizing mobile services, community acquired infections can be managed at home without a hospital visit. 35 seshadri & john april 2020. christian journal for global health, 7(1) 4. multiple hot-lines should be manned round the clock by appropriate health personnel to provide medical advice and counselling. tertiary level and medical college hospitals must serve as resource centres for practitioners in order to guide them in caring for complex problems, for example, complicated diabetes, hypertension, community acquired infections, etc. 5. where there is a functioning and reliable system, samples for lab tests should be collected at home, in a dedicated community level blood collection facility, or in a wellequipped mobile van for remote villages. samples are then transported to the lab and the results of tests communicated to concerned practitioners. 6. use a syndromic approach to diagnose covid-19.2 then treat such patients and prevent spread to their family members using appropriate home isolation and other prophylactic measures. 7. pcr or rapid tests used only for confirming diagnosis when it will affect care, or for welldesigned and ethical studies, so that resources saved can be put to better use. 8. dedicated ambulance services with adequately protected personnel to carry sick infected subjects to a dedicated covid centre. 9. have separate emergency facility for patients with acute respiratory problems. a dedicated team with appropriate personal protective equipment should see these patients. those needing admission for respiratory failure should be admitted to a separate icu facility for covid-19. 10. major hospitals in either private or public sector can be designated to take on the management of the town and surrounding villages and to set up a model system of referral and management in the surrounding areas. 11. importantly, continue to manage emergencies in non-covid patients, who need hospital-based care in a separate facility manned by a different set of healthcare personnel. in other settings people are dying from late presentation after being encouraged to stay away from medical facilities. 12. every patient coming to hospital for any emergency should be considered to be potentially infected with sars-cov2 and all the staff strive to take suitable precautions (respiratory as for covid-19 and universal as for hiv). 13. where safe, non-urgent surgical procedures should be postponed each patient going for surgery to have a screening pcr on a nasopharyngeal swab and ig m antibody (as soon as it is available widely) and lab report to be seen before taking up for surgery, similar to the present system in place for hepatitis b, c, and hiv. as even this will miss out a proportion (~10 %) of sarscov-2 infected patients3, respiratory precautions as for covid 19 and universal precautions as for hiv infected patients will be mandatory for every surgical patient and procedure. conclusion and future hope the pandemic will eventually wane when around 50-60% of the population have been infected and developed immunity.4 this may take a few more months. during these crucial months ahead, medical professionals should ensure that they safe-guard their health and at the same time put in their best efforts to tend to the sick and suffering. we make these suggestions based on our significant clinical experience and understanding 36 seshadri & john april 2020. christian journal for global health, 7(1) of the evidence so as to inform the approach of hospitals in india to this pandemic. we also feel that the above suggestions could be applicable to other middleand low-income countries which are trying to cope with this pandemic. references: 1. nacoti m, ciocca a, giupponi a, brambillasca p, lussana f, pisano m, goisis g, bonacina d, fazzi f, naspro r, longhi l, cereda m, montaguti c. at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation. nejm catalyst | march 21, 2020 https://doi.org/10.1056/cat.20.0080 available from: https://catalyst.nejm.org/doi/full/10.1056/cat.2 0.0080?fbclid=iwar1lworq5ziomshbbugfp6 n0w-n_6ti90vjndf-yymggoirdfms2hph8fo 2. seshadri ms, john tj. covid-19 pandemic: defining the clinical syndrome and describing an empirical response. christian journal for global health 7(2); april 2020. https://doi.org/10.15566/cjgh.v7i1.365 3. guo l, ren l, yang s, xiao m, chang d, yang f, dela cruz cs, wang y, wu c, xiao y, zhang l, han l, dang s, xu y, yang q, xu s, zhu h, xu y, jin q, sharma l, wang l, wang j. profiling early humoral response to diagnose novel coronavirus disease (covid-19). clinical infectious diseases, ciaa310. 2000 march 21. https://doi.org/10.1093/cid/ciaa310 available from: https://academic.oup.com/cid/advancearticle-abstract/doi/10.1093/cid/ciaa310/5810754 4. raoult d, zumla a, locatelli f, ippolito g, kroemer g. coronavirus infections: epidemiological, clinical and immunological features and hypotheses. cell stress 4(4); 3 feb 2020: 66-74. https://doi.org/10.15698/cst2020.04.216 competing interests: none declared. correspondence: dr. seshadri, india. mandalam.seshadri@gmail.com cite this article as: seshadri seshadri ms, john tj. hospital readiness for covid-19: the scenario from india with suggestions for the world. christian journal for global health. april 2020;7(1):33-36. https://doi.org/10.15566/cjgh.v7i1.375 © authors this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1056/cat.20.0080 https://catalyst.nejm.org/doi/full/10.1056/cat.20.0080?fbclid=iwar1lworq5ziomshbbugfp6n0w-n_6ti90vjndf-yymggoird-fms2hph8fo https://catalyst.nejm.org/doi/full/10.1056/cat.20.0080?fbclid=iwar1lworq5ziomshbbugfp6n0w-n_6ti90vjndf-yymggoird-fms2hph8fo https://catalyst.nejm.org/doi/full/10.1056/cat.20.0080?fbclid=iwar1lworq5ziomshbbugfp6n0w-n_6ti90vjndf-yymggoird-fms2hph8fo https://catalyst.nejm.org/doi/full/10.1056/cat.20.0080?fbclid=iwar1lworq5ziomshbbugfp6n0w-n_6ti90vjndf-yymggoird-fms2hph8fo https://doi.org/10.15566/cjgh.v7i1.365 https://doi.org/10.1093/cid/ciaa310 https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciaa310/5810754 https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciaa310/5810754 https://doi.org/10.15698/cst2020.04.216 mailto:mandalam.seshadri@gmail.com https://doi.org/10.15566/cjgh.v7i1.375 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ references: commentary dec 2019. christian journal for global health 6(2) humble thyself: the imitation of christ in medical missions danielle ellisa a mts, md(c), university of north carolina chapel hill school of medicine, and theology, medicine, and culture initiative, duke divinity school, durham nc, usa abstract missions have been a part of the christian faith since its genesis. various approaches to transmitting the faith through missions have been implemented over time, some with unforeseen and frankly negative, long-term political, social, and even theological consequences. in medical missions, specifically, the consequences include the potential of compromised individual and collective health. these vulnerabilities make it essential to consider the theoretical and practical approaches with which we, as christians, engage with our neighbors. missiologists critically and theologically consider the motives, methods, and mandates of the christian believer in the world. efforts to reconfigure the role of missions from a past intertwined with imperialism to one that brings each party into partnership are ongoing. in medical missions, questions about how to assume a christian posture are complicated, not only by the sociohistorical context of the missions movement but also by the fact that medicine in and of itself engenders imbalances in power. this paper puts forth a proposal for a posture in medical missions as understood through the lens of philippians. in the context of paul’s mission to this group of early believers, the apostle repeatedly encourages his congregation to imitate christ. in his letter to the philippians, he lays out what christ did and how his followers might hope to be like him. paul describes jesus’ wholly countercultural disposition and actions, giving his audience the opportunity to consider how this might inform their own lives. in so doing, he also provides a framework for understanding the ideal missionary. what follows is a pauline construal of the call to imitation as a disciple, a discussion of how those engaging in medical missions might embody the same posture as the incarnate christ, and a reflection on how a shift in posture might facilitate greater participation for both disciples and disciplers in god’s restoring work on earth. key words: humility; medical missions; imitation 44 ellis dec 2019. christian journal for global health 6(2) introduction the sense that bearing witness to the character of jesus is essential to the christian faith has been present among believers throughout history, likely generated by the “missional” spirit that pervades the new testament in all of its “sending” language.1 that said, “missions” qua evangelism (i.e., institutionalized missions targeting primarily overseas populations) dates only back to the sixteenth century, introduced by jesuit christians to refer to the conversion of distant pagan territories, particularly colonial territories.2 this conceptualization of missions developed largely from the theological conviction that the incarnation of jesus requires the gospel to be transmitted and received “under the same conditions that we receive other communication” (i.e., verbally) and the interpretation of matthew 28:19 or “the great commission” as a mandate specifically for overseas missions.3 the emphasis on evangelism was so strong that during the seventeenth and eighteenth centuries, when medical missions in the modern sense began to take hold, medical missionaries were often encouraged to practice medicine only as an “occasional occupation”, and leadership within missions organizations questioned whether medical knowledge actually lost rather than gained influence among native populations as “european medicine . . . was not at all efficacious in the colonies.”4 medical missons, as performed in this era, have engendered a sense of mistrust, not only among local people but also among the emerging secular global health community. this sentiment is best exemplified in this excerpt from a study executed by an academic institution investigating so-called, faith-based health providers (fbhp) in sub-saharan africa: [faith-based organizations] have been neglected by the worlds of research and policy for decades, mainly as a result of a general refocusing on public health provision and also since the historical (and sometimes present) drivers of faith-based health provision have been treated with mistrust, especially in connection with the controversies around health care provided with the underlying intent to proselytize . . . the slowly emerging evidence on fbhps suggests that they are not simply a health systems relic of a bygone missionary era, but still have relevance and a part to play (especially in fragile health systems), even if we still know little about exactly how they function.5 at the risk of suggesting that historical approaches have been exclusively harmful, one must acknowledge the role of colonial-era missions and medical missions in transmitting the christian faith and caring for the health of the world’s people.1 nevertheless, given the actual and potential dangers of missions and medical missions, it is essential to consider the theoretical and practical approaches with which we as christians engage with our neighbors. the term “missionary”, meaning “the one sent” (gk. apostolos), is found in the new testament 79 times. thus, in considering a posture for medical missions, i turn to the quintessential apostle, paul. what follows is a pauline construal of the call to imitation as a disciple and a reflection on how those engaging in medical missions might embody the same posture as the incarnate christ, facilitating greater participation for both disciples and disciplers in god’s restoring work on earth. paul’s letter to the church at philippi is one of his most unusual and yet, arguably, most impactful. paul begins this letter with an introduction that calls readers to imitate christ’s humility: 1 therefore if you have any encouragement from being united with christ, if any comfort from his love, if any common sharing in the spirit, if any tenderness and compassion, 2 then make my joy complete by being like-minded, having the same love, being one in spirit and of one mind. 3 do nothing out of selfish ambition or vain conceit. rather, in humility value others above yourselves, 4 not looking to your own 45 ellis dec 2019. christian journal for global health 6(2) interests but each of you to the interests of the others. (phil 2:1–4, niv) paul’s appeal in vv. 3–4 to adopt a christ-like posture of humility is expounded upon in vv. 5–11. specifically of phil 2:5–11, commentator samuel bockmuehl notes that “the christological argument [here] provides the spiritual focus, assurance, and incentive for the letter’s various instructions.”6 the theology paul espouses in these seven verses unpacks not only some of the most foundational truths about christ, but also a pauline vision of what those truths mean for how followers of christ might live as disciples, as disciplers, and for those called as practitioners of medicine. paul’s intentions, christ’s actions paul’s exhortation to the philippians in phil 2:5 frames the rest of this text. the command in the niv reads “in your relationships with one another, have the same mindset as christ jesus.” here, paul calls his readers to imitate christ, as he does in a number of his epistles (cf. 2 cor 8:9; rom 15:1–3; 1 thess 1:6).7 gordon fee, a new testament scholar, observes that “for paul, ‘imitation’ does not ordinarily mean, ‘do as i did,’ but rather ‘be as i am.’”8 the qualifier “in your relationships with one another” suggests that paul’s subsequent elaboration of christ’s behavior, that which garners the command of imitation, can be understood to inform not only our mindsets, but also our relationality. from this launching point, we can proceed with an assessment of the doings and ways of being of jesus that, for paul, we should embody. jesus’ actions in the following verses— presumably, the ones which should serve as the foundation for the believer’s mindset—are two-fold: he “made himself nothing by taking the nature of a servant” and “humbled himself by becoming obedient to death” (phil 2:7–8, niv). let us begin with the first of jesus’ actions: “[making] himself nothing” (phil 2:7). the greek word that translates to “made himself nothing” (kenosis) suggests “selfemptying.”9 paul’s other uses of the word “kenosis” refer to the idea of “rendering useless” (cf. rom 4:14; 1 cor 1:17, 9:15), so paul is likely suggesting a nullification of privileges that jesus might have rightfully claimed.10 later, we learn the nature of jesus’ self-emptying: “ . . . being in very nature god, did not consider equality with god something to be used to his own advantage. rather, he made himself nothing by taking the form of a servant” (phil 2:6– 7). so, then, we might conceptualize jesus’ first action not as being stripped of his divine rights, but as a rendering useless of them—a decision to not count them as something to be used to his advantage. in his being made like humans, he assumes a posture of servanthood and susceptibility rather than one of superiority. because jesus’ divinity and humanity coexist in hypostatic union, his kenosis does not change who he is, but rather speaks to a voluntary change in status. in so doing, he subverts the earthly narrative of the likeness of men (as that which takes advantage of rights) and instead begins to write a new one, wherein to be made like man is to render any claim to rights as void and take on an essence of submission and insufficiency. next, paul says of christ that he “humbled himself and became obedient to death.” the greek word meaning to “humble oneself” (tapeinoō) means to assign a lower rank or place to.11 this action reflects christ’s taking the form of a servant and effectively adopting a position of low rank rather than one of honor. moreover, we see that his selfhumbling also entails a disposition of obedience. but just how is self-emptying distinct from self-humbling, particularly since the words appear in adjacent clauses and may appear to suggest similar actions? theologically, the two flow from christ’s two natures: he empties himself as a function of being found in the form of god and humbles himself as a function of being found in the form of a servant. in effect, as god, he divested himself of a claim to privilege; as man, he humbled himself; and in both of these, he acted deliberately. practically, one concerns an internal change in posture and the other a way of relating to others externally. 46 ellis dec 2019. christian journal for global health 6(2) pauline imitation and missions paul, arguably one of the greatest missionaries in history, effectively grounded his approach in the imitation of christ. paul, like jesus, adopted a disposition of obedience from the moment of god’s revelation to him on the road to damascus. he deliberately lowered himself to the rank of those with whom he sought to share his life. it is this example that paul calls the church at philippi and, ultimately, all followers of christ to imitate in philippians 2:5–11. paul’s distinction between that which christ did while in the form of a servant and likeness of man and what he did while in the form of god is not to promote a nestorian christology (i.e., to suggest that jesus acted in one way as god and another as human), but to affirm two components of imitation. the first, not divesting himself of rights, but divesting himself of claim to those rights and voluntarily embodying a servant’s posture; the second, humbling himself or accepting a lower rank in obedience. the first, an internal change in posture; the second, informing a pattern of relationship. each is valuable in informing a christlike mindset, but a distortion of missions that under-emphasizes one or the other is problematic. missiologist david bosch notes the significance of kenosis in missions: “the affliction missionaries endure is ultimately bound up in their mission.”12 in a discussion of four cardinal missionary motifs in scripture, bosch highlights martyria—suffering. missions, in light of jesus’ mission of self-emptying, is not a triumphalist enterprise but rather inherently done in weakness.2 related to this weakness is an acknowledgement that missions is not what the missionary, having taken the form of a servant as jesus did, can do, but what god does to and through the servant. an underappreciation of the weakness engendered by kenosis can lead to an overly triumphalistic view of missions that overemphasizes the role of human work in the mission’s “success”. one consequence of relying so heavily on human effort in missions is the propagation of the savior complex. this phenomenon, codified in 2012 by teju cole, refers to the way in which distorted narratives that situate particular countries and peoples “as places in need of heroism . . . perpetuate the need for external forces to come in and save the day . . . [and reward people for] ‘saving’ those less fortunate.”13,14 bosch writes: perhaps this [dependence on their own work] is, in part, what lies behind the tendency—particularly in protestant circles—to interpret the matthean version of the great commission (matt. 28:18–20) primarily as a command and, with that, to overemphasize the autxiliary verb “go” (greek: poreuthentes). as i have argued elsewhere, this is based on a faulty exegesis . . . it is also, however, the product of a deficient theology: in semi-pelagian manner, we tend to prioritize human intervention and relegate the power of god to secondary status.12 (p.185) the idea of self-emptying suggests something of which to be emptied, something to which one can no longer lay claim. for jesus, that is equality with god; for a missionary coming from an imperial or high-income country, that might be something like the social, financial, and cultural capital conferred by their political membership. christ’s kenosis, his rendering void his claim to divine rights and assuming a posture of servanthood, reminds missionaries emulating him that it is in weakness, insufficiency, and dependence on god, not triumphalist self-reliance we ought be sent. moreover, it should serve as a reminder, particularly for those coming with capital, that the way by which one enters the kenotic weakness of christ does not mean changing one’s identity, but divesting oneself of a claim to the rights associated with the identity. to divest oneself of claim to those rights is not merely a matter of “going overseas”, but a function of the posture one assumes. this posture is informed by the second of christ’s actions, humility, which is of equal importance in shaping a faithful christlike mindset in missions. 47 ellis dec 2019. christian journal for global health 6(2) the way in which christ humbles himself by assigning himself a lower rank might be understood to inform a missions mindset externally: it sheds light on how he related to those to whom he was called. douglas campbell notes that paul’s journey as a church planter is similarly characterized by having humbled himself in obedience. firstly, paul was willing to go the distance, not only geographically, but also socially.* secondly, paul was willing to set aside his “capital”. a welleducated roman citizen, paul had access to more social and economic capital than many of the people to whom he sought to preach the gospel. and yet, he leaves evidence in his letters that he set aside that capital, assigning himself a lower rank—humbling himself, we might say. in his ministry at thessalonica, for example, paul became a day laborer because the thessalonians were.† campbell notes the significance of “paul [arriving] in thessalonica looking like the people he was hoping to befriend and convert. he adopted the persona of a handworker and worked alongside the humble thessalonians . . . he abandoned his cultural capital, lowering himself to the place where the thessalonians lived, and became like one of them, so they could become like him.”15 bosch notes that any religion that “claims universal validity” and is “inherently missionary” is at risk for paternalism; in christian missions, he says, paternalism is an occupational hazard.12 in a model of missions that underappreciates christ’s deliberate humility, relating to local peoples paternalistically is all too easy. campbell describes the dangers of this posture in missions: * consider that the most prominent and likely initial convert in the city of paphos was quintus sergius paulus, a wealthy aristocrat. by contrast, the church in philippi grew and flourished following paul’s connection with a god-worshipping artisan named lydia. † paul writes “because we loved you so much, we were delighted to share with you not only the gospel of god but our lives as well. surely you remember, . . . missionaries arriving with a lot of capital are tempted to view their potential friends as people in need . . . the result is a patronclient relationship and is not a relationship of equality and of authentic friendship. a patron who frames a friend in terms of need risks [is] imposing a set of deficiencies on that person from outside . . . 15 the consequences of such missions are devastating: . . . converts [were] framed in terms of need and were victimized and infantilized. missionaries were framed in terms of provision and identified with european mores—often described as quintessentially white values. authentic relationships were distorted and difficult.15 thus, even when paternalism is not the intended mode of relationality between missionaries and local people groups, the sociohistorical contexts—colonialism, historically, and capitalism, more contemporarily—in which missions have been practiced may engender such dynamics. efforts at partnership like the kind demonstrated by christ and emulated by paul demand an intentional and even unnatural subversion of the dynamics at play. to assign oneself a lower rank is indeed not often “natural” but the sort of humility to which we are called. but what of medical missions? to understand how a model of missions informed by an internal kenotic disposition and a pattern of relationship grounded in self-humbling brothers and sisters, our toil and hardship; we worked night and day in order not to be a burden to anyone while we preached the gospel of god to you” (1 thes 2:8–9). paul recognizes his imitation of them as a launching point for them imitating him in return, and by the transitive property, imitating christ (“i plead with you, brothers and sisters, become like me, for i became like you.” gal 4:12). 48 ellis dec 2019. christian journal for global health 6(2) maps onto medical missions, requires an acknowledgement of the ways the practice of medicine is distinct from that of missions. firstly, medicine is a service with its own telos: improving the health of those in one’s charge. although medical missionaries in the modern era (i.e., the sixteenth century onwards) were concerned primarily with evangelism, faith-based organizations delivering medical care in lowand middle-income countries began to see the provision of healthcare as a good in its own right around world war i.4 the end of medicine is, therefore, set apart from the end of missions proper, and thus negotiating the joining of the two in the practice of medical missions is challenging. secondly, even outside of the social, cultural, and historical factors that have contributed to economic and political inequity between regions of the world, medicine engenders its own power imbalances between patient and physician. that in mind, the pauline vision of missions speaks to a vision of medical missions nonetheless. christ’s kenosis informs the missionary’s inward rendering void claim to his privileges and assumption of a servant’s disposition. medical missionaries, in the same way, might embrace the weakness that kenosis engenders, avoiding the triumphalism and self-reliance towards which medicine tempts practitioners. this temptation is true of medicine anywhere, but perhaps even more so in settings with great need (i.e., where great strides are “easy” to make). similarly, just as god is the author and perfector of salvation, he is the great healer. a kenotic disposition reminds medical missionaries that the physician, embodying the posture of a servant, is merely an intermediary of god’s work. finally, it should remind medical missionaries coming from settings with substantial medical resources that although they need not divest themselves of those rights and privileges (in fact, it is advantangeous for them to make use of those while practicing medicine in settings with unmet need), they should not allow the privilege conferred by those settings to impede their capacity to embrace weakness and vulnerability. christ’s humility, as in the case of missions broadly, should inform the way medical missionaries relate to local persons and organizations. in relating to patients, especially considering that the physicanpatient relationship is inherently unequal, this kind of humility is particularly salient. in relating to local practitioners and healthcare systems, a pauline model of missions would move medical missionaries to assign themselves a lower rank, to work with intention against the paternalism that differences in resources, training, and the like might naturally engender. to begin, this would mean taking the time to learn the local system and its stakeholders. after all, it would be challenging to humble onself without knowing practically what that meant in the missionary’s specific context. the time required to inculcate deep understanding of a system, culture, and its people is significant and would likely require that medical missionaries conduct either long-term continuous or long-term intermittent trips rather than short-term ones. moreover, relationships between medical missionaries and local organizations (both governmental and non-governmental) would take the form of partnerships. in a partnership, medical missionaries would shift from technocratic, selfgenerated projects and solutions towards asking local practitioners what their needs are and how missionaries can be most useful in strengthening their capacity to address those needs. practically speaking, that may include investing in training programs, cultivating a culture of quality improvement, and building up not only individuals but whole systems. as the missionary par excellence, christ provides the ultimate model for a faithful posture and pattern of relationship. in philippians 2, paul calls believers to imitate christ, rendering void claims on the rights and privileges they hold and humbling themselves in obedience. to imitate christ as a medical missionary, then, does not so much have implications on the delivery of care as it does on the posture from which one operates and the way one relates to one’s surrounding community. to be a 49 ellis dec 2019. christian journal for global health 6(2) disciple, a discipler, or a practitioner of medicine with the posture paul calls us to imitate is one and the same—a call, like jesus himself, to deliberately take on the posture of servanthood and humble ourselves, coming alongside those we serve as healers and as followers of christ. references 1. robert dl. christian mission: how christianity became a world religion. john wiley & sons ltd.; 2009. http://dx.doi.org/10.1002/9781444308808 2. bosch dj. reflections on biblical models of mission. in: phillips jm, coote rt, editors. toward the twenty-first century in christian mission. grand rapids, mi: eerdmans; 1993. p.175-192. 3. walls af. the missionary movement in christian history: studies in transmission of the faith. maryknoll, ny: orbis books; 1996. 4. hardiman d, editor. healing bodies, saving souls: medical missions in asia and africa. new york, ny: rodopi; 2006. 5. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock m, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015. http://dx.doi.org/10.1016/s0140-6736(15)60251-3 6. bockmuehl m. the epistle to the philippians. chadwick h, editor. london: a & c black limited; 1998. 7. paul h, jesus i, kim s. imitatio christi (1 corinthians 11:1): how paul imitates jesus christ in dealing with idol food [1 corinthians 8-10]. theology. 2003. 8. fee g. philippians 2:5-11: hymn or exalted pauline prose? bull biblic res. 1992;2:29-46. 9. lexicon : strong’s g2758 kenoō. blue letter bible. https://www.blueletterbible.org/lang/lexicon/lexicon.c fm?strongs=g2758&t=nkjv 10. hooker m. philippians. in: dunn jdg, editor. the cambridge companion to st paul. cambridge: cambridge university press; 2003. p. 105–15. [cambridge companions to religion]. https://doi.org/10.1017/ccol0521781558 11. lexicon : strong’s g5013 tapeinoō. blue letter bible. [internet]. https://www.blueletterbible.org/lang/lexicon/lexicon.c fm?strongs=g5013&t=nkjv 12. bosch dj. the vulnerability of mission. in: scherer ja, editor. new directions in mission and evangelization 2: theological foundation. maryknoll, ny: orbis books; 1994. 13. cole t. the white-savior industrial complex. the atlantic [internet]. 21 mar 2012. available from: https://www.theatlantic.com/international/archive/201 2/03/the-white-savior-industrial-complex/254843/ 14. aronson ba. the white-savior industrial complex: a cultural studies analysis of a teacher educator, savior film, and future teachers. j crit thought prax. 2018. http://dx.doi.org:10.31274/jctp-180810-83 15. campbell d. paul: an apostle’s journey. eerdmans publishing co; 2017. peer reviewed: submitted 8 july 2019, accepted 12 oct 2019, published 23 dec 2019 competing interests: none declared. correspondence: danielle ellis, duke divinity school, usa. danielle.ellis@duke.edu cite this article as: ellis d. humble thyself: the imitation of christ in medical missions. christian journal for global health. dec 2019; 6(2):44-49. https://doi.org/10.15566/cjgh.v6i2.315 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.1002/9781444308808 http://dx.doi.org/10.1016/s0140-6736(15)60251-3 https://www.blueletterbible.org/lang/lexicon/lexicon.cfm?strongs=g2758&t=nkjv https://www.blueletterbible.org/lang/lexicon/lexicon.cfm?strongs=g2758&t=nkjv https://doi.org/10.1017/ccol0521781558 https://www.blueletterbible.org/lang/lexicon/lexicon.cfm?strongs=g5013&t=nkjv https://www.blueletterbible.org/lang/lexicon/lexicon.cfm?strongs=g5013&t=nkjv https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/ https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/ http://dx.doi.org:10.31274/jctp-180810-83 mailto:danielle.ellis@duke.edu https://doi.org/10.15566/cjgh.v6i2.315 http://creativecommons.org/licenses/by/4.0/ a mts, md(c), university of north carolina chapel hill school of medicine, and theology, medicine, and culture initiative, duke divinity school, durham nc, usa introduction paul’s intentions, christ’s actions pauline imitation and missions but what of medical missions? references original article sept 2018. christian journal for global health 5(2):3-20 a qualitative study of an indigenous faith-based distributive justice program in kakuma refugee camp in kenya david boana, benjamin andrewsb, kalen drake sandersc, daniel martinsond, elizabeth loewere, and jamie atenf a phd, adjunct professor, wheaton college and director of humanitarian advocacy & service, world evangelical alliance b,c,d ma, psyd, wheaton college e ba, wheaton college f phd, founder and executive director of the humanitarian disaster institute and blanchard chair of humanitarian & disaster leadership at wheaton college abstract justice takes many forms, such as social justice (equitable human rights), procedural justice (fair process, particularly in resolution of disputes), distributive justice (equitable distribution), and more. distributive justice is an important theme in international community psychology, overlapping with concepts of peace, equity, compassion, and more. refugees, who often experience pervasive injustice, offer insights into justice when they create a just community. the united refugee and host churches (urhc) is a network of churches in kakuma refugee camp (kenya) and the surrounding turkana community founded in 1996 by refugees and people from the local turkana community. the urhc addressed ongoing conflict and distrust in the camp by establishing procedural and distributive justice. this qualitative study described the methods used by the urhc to restore justice and reduce conflict in the camp and build sustainable capacity. the project team interviewed 23 urhc members and leaders and identified eight themes describing urhc strategies. we discuss each theme and the network’s work as examples of applied distributive and procedural justice. we conclude by highlighting several implications, program impact, and recommendations for future research. key words: refugee, justice, faith, distributive justice, kenya 4 boan, andrews, sanders, martinson, loewer & aten sept 2018. christian journal for global health 5(2):3-20 introduction justice is an important research topic in community psychology and health as it overlaps with multiple important issues, such as peace, trauma, health, well-being, and conflict resolution. 1-5. while justice is a universal issue, people from different cultures view justice from their own cultural perspective.6,7 for example, people from somalia see conflict and justice from a social and political rather than a personal perspective.8 examining justice in a diverse environment could shed a crosscultural light on how justice develops and changes the community. one of the unique cultural perspectives addressed in this paper is religious culture that brought about distributive justice and community change through a network of churches. in 2012, the international association for refugees (iafr) contacted a group of graduate students and faculty in psychology at wheaton college in illinois to request an objective assessment of a refugee founded and operated church network in the kakuma refugee camp. it was reported that this network was having a significant positive impact on the stability of the camp. if accurate, this project represented an opportunity to study the development of distributive justice practices in a culturally diverse environment known for a community wide perception of injustice and frequent conflict. further, it could demonstrate the contributions of a network of churches to community peace. the aim was to verify whether there were established processes for community peace that might be shared with other networks and validate the work of the network to the united nations high commissioner for refugees (unhcr). literature review the concept of procedural and distributive justice goes back to thibaut and walker’s work on procedural fairness.9 procedural justice is one type of justice, along with distributive justice or the just distribution of goods, that are traditionally seen as expressions of a basic self-interest motive (people are mainly motivated by self-interest and getting what they are due).10 lerner and clayton challenged this self-interest approach to justice by suggesting that justice is a basic human drive along with selfinterest rather than just an expression of selfinterest.10 in this view, people are highly motivated to see the world as a just place, and not only motivated by self-interest. thus, while there are cultural differences in the application of justice, justice is a basic human imperative with significant consequences for human relations and mental health. lerner and clayton see people as developing “prepared solutions” in response to injustice that include violent retaliation (p. 192). this helps us to understand the conditions in the refugee camp where people very quickly align into their “moral community” when injustice is perceived and seek to correct the offence through vengeance (p. 192). in this context, the faith network in the camp established a system for ensuring just distribution, followed by procedures for the fair and non-violent resolution of conflict over perceived injustice. in the refugee camp, the subject network (united refugee and host churches, hereinafter urhc) developed without guidance or implementation support from the non-government organizations (ngos) in the camp. this means the methods they developed arose from within the local groups rather than being imported from an international ngo. in practice, although several of the camp contractors are faith-based, the ngo contractors in the camp are prohibited by unhcr from working with any one faith group as it would be perceived as discriminatory and potentially lead to conflict. faith based communities play an important mediating role in their communities, including promoting justice, although there are significant differences in how groups carry this out depending on theological orientation and culture.11,12 building a social network of faith organizations has shown positive impacts on the community.13 for example, in a study on refugees in australia, humpage and martin noted three impacts from faith community networks: 1) they build a shared identity 5 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. that fosters positive relationships; 2) the network fosters relationships with the larger community, and 3) it fosters relationships with people in positions of power.14 overall, the links between religion, community development, and justice are well established even if the mechanism is less than clear.15 the subject network in this paper reflects those three impacts, allowing us to gain insights into how it develops. since most of the people involved in starting the network were available, there was an opportunity to uncover the process of development, an area in need of further research. for example, a commitment to justice is reportedly linked to exposure to injustice, mentoring, and education, but this work needs to be extended to different cultures and faith traditions.16,17 indigenous networks are also known to be more sustainable over time and have a positive influence on development, but questions remain concerning the mechanisms of sustainability.18 how do justice initiatives develop over time, how are they implemented, are there development stages, and how are they sustained? this paper adds to the current literature by describing how the network developed the ability to create and maintain those impacts. the setting kakuma refugee camp is in the turkana district in northwestern kenya. the camp serves refugees who were forcibly displaced from their home countries due to war or persecution. established in 1992 to serve a maximum of 60,000 sudanese refugees, the camp has expanded to serve refugees from somalia, ethiopia, burundi, the democratic republic of congo, eritrea, uganda, and rwanda. according to the most current united nations high commissioner for refugees (unhcr) statistics, the camp population is close to 180,000 refugees. in 2007, kakuma refugee camp hosted 21% of the total refugee population in kenya.19 the unhcr provides administration while direct services, such as housing, health, and mental health, are provided by contracting non-government organizations (ngos). multiple tribal groups from nine different countries live in the camp where they have formed an estimated 55 protestant denominational groups (appendix a). due to the potential for the team’s presence to increase tensions between the christian groups and other faith groups, the team was directed by unhcr to limit contacts to the members of the urhc network. urhc began in 1997 when a refugee pastor formed the united refugee churches (urc) to promote cooperation and eliminate conflict between the churches in the kakuma camp. the camp situation at that time was one of continuing conflict between tribes and denominations wherein a donation to a group from outside the camp triggered conflict between groups. the distrust and perceived injustice among refugees was so high that donations immediately triggered suspicion and charges of corruption, often leading to open violence. adding to the complexity and conflict of the refugee camp was the refugee’s sense of justice denied. refugees do not see themselves as having access to protections under the law and often develop a strong sense of injustice and chronic insecurity.20 this is compounded by the complexity of camp life and sets the stage for refugees to resort to theories of corruption to explain events in the camp.21 there is an assumption of injustice among refugees, which may be adaptive in that it makes camp life more understandable. it was in this system of entrenched belief in injustice that the urhc set about to change the justice dynamic in the camp. the urhc addressed this environment of distrust by forming a central committee to be the recipient and distributor of outside donations and take responsibility for fair distribution (distributive justice). this provided a single point of contact that simplified the donation process for outside agencies and reduced conflict, which in turn increased donations. the central committee committed itself to transparency, to ensuring equitable distribution, and to deferring its own interests to those of group members. other churches in the camp were attracted to the group when they saw that donors preferred to deal with a single and central point of contact and by the group’s 6 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. success in reducing conflict and building trust. building on this success, and to build sustainable capacity, the urhc later created the kakuma interdenominational school of missions (kisom) within the camp to train church leaders. kisom courses included teaching the biblical basis for justice and the connection between religious belief, fair treatment, and distributive justice. urhc’s success in reducing conflict contrasts with what would be predicted from the literature and local culture. when local constituents engage in peace building and conflict resolution, they often face the challenge of convincing their own supporters, who represent different tribes and nationalities, to accept the agreement.22 this is particularly true in northern kenya, a traditional pastoral community with a high rate of conflict over access to grazing and ownership of livestock and a high rate of theft.23 convincing people to set aside traditional and aggressive ways of protecting their interests is an extraordinarily difficult task. aukot reported on the long-standing conflict between the refugees in kakuma and local turkana people exacerbated by support given to refugees without consideration for the impact on the local tribes.24 his opinion was that, “local integration, while needed, is simply not possible.”(79) the success of urhc stands in contrast to these reports. as noted, urhc is an integrated organization, expanding its presence in the surrounding community and reaching out to other faith groups. it is their success in a challenging setting that makes them particularly interesting for study. their success appears to be based upon a fundamental sense of procedural and distributive justice as the starting point for restoring basic trust. this study identified the system, methods, and strategies used by urhc. methods project team a project team was formed at a u.s.-based graduate school (wheaton college) with several faculty and graduate students in psychology. from this group, four team members (one faculty and three students) traveled to kakuma to plan the project together with urhc. none of the team members spoke swahili or had any prior experience with the refugee camp or the network, although all had prior experience in east africa. all interviews were conducted through local interpreters who lived either in the camp or the local community. an expanded team with additional students analyzed the interviews. procedures urhc members were co-implementers of the project. during a planning trip to the camp, and prior to starting any interviews, the project team explained the methods to the urhc leadership team so they could make an informed decision about participating in the project and communicate the project to potential participants. during a week of planning, the urhc leadership contributed to the design, the survey questions, and selection of the participants. the participants were interviewed by a team member together with an interpreter. participants were provided with a verbal and written overview of the study, as well as their rights as participants (including confidentiality). after their questions and concerns were addressed, the interviewer obtained written informed consent from the participant. there were no monetary rewards for participation. interviews were conducted in churches in various locations in the camp. travel in the camp was very difficult, especially during rain, so the team went to the closest location for the participants to limit their need to travel. the team was assisted by the national council of churches kenya which provided transportation across the camp. on average, interviews took 45 to 60 minutes. an initial interview was done by the faculty member of the team with other team members observing. this interview was then discussed by the team. second interviews were done by team members with faculty observing and helping if needed. at the end of each day of interviews, the team met and debriefed about the process and the need for any adjustments. 7 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. participants participants were selected using purposive sampling. the selection criteria started with the identification of key demographic and role groups within the urhc population, such as students, local community leaders, non-leaders, teachers, women in leadership, and non-leadership roles, as well as recent urhc participants and long-term urhc participants. all participants were adult members of the camp and members of urhc churches. the aim of the selection process was to have a diversity of viewpoints and avoid having network leaders dominate the interviews. as described earlier, for camp policy reasons, it was not possible to interview refugees who were not part of the urhc network. participants were not compensated but were motivated by a desire to share their story with others. refugees often have a sense of being forgotten by the world, so attention from an external group was a strong motivator. twenty-three individual clergy and church members living in the kakuma refugee camp were selected for interviews, 13 male and 10 female participants from various christian faith traditions (e.g., pentecostal, episcopal, anglican), ranging in age from 25 to 65 (ages were estimated as not everyone knew their age or birthdate). the interviews were recorded and the english translation transcribed. participant characteristics are listed in table 1. urhc membership characteristics are in appendix a. table 1. participant characteristics participant intervie wer nationality age church denomination role years with urhc m1 faculty burundian 40 international pentecost holiness church kakuma pentecostal pastor, board member 15 m2 faculty ethiopian oromo evangelical church adonai evangelical pastor; board member 12 m3 student sudanese (nuba mountains) episcopal church of sudan episcopal treasurer, pastor, and board member 8 m4 student ethiopian 47 adonai evangelical adonai evangelical zone leader 9 m5 student congolese 45 iphc pentecostal zone leader 5 m6 student sudanese (nuba mountains) 26 anglican/episcopal zone leader 7 m7 student kenyan 24 congolese pentecostal church of kenya pentecostal zone leader 2 m8 student kenyan (turkana) 27 release pentecostal church pentecostal chairman in host community 1 m9 student kenyan (ludwar county) 41 fountain of life church pentecostal pastor 4 m10 faculty unknown m11 faculty sudanese (northern) unknown m12 student congolese international pentecostal holiness church pentecostal pastor 2 m13 student congolese 27 ebenezer fellowship center pentecostal youth camp coordinator 5 w1 faculty international pentecost holiness church kakuma pentecostal none 8 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. w2 student kenyan (turkana) 28 oromo evangelical church living faith (pentecostal?) none 4 w3 student kenyan (turkana) 30 release pentecostal church pentecostal none 10 w4 student kenyan (turkana) 27 release pentecostal church pentecostal none 4 w5 student kenyan (turkana) 33 kenya church of christ church of christ none 4 w6 student sudanese (nuba mountains) 38 episcopal church of sudan episcopal ministry leader w7 student sudanese (nuba mountains) 30 episcopal church of sudan episcopal ministry leader 2 w8 student sudanese (nuba mountains) 37 episcopal church of sudan episcopal executive committee w9 student sudanese 36 the good shepherd african inland church ministry leader 8 w10 student sudanese 32 episcopal church of sudan episcopal student, ministry leader 8 m14 student ??? ??? ??? ??? unknown m15 student sudanese ? student, ministry leader 4 measures there was no theoretical model or existing protocol used in the development of the interviews. a variation on the standard protocol was created for interviews with women to explore whether women experienced benefits from the urhc programs. examples of questions from the interview protocol included: “how has the urhc been good for the camp and the host community?,” “can you describe an example of a conflict, either within the urhc or between a urhc member and another person or group, and how this was settled?,” and “what do you hope the urhc will do in the future?” (see appendix b). basic demographic questions (e.g., age, gender, education) were asked of all participants. analysis using nvivo, the data analysis used the constant comparative method, which consists of three types or stages of data analysis: (a) open coding, (b) axial coding, and (c) selective coding. open coding is the process of examining the data, naming elements in the data, and categorizing the data. axial coding consists of further developing, expanding, and organizing the categories.25 selective coding is the “process of selecting one category (core), systematically relating it to other categories, validating relationships, and fitting in categories that need refinement.”26 the coding team categorized the data individually, then met to discuss and align the categories. this process continued until the researchers reached conceptual redundancy (i.e., when no new concepts or information emerge from the data) at which point the analysis was deemed complete.27,25 all reported themes reported met the following criteria: (a) were formal and replicable tactics conducted by urhc to achieve its goals; (b) involved specific actions that were defined and taught by urhc and not independent or ad hoc actions by an individual; and (c) were observed and reported by at least two individuals in separate interviews. eight strategies were identified from the data. four strategies were described as developmentally foundational, meaning they made other strategies possible. this helped to clarify the developmental nature of the work of urhc wherein later strategies were enabled by earlier strategies. following the initial analysis, the team provided a draft report to the urhc leadership team for review. this review involved two steps: first, an interpreter read the report to the leadership group 9 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. while the team noted areas of question or clarification. simple corrections or clarifications were addressed in the meeting. the leadership team then met privately to discuss the report and to ensure comprehension among people for whom english was not their first language. a joint meeting was held after the private discussion where the report was reviewed and discussed again. following the debrief meeting with the leadership, the project team interviewed the leaders as a group regarding any additional specific activities related to any of the themes. results the analysis identified eight strategies that represent formal strategic actions by urhc to create distributive justice. “formal” means the strategy was linked to a formal structure such as the school (kisom), or a community structure (the zone structure), or tied to a specific method that was taught to and implemented by multiple people. several of the strategies have two or more components. a component is defined by a variation in strategy created to address a specific sub-group or setting. for example, there are different approaches to conflict resolution depending on whether the focus is on a family conflict or a community-wide conflict. community building several participants noted the lack of community in the camp at the time urhc began, in contrast to the current state: “first, the greatest obstacle [urhc] faced in the camp was that everyone had their own church. the burundi had a church, the somalis had church, and everyone was off to themselves. each church just focused on their own tribal background and culture. time after time the leadership of urhc came with a problem of bringing the people together, and then in time, they became one thing. they have given up their traditional ways of worship;” and, “in the past the churches had no bonding together, there was no coming together, we were independent. the bible baptist were independent. we present our own denomination, we were not a single church.” interviewees described how people were grouped by tribe and denomination and would, before urhc, fear crossing group boundaries. community building refers to developing a community where people can safely move between groups without fear. one participant said, [now] “[the pastors] preach together so there are no longer national boundaries between the preachers. because they are together: the congolese, the somalis, burundi, all the divided countries come together because of urhc.” cooperation with the turkana community churches is part of community building. initially suspicious of the association, several area churches filed suit to prevent the association from being incorporated. today, several turkana community churches are members of the urhc, participating equally in all urhc resources. people no longer fear moving between camp and host community churches since they have become one community. participants reported that successful community building is based on principles of justice in managing resources, together with faith in the integrity of the urhc. the leadership spoke of ensuring that when distributing resources, the leadership receive a share of resources only after members have received theirs. other methods included: (a) teaching a shared sense of purpose through service, (b) teaching a concept of one church that units local churches, (c) reducing barriers between churches, (d) creating a common purpose and mission, (e) transparent resource management to promote trust and ensure justice, and (f) providing leadership support to member churches. community organization “every community is organized according to the way they came [to the camp]. an example is my community, the burundi community, we have a council of elders, and there is a council of elders in every community. so, what they do now they elect a community council of elders, and they put a pastor on the council so the pastor can help them. like me and my community, i was just appointed to the 10 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. chairman of the council of elders. so, whenever they sit down, they consult me and ask if they are handling it the right way or not.” the community building required developing structures and roles. urhc has a formal structure with zonal leaders elected by the pastors within a zone that report to the council of elders who attend to the specific needs of the respective zones and facilitate accurate communication. they also have an executive committee and faculty for the school (kisom) and are incorporated as a not-for-profit organization. these organizational structures lend formality and sustainability to the work of urhc. urhc is further organized into six zones that plan the training and services for their local community and bring those needs to urhc. urhc then coordinates local needs and develops programs in response. conflict resolution containing, preventing, and resolving conflict was a major focus of urhc described by many interviewees, such as “a person from one side and another side wanted revenge, but now the pastors from urhc community came together with the pastors from the refugee camp and discuss the issue so the situation would not build with them fighting.” urhc teaches conflict resolution methods that emphasize an accountability for beliefs (setting an example, modeling faith), standards for behavior in families and for leaders, communication (countering rumors with accurate information), and the authority of the urhc to intervene as a trusted arbitrator. we grouped the conflict resolution work of urhc into three sub-categories. church conflict participants described the active intervention in church conflicts by urhc leadership. for example, “sometimes in the church . . . there is a disagreement to the level whereby the church, they want maybe to cut the church into two, or division. so, when it reaches that level, most of time we go to the urhc to come in so that they may just bring them together . . . (this has) been happening in several occasions.” conflict between and within churches might involve a conflict between a pastor and church members, between church leaders, or between churches. in these cases, the urhc leadership may directly intervene in the problem and guide people to some resolution. community conflict participants described intervention in community conflict as different from church conflict within the camp because it is between refugees and local host community members or refugees not from a network church. for example, “so, a pastor was killed [who] was a congolese man from the nazareth, and the reason he was killed was not clear, but some people say that it was maybe he had a conflict with somebody who revenged against him. a person from one side and another side wanted revenge, but now the pastors from urhc community came together with the pastors from the refugee camp and discuss the issue so the situation would not build with them fighting.” urhc would manage conflict using its communication system to contain rumors that could lead to an explosive escalation of the conflict, and then exercising its role as a trusted broker to intervene. family conflict family conflict, including marital conflict, represents one of the most common areas for serious conflict. participants described urhc as actively confronting family conflict and that their role was supported by camp ngos, such as “urhc also is involved in matters concerning families. when sometimes the wife and husband have conflict, when we know that, and even if they go to [an ngo], they [the ngo] may refer the cases to us. we asked them if they have a pastor, and they say yes to have their pastor should help.” 11 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. conflict between parents and children and between couples is most often addressed at the local level by the elder or community advisor. the advisor both responds to requests to assist with conflict but can also intervene without a request when he or she becomes aware of a conflict. education education, one of the fundamental strategies of urhc, began as a means for equipping refugees to become missionaries and pastors. it expanded to becoming the means through which urhc creates unity, teaches standards for behavior, and advances the role of women. the attention to women stands out among their educational strategies and is addressed as a separate strategy. “they teach us about staying together and teach us about thinking about your wife and supporting one another . . . they talk about counseling and psychology. they teach us many different things.” education included practical lessons about relationships, roles, and the importance of compassion and traditional rituals. for example, “there was a time they teach us a lesson about comfort. sometimes they organize big occasions, such as when someone is getting married, and they teach us [during these events].” education was also the means for creating and strengthening leaders. “(from urhc) i learned how a leader should be, and also how a leader should help others to come up as leaders also. that is the main thing i learned, the way i can be, the leader should be.” trust building and transparency keeping community actions hidden contributes to distrust and a belief in conspiracy theories. therefore, transparency was widely recognized as an essential condition to counteract distrust. as one participant put it …“that is a trust that they have built. it is transparency. there is no evidence that there is anything that is hidden [from the community by urhc].” “you cannot command people to trust you or obey you, you need to earn it. you have to earn trust; you have to earn respect. you can only earn trust and respect through what you are doing. so, from there, then the people decide to respect you. then they decide to involve you in their matters but first they need to see who you are, they need to see you have compassion, you have a heart, before they can come to you for help.” trust is the foundation for the credibility of urhc and the source of its authority to manage the distribution of resources, confront and prevent conflict, and advance the interests of vulnerable people. as one participants said, “without transparency, the ministry will not grow . . . it is the basis of ministry.” urhc leadership emphasizes that trust is the foundation of their ministry; transparency is one of the main strategies for building trust. meetings are open and regularly communicated across the camp, with sms messaging via cell phones as the main means of communicating. resources are managed in an open way, with leaders attending to their own interests last. care for the vulnerable building on the belief in serving the vulnerable, even in a community of vulnerable people, urhc prioritized care for the most vulnerable in the camp. “we are looking at ministry for widows and for orphaned children, street children, and also for the disability children. we are putting things better as we go.” care for the vulnerable is a fundamental area of service for urhc. it links to their effort to establish trust and demonstrates a core tenet of their faith. vulnerable people are served simply based on being disadvantaged or at high risk for harm, without respect for any external factors, such as faith or tribe. currently, service to the vulnerable focuses on widows and single mothers (distinct from women in general, who are also served), children, and youth (adolescents and young adults). the resources for serving those in need come mainly from urhc 12 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. member tithes and, when available, outside donations. people are asked to tithe from their biweekly food allocation. this required a basic change in attitude for people to give from their limited supplies of food. one participant described this as . . .” because sometime i may say, “ah, if i give this, where am i going to get it?” yeah. no. for us, we should live freed, free, knowing our god is our provider; our god is our god who is rich. help our peoples in the church to know all these sides. no matter of fear again. our home, the right home is in heaven, whereby we live a peaceful life there. and that is how we help the pupils in the churches how to live. and that is now how we have seen there is a great change.” communication while technology (cell phones) has enabled communication, the essential quality described by participants was a proactive effort to be inclusive concerning community information and proactive about ensuring that people are informed. for example, “we have phones, and with those phones, they can call me, so when there is something we need to do, we can call one another. we can be together and plan what to do. even the people outside the camp, they can communicate; they can have access to what’s going on.” communication is fundamental to an effective program and is one of the foundational areas of programming. conflict often erupts when rumor replaces fact and people take sides based on geography and tribe. a communication system is essential to distribute accurate information to counter rumors and to communicate when urhc leadership is addressing a dispute. when rumors threaten to escalate a conflict, urhc gathers and disseminates the facts, stressing that this information can be trusted because you know urhc, and you know you can trust us; therefore, leave it to us to settle this fairly. women’s roles the discussion of women’s roles stood out to the project team as an area where the urhc was actively changing a culture that traditional kept women subservient and oppressed. this was expressed by one participant who said, “in the urhc, women, they are treated well because they do get some services like education in terms of giving them, teaching about their families, educating the ways of getting something, like maybe they can even teach some good things of living with other people in that area.” participants also described the proactive nature of supporting women . . . “they encourage women to go to school because for women to go to school is very hard. some refuse because they say they don’t have time. but urhc encourages them to go to school then they go, and they finish, and they get a certificate. . . . urhc encourages them and tells us to encourage them. they say, ‘we will help. you can also do the work of god.’” the work by urhc was contrasted by participants with the traditional women’s roles, as in, “yes, before we came to the church, we are treated different women. they were saying that a woman doesn’t have voice to stand in front of people or to talk, but when we become a christian now, we are equal. there is no women in the church, and there is no men. we are all the same. if you can stand in front of people, you can — if you are able to preach the bible, you can stand and preach the bible. and now, there are some women that become pastors now. so, i have seen no difference in the church now. we are the same.” urhc leaders recognize they are competing with cultures and traditions that discriminate against women, either explicitly or implicitly, by emphasizing the traditional domestic role of women. such cultural expectations limit the time women have available to serve in other roles. the urhc does not restrict from membership churches that deny women leadership opportunities. instead, they see this as an opportunity to teach and influence 13 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. these churches to adopt views more respectful of women. in addition to education concerning theology and roles, women are taught business survival skills. as one participant noted, “we can teach them about business. in that business, it can continue having many, many skills so that it can develop a business that can run.” thus, women report finding themselves in a different relationship to the community because of support and education from urhc. women report feeling empowered to take care of themselves and to be more active in the community and in their homes. they are taught that they are equal to men, at least in the church, and encouraged to create support groups to help and support one another. discussion the research team, along with the urhc, identified clear and specific strategies used by the urhc that aided in providing necessary services to refugees, aide to the vulnerable, education for those without, resources for those in need, and hope and a sense of purpose to many in kakuma. these strategies developed without outside intervention. there were no external organizations, programs, or advisors involved in the development of these strategies; they arose entirely from the study, beliefs, and values of the members. justice strategies the work of urhc demonstrates the application of principles of procedural and distributive justice in a complex setting characterized by distrust and violence and a pervasive sense of injustice. the development of justice began with four key strategies that appear to have created the climate necessary for the development of the subsequent strategies. these four are: 1) trust building / transparency; 2) communication; 3) serving the vulnerable; and 4) education. these strategies are linked to establishing justice by emphasizing transparency and fairness in distribution, justice in serving all people in accordance with their need (serving the vulnerable), open communication, and using education to explain and gain acceptance of their procedures. these four strategies established the reputation of urhc in the community as a just and trustworthy institution and enabled the later strategies. these strategies focus on the community culture and environment and are based on a set of values that include respect, openness, service, and empowerment. these values are also linked to the faith of the urhc members, creating a basis for shared commitment to the strategies. impact our interviews also revealed the basic impact of the program on quality of life. people spoke of a reduction in fear, a restored sense of community, and a renewed sense of purpose. several people spoke of having a purpose in their lives related to carrying out the mission of urhc, even if their path in life does not lead to being resettled in their home country. our impression is that this reveals a link between trauma and justice, raising the possibility that when the community environment addresses issues of injustice, there is potential for greater healing on the part of the survivors of trauma. this alignment of faith, values, justice, and community raises the question of whether these strategies can be transferred to communities and cultures of different faiths. certainly, there are examples of christian communities that do not teach these same values and life practices, as well as of non-christian communities that do share these values. we suggest that the core values are not unique to christian theology, but the formal and grassroots effort to link values, faith, and behavior is a unique effort of the urhc. the four fundamentals of trust, communication, service, and education (empowerment) are even more engaging because urhc has a well-developed supporting theology. this supporting theology makes these fundamentals even more influential and engaging because it emphasizes connection to basic personal values. 14 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. while the quantitative assessment of impact within the refugee and host communities was not within the scope of this project, participants noted numerous examples of positive outcomes from the work of the urhc. these include: peace and purpose. this is the most striking example of impact. numerous urhc members reported having a greater sense of peace and purpose since joining the urhc. in one church meeting, when calling for donations from the members, the pastor asked the congregation how many people felt “poor.” not one person raised a hand. though this may have been the result of feeling the need to conform, it is still an interesting occurrence. this same church has used a considerable amount of their resources to provide meals for hungry children and other resources for those in need. thus, it seems reasonable to link at least one aspect of increased peace in the camp to the work of the urhc. security. several participants reported the ability to attend other churches without fear, greater cooperation between churches where previously there was conflict and an overall decrease of fear and conflict in the camp, as well as between the camp and community. while such improvements cannot be attributed solely to the urhc, some aspects of this sense of safety appear to be an outcome of the community building efforts of the urhc. care for the vulnerable. the quality of life for the most vulnerable among the refugees may also be attributed, in part, to the urhc. single mothers and children are sought out by urhc members for assistance and have benefited from the work of the urhc. overall, many people at the camp expressed surprise that urch was equipping refugees to care for those with unmet needs both within and outside the camp, rather than taking resources from the surrounding community. reduced conflict. urhc programs directly aimed to intervene in family conflict as a means of reducing larger community conflicts. we also note that some of the urhc members helping with conflict benefited from training programs, such as the jesuit refugee services (jrs) community counselor program, which has trained several urhc members. the jrs program is open to all people in the camp and does not specifically align with the urhc program, nor did it play a role in the formation of urhc. the urhc programs have worked to extend the impact of such services. education. many of our participants expressed developing a greater sense of purpose and hope in their lives because of receiving education. urhc members are trained for specific roles in the church and community. as a result, many participants reported that their lives in the camp have a new purpose. implications and significance these findings add support to the lerner and clayton model that describes people as striving to see the world as a just place and resorting to violence if necessary to counter a perceived injustice.10 urhc established itself as a trusted broker for the community, which allowed it to intervene at several levels. first, it shapes perceptions driven by rumor by providing accurate and trusted information. conflict is contained when perceptions of injustice are contained. second, they relieve individuals and tribes of the burden of entering a conflict by acting as a trusted representative. this prevents one group from seeing themselves as being further victimized by the original party. finally, they contain conflict by teaching peaceful methods of resolution that are based on their spiritual beliefs. urhc taught that avoiding conflict is not only good for its own sake, but necessary to have the type of witness god expects of his followers, such as in “blessed are the peacemakers” (matthew 5:9) and demonstrating humility, mercy, and justice (micah 6:8). from these interviews and discussions, we drew the following implications: 1. building a system on a foundation of procedural and distributive justice allowed for basic change in the pattern of conflict in a refugee population with deeply entrenched distrust. 15 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. 2. urhc has clear and specific strategies that they are applying both in the camp and in the larger community. 3. while we cannot yet document the full extent of impact, nor quantify that impact, urhc has had an impact on many people in the camp. the urhc programs have clear and specific targets and observable impacts, many of which are noted in this report. 4. the urhc program is a classic example of a grassroots, community-based effort at peace and reconciliation. as such, it is an example of how grassroots efforts in other areas might be promoted, as well as illustrating how ngos might align with the work. 5. given the trust and reputation established by urhc, there is a significant opportunity to serve the camp through equipping the urhc to train people in community-based trauma care. developing a training program in this area, in cooperation with the ngos focusing on mental health (such as jrs), would likely be of benefit. 6. the impact of giving and demonstrating generosity is a counter-intuitive finding that nonetheless has much support in the social science literature. this could be another area of study to quantify how such a ministry has benefitted the members of the camp as well as the churches themselves. 7. our emphasis on the success of urhc should not be taken as discounting the work of the unhcr and the contracting ngos working in the camp. urhc operates in an environment that made their work possible. they received training from ngos and find the ngos open to supporting them, training them, and generally working together. this is a collaborative approach to community work that warrants further documentation. finally, it is also important to note the relationship between this group and other faith groups in the camp, most notably the muslim community. the work to date by this group has been across refugee and host community churches that share a common theological view. the group recognizes its responsibility to serve across faith, tribal, or geographic boundaries. currently, the group is exploring the possibility of cooperating with muslim community groups. however, in an area where al shabab is active, such contacts are very risky and must move with great caution. conclusion it is our hope that this research will help bring greater attention and insight into faith-based grassroot peace and reconciliation efforts. moreover, we hope that this article will lead to more research in this understudied focus of investigation — and ultimately — greater care for refugees. references 1. tint b, chirimwami v, sarkis c. diasporas in dialogue: lessons from reconciliation efforts in african refugee communities. conflict resol q. 2014;32(2):177–202. https://doi.org/10.1002/9781119129813 2. bemak f, chung rc-y. refugee trauma: culturally responsive counseling interventions. j couns dev. 2017;95(3):299–308. https://doi.org/10.1002/jcad.12144 3. chase le, rousseau c. ethnographic case study of a community day center for asylum seekers as early stage mental health intervention. am j orthopsychiat. 2018;88(1):48–58. 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(eds.). using grounded theory in nursing. new york: springer; 2001. 27. johnson b, christensen l. educational research: quantitative and qualitative approaches. needham heights, ma: allyn & bacon 2003. peer reviewed: submitted 12 april 2018, accepted 3 july 2018, published 22 sept 2018. competing interests: none declared. correspondence: dr david boan, wheaton, il, usa. dboan@worldea.org https://doi.org/10.1207/s15327965pli1604_06 https://doi.org/10.1177/136346150003700306 https://doi.org/10.1007/s10464-010-9388-8 https://doi.org/10.1007/s10464-010-9388-8 https://doi.org/10.1080/00224545.2011.614969 https://doi.org/10.1007/s10464-012-9493-y https://doi.org/10.1093/cdj/bsi022 https://doi.org/10.1093/cdj/bsh029 https://doi.org/10.1007/s10464-012-9552-4 https://doi.org/10.1007/s10464-012-9552-4 https://doi.org/10.1007/s10464-012-9552-4 https://doi.org/10.1007/s10464-012-9552-4 https://doi.org/10.1080/09614524.2012.685862 http://kanere.org/about-kakuma-refugee-camp/ http://kanere.org/about-kakuma-refugee-camp/ https://doi.org/10.1111/lasr.12041 https://doi.org/10.1093/afraf/adn044 https://doi.org/10.1111/0149-0508.00118 https://doi.org/10.1111/0149-0508.00118 https://doi.org/10.1002/jid.985 17 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. cite this article as: boan d, et al. a qualitative study of an indigenous faith-based distributive justice program in kakuma refugee camp in kenya. christian journal for global health. sept 2018; 5(2):3-20. © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org appendix a: the churches, nationalities and languages of urhc (as of 2014) table 1. urhc member churches as of 2014 and location urhc member churches location urhc zone presbyterian church of sudan kakuma 1 episcopal church of sudan zone 1 winners chapel church calvary pentecostal church kenya assemblies of god african inland church family pentecostal ministry worldwide church of god episcopal church of sudan kakuma 3 cornerstone church baptist church of sudan kakuma 1 sudanese church of christ kakuma 1 sudanese church of christ kakuma 3 episcopal church kakuma 1 zone 3 episcopal church kakuma 3 pefa adonai oromo evangelical church methodist church of sudan international pentecostal holiness church kakuma 1 zone 1 international pentecostal holiness church kakuma 1 zone 2 international pentecostal holiness church kakuma 1 zone 3 international pentecostal holiness church kakuma 2 international pentecostal holiness church kakuma 3 evangelical lutheran church kakuma 1 ethiopian evangelical church bethel gospel church friends church united christian church kakuma 1 united christian church kakuma 2 kenya christ gospel ministry kakuma town kenya christ gospel ministry nadayal town release pentecostal church of kenya kakuma town release pentecostal church of kenya native 1 town ebenezer fellowship center kakuma 1 bible baptist church laorunp’ove town grace revival center kakuma 3 bible baptist church kakuma town http://creativecommons.org/licenses/by/4.0/ 18 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. anglican church of sudan kakuma 1 zone 3 fountain of life international kakuma town evangelical free church of sudan kakuma 1 christ united church kakuma town episcopal church of sudan kakuma 1 presbyterian church of sudan kakuma 2 release pentecostal church nadapal town fountain of life church international nakwangat town full gospel church of kenya town grace communion international kakuma 1 evangelical lutheran church kakuma 3 baptist church kakuma town baptist church kakuma 2 phase 2 new apostolic church kakuma 2 free methodist church kakuma 2 redeemed christian church kakuma 1 zone 4 pentecostal church kakuma 2 phase 2 faith home church kakuma town presbyterian church of sudan kakuma 1 episcopal church of sudan zone 1 winners chapel church calvary pentecostal church kenya assemblies of god african inland church family pentecostal ministry worldwide church of god episcopal church of sudan kakuma 3 cornerstone church baptist church of sudan kakuma 1 sudanese church of christ kakuma 1 sudanese church of christ kakuma 3 episcopal church kakuma 1 zone 3 episcopal church kakuma 3 pefa adonai oromo evangelical church methodist church of sudan international pentecostal holiness church kakuma 1 zone 1 international pentecostal holiness church kakuma 1 zone 2 international pentecostal holiness church kakuma 1 zone 3 international pentecostal holiness church kakuma 2 international pentecostal holiness church kakuma 3 evangelical lutheran church kakuma 1 ethiopian evangelical church bethel gospel church friends church united christian church kakuma 1 united christian church kakuma 2 kenya christ gospel ministry kakuma town kenya christ gospel ministry nadayal town release pentecostal church of kenya kakuma town release pentecostal church of kenya native 1 town ebenezer fellowship center kakuma 1 bible baptist church laorunp’ove town grace revival center kakuma 3 bible baptist church kakuma town anglican church of sudan kakuma 1 zone 3 19 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. fountain of life international kakuma town evangelical free church of sudan kakuma 1 christ united church kakuma town episcopal church of sudan kakuma 1 presbyterian church of sudan kakuma 2 release pentecostal church nadapal town fountain of life church international nakwangat town full gospel church of kenya town grace communion international kakuma 1 evangelical lutheran church kakuma 3 baptist church kakuma town baptist church kakuma 2 phase 2 new apostolic church kakuma 2 free methodist church kakuma 2 redeemed christian church kakuma 1 zone 4 pentecostal church kakuma 2 phase 2 faith home church kakuma town international pentecostal holiness church kakuma 1 zone 3 international pentecostal holiness church kakuma 2 international pentecostal holiness church kakuma 3 evangelical lutheran church kakuma 1 ethiopian evangelical church bethel gospel church friends church united christian church kakuma 1 united christian church kakuma 2 kenya christ gospel ministry kakuma town kenya christ gospel ministry nadayal town release pentecostal church of kenya kakuma town release pentecostal church of kenya native 1 town ebenezer fellowship center kakuma 1 bible baptist church laorunp’ove town grace revival center kakuma 3 bible baptist church kakuma town anglican church of sudan kakuma 1 zone 3 fountain of life international kakuma town evangelical free church of sudan kakuma 1 christ united church kakuma town episcopal church of sudan kakuma 1 presbyterian church of sudan kakuma 2 release pentecostal church nadapal town fountain of life church international nakwangat town full gospel church of kenya town grace communion international kakuma 1 evangelical lutheran church kakuma 3 baptist church kakuma town baptist church kakuma 2 phase 2 new apostolic church kakuma 2 free methodist church kakuma 2 redeemed christian church kakuma 1 zone 4 pentecostal church kakuma 2 phase 2 faith home church kakuma town 20 boan, andrews, sanders, martinson, loewer & aten july 2018. christian journal for global health 5(1):3-20. table 2. nationalities and major languages represented within urhc nationalities major languages burundi kiwyarwanda & kirunadi rwanda english congo swahili ethiopia arabic somali dinka south sudan nuev eritrea kiganda uganda somali kenya amava (ethiopia) burundi oromo moro (nuba) turkana bari (equatoria) kiwyarwanda & kirunadi appendix b: interview protocol 1. peace and conflict resolution o please describe an example of a conflict, either within urhc or between a urhc member and another person or group, and how this was settled. o what role did urhc play in settling this conflict? for example, did it teach a way to settle conflict, or manage the conflict, or something else? o if there was some way urhc helped with the conflict, how did it learn to do this or how did this help come about? o did you personally learn anything about peace or resolving conflict? 2. general insights and lessons o what about urhc and its people have made it a success? o how has urhc been good for the camp and the host community? o what have the people of urhc learned about running a successful association in a refugee camp? o can you tell us a story about how urhc has helped other people? 3. community service and impact o who has urhc helped and how have they helped? o what improvements have you observed in the camp or community that might be due to the work of urhc, even if in part? o what do you hope urhc will do in the future? o if you wanted to tell the world a story of how urhc has helped the camp and/or community, what story would you tell them? 4. women’s roles o what is life like for women within the camp who are members of churches? o does urhc take any action regarding treatment of women? o how has it come about that women have, in some cases, leadership roles within churches in the camp? does urhc have any part in supporting these leadership roles? if so, can you tell us a story about that? original article may 2016. christian journal for global health, 3(1):46-56. a preliminary investigation of the barriers to clean water access in the urban slums of kolkata, india holly anne beistline a a mph, liberty university school of public health, usa abstract introduction: safe drinking water is scarce in kolkata. inadequate knowledge and poor practices of storing and cleaning drinking water can cause severe effects on the health of the population. there is a need to understand the current trend of attitudes and practices of individuals living in urban slums to reduce water-borne diseases and mortality. this limited convenience sample study attempted to explore and identify areas for further study regarding the barriers of clean water access in urban slums of kolkata, india. methods: this pilot cross-sectional study was conducted in kolkata, india during july 2014. five urban slums were selected based on proximity and cooperation from the community. a sample of 50 women was taken, representing the five slums, with a sample of 10 women taken from each slum. results: the majority (80%) of the participants said they regularly have enough water available to meet the needs of their household. fifty-two percent of subjects received their water for drinking from a tap, hand pump, or time pump. thirty percent had water pumped into their homes, and 18% purchased their water from a water truck. fourteen percent said they did not treat their water because it was too time consuming, 40% said it was too much work, and 34% said it was not needed. ninety percent said they felt it was important to clean their water, almost half (48%) thought their water was not clean, but only 42% used some method to clean their water. many subjects (68%) stated they knew how to clean their water, but 66% were unaware that visible dirt is not an indicator of illness-causing bacteria in water. conclusions: more focus should be directed towards improving awareness and knowledge and changing attitudes, motivation, and perceived susceptibility to disease from water within slum communities in kolkata, india. introduction access to improved drinking water is a main public health concern around the globe. the urban slums of kolkata, india, present many unique public health challenges, among them the scarcity of safe drinking water. less than half the households within kolkata have improved sanitation facilities. 1 the united nations rates india 120th for water quality among the 122 selected nations covered. 2 unicef and world health organization 47 beistline may 2016. christian journal for global health, 3(1):46-56. report that 67% of indian households do not treat their drinking water, even though it could be chemically or bacterially contaminated. this is concerning because only a quarter of the total population in india has drinking water on their premises. 3 diarrhea is the second leading cause of death globally in children under five years. 4 in india, pneumonia and diarrhea account for 50% of deaths of children under five. 5 it has been estimated that 15–20% of community diarrheal disease in developing countries is attributed to unsafe drinking water, with recent studies indicating even higher percentages of waterborne diarrheal disease. 6 according to india’s national family health survey from 2005-2006, the under-five mortality rate among the urban poor was 72 per 1000 live births, significantly higher than the overall urban average of 52 per 1000 live births. 7 the major etiological agents accounting for over a million diarrheal deaths per year, particularly in developing countries, are escherichia coli, rotavirus, vibrio cholerae, and species of shigella, which are spread through contaminated water and food or from person to person. 8 india is a lower middle income country, with a total population of 1.252 billion as of 2013. 9 kolkata is the capitol of west bengal, a state of india. it is located on the eastern bank of ganga river. kolkata is the 7th biggest city of india in area and population. 10 in the year 2000, approximately 21% of the total urban population of india lived in slums. specifically in kolkata, 86% of the poor live in slums. 1 the government of india defined slums as “those areas where buildings are in any respect unfit for human habitation,” according to the slum act of 1956. 11 generally, slums consist of clusters of homes constructed with temporary building materials. living conditions are difficult within the slums due to a lack of basic amenities such as many families sharing a common latrine, no official arrangements for water supply, and poor drainage systems. 1,12 registered or legal slums, “bustees,” are recognized by the calcutta metropolitan corporation (cmc) because of the title of the land. illegal or unauthorized slums are known as squatter settlements. squatter settlements can be found along the sides of canals, garbage dumps, railway tracks, and roads. 12 a study from 2012 tested water from various slum locations in kolkata. samples were taken from 117 main sources from taps and tube wells, 200 from stored water for drinking, and 200 from stored water for washing. when analyzed, 28% (56/200) stored drinking water samples and 8% (10/117) main water sources were found to be contaminated with fecal coliforms. 6 they also stated that the tube wells were usually not very deep and did not penetrate the impervious layer of soil. moreover, they concluded that low levels of personal and domestic hygiene led to extensive environmental contamination, resulting in contamination of these water sources. 6,13 the southern portion of kolkata is serviced by a 120mgd water treatment plant called garden reach water works (grww). the treated water from the plant is transported through dedicated lines to a number of booster pumping stations that in turn serves the consumers’ water networks. in total, 2.3 million residents are served through the present system. 14 until access to piped treated water is attained, water purification at the point of consumption or point-of-use water treatment, has emerged as a costeffective approach to protect populations lacking safe water. 15 inadequate knowledge and poor practices of storing and cleaning drinking water can cause severe effects on the health of the population. for reduction of water-borne diseases and mortality, there is a need to understand the current trend of attitudes and practices of individuals living in urban slums. 16 many attempts have been made by the indian government and non-governmental organizations (ngo’s) to change behaviors associated with water consumption, but there is still a lack of practice within the slums of kolkata. in order to reduce child mortality in kolkata associated with clean water, the behaviors and 48 beistline may 2016. christian journal for global health, 3(1):46-56. barriers of clean water access in urban slums must first be understood. methods this pilot cross-sectional study was conducted in kolkata, india, during july 2014. five urban slums were selected conveniently based on proximity and cooperation from the community. a convenience sample of 50 women was taken from 5 different slums, with a sample of 10 women taken from each slum. mothers were surveyed because they were the primary water gatherers. 16 women were contacted by selecting residences at random throughout each slum community. mothers that gave oral informed consent after the study’s purpose was explained to them were included in the study. if no eligible participant was found at the time of interview, an additional household was chosen. all interviews were conducted during the late afternoon when the mothers were more likely to be home. confidentiality of the participants was maintained by assigning a number to each of the participants. preliminary data was gathered concerning basic household information such as the type of slum, age, religion, how many children under the age of 5 the participants had, and how many individuals lived in their household. next, information was gathered about individuals’ attitudes towards water treatment practices. the variables contained in the survey included topics related to water safety, effects of unsafe drinking water on health, and the practices that were adopted to make water safe to drink. a participatory appraisal was used to collect information about the type of slum, estimated total population, average family size, educational systems available, average household income, surrounding environment, the various sources of drinking water, distance of water source from household, timings of water supply, and water storage practices. slum number 1, udayan polly, received drinking water from daily deliveries via a water truck. each tank held 3,600 liters of water and required each community to deposit $7.50 (about 450 rupees) per tank. 10 water samples taken from water pumps within slum number 1 found high fecal contamination, 100-1000 e. coli per liter of water. water was tested at water testing lab deo tech in kolkata. water samples were collected from slum number 5, mudapara, by kolkata city mission on july 10, 2014. this sample was tested at n.d. international in kolkata. no high levels of e. coli or other harmful coliforms were detected in the sample taken from a timed water tap within the slum number 5 community. the health belief model (hbm) is based on the concepts that health-related interventions will only be effective if recipients are aware of their susceptibility to disease and feel they are capable of taking a role in addressing the problem. 17 using the health belief model, a questionnaire was constructed based on the perceived seriousness, perceived susceptibility/perceived threat, perceived benefits, perceived barriers, cue to action, and selfefficacy associated with clean water. the survey comprised of the following sections:  household data: age of the subject, household size, and the number of infants living in the household.  water practices: information was gathered about the main source of water, quantity and quality available, if any methods are used to clean water, and reasons why they do not treat their water.  water knowledge: attitudes and beliefs of drinking water’s cleanliness, knowledge of how to clean water, how to tell if the water is clean, knowledge of consequences of drinking contaminated water, and number of known cases of stomach illness within the last year. data collected from the questionnaire was analyzed in order to understand the behaviors and barriers associated with clean water in kolkata slums. descriptive analysis was performed using ibm spss statistics program version 22. chisquare analysis was performed to compare the 49 beistline may 2016. christian journal for global health, 3(1):46-56. qualitative variables using ibm spss statistics program version 22. results a total of 50 participants were enrolled in the study conducted in july 2014 in urban poor slum settings in kolkata, india. the mean age of the participants was 30.46 years (sd=11.56), with a mean family size of 5 individuals (sd=0.64), and a mean of 1.49 children below the age of 5 years per household (sd=0.54) (table 1). table 1. household descriptive data kolkata, india slums, 2014 min max mean standard deviation respondent age (years) 17 75 30.46 11.56 family size 1 8+ 5.00 0.64 number of infants 0 5 1.49 0.54 note: n=50 the majority (80%) of the participants said they regularly had enough water available to meet the needs of their household. results showed that 52% of the subjects received their water for drinking from a tap, hand pump, or time pump. thirty percent had water pumped into their homes, and 18% purchased their water from a water truck. additionally, only 4% used water filters to purify their drinking water, while 36% boiled, 2% used chlorine or iodine, and a little over half (58%) of the subjects did not treat their water at all (figure 1). fourteen percent said they did not treat their water because it was too time consuming, 40% said it was too much work, and 34% said it was not needed (table 2). . figure 1. method used to treat water in slum homes kolkata, india prior to consumption, 2014 50 beistline may 2016. christian journal for global health, 3(1):46-56. table 2. water practices in slum homes kolkata, india, 2014 variables results 1. do you have enough water regularly available to meet the needs of your household? a. always 80% (n=40) b. most of the time 6% (n=3) c. sometimes 14% (n=7) 2. what is the main source of water for drinking and cooking in your household? a. pump/tap/well 52% (n=26) b. piped into home 30% (n=15) c. water truck 18% (n=9) 3. what method, if any, is used to treat the water prior to human consumption? a. none—not treated 58% (n=29) b. boiling 36% (n=18) c. chlorine/iodine 2% (n=1) d. filter 4% (n=2) 4. if you do not treat your water before drinking, why? a. time consuming 14% (n=7) b. too much work 40% (n=20) c. not needed 34% (n=17) a little more than half (55%) of the subjects reported themselves or their children experienced stomach illness and diarrhea 1-5 times a year, 22.5% said once a month, 10% reported more than once a month, and 12.5% reported never (figure 2). figure 2. reported stomach illness & diarrhea frequency for respondents and children in slum kolkata, india, 2014 the subjects’ water knowledge is outlined in table 3. most (88%) participants said that some sort of stomach illness was associated with their water source (figure 3). the majority, (90%) felt it was important to clean their water before drinking (table 3). 51 beistline may 2016. christian journal for global health, 3(1):46-56. table 3. clean drinking water knowledge and beliefs in slum homes kolkata, india, 2014 variables results 1. what health conditions are generally thought to be associated with the use of water from this source? a. none 16% (n=8) b. stomach illness/diarrhea 68% (n=34) c. fever or parasite infection 10% (n=5) d. both diarrhea/stomach illness and fever/parasite infection 4% (n=2) 2. how many times a year do you or your children experience stomach illness and diarrhea? a. never 18% (n=9) b. 1-5 times/year 46% (n=23) c. once a month 28% (n=14) d. more than once a month 8% (n=4) 3. do you think your drinking water is safe? a. yes 48% (n=24) b. no 48% (n=24) c. don’t know 4% (n=2) 4. do you feel it is important to clean your water before drinking? a. yes 90% (n=45) b. no 10% (n=5) figure 3. heath conditions thought to be associated with respondent’s source of drinking water in slum kolkata, india, 2014 in answering the question on whether or not you can tell if your water is contaminated, 66% thought it was possible to tell if drinking water is dirty simply by looking and seeing visible dirt, while 34% understood that it was not possible to tell if drinking water was dirty just by looking at it. sixty-eight percent said they knew how to clean their water, and 24% said they did not know how to clean their water (table 4). 52 beistline may 2016. christian journal for global health, 3(1):46-56. table 4. clean drinking water knowledge and beliefs in slum homes kolkata, india, 2014 continued variables results 1. how can you tell if your water is contaminated? a. visible dirt 66% (n=33) b. can’t tell just by looking 34% (n=17) 2. do you know how to clean your water? a. yes 68% (n=34) b. no 24% (n=12) there was a significant relationship between each slum and the belief that their water was safe. the majority in slums 1 and 2 felt their water was safe, while majority in slums 3, 4, and 5 felt their water was not safe (table 5). there was a significant relationship between water source of tap/well/pump and the belief that it was not safe (table 6). table 5. belief of safe water vs. slum chi-square contingency table slum total 1.00 2.00 3.00 4.00 5.00 safe yes 7 9 2 3 3 24 29.2% 37.5% 8.3% 12.5% 12.5% 100.0% no 1 1 8 7 7 24 4.2% 4.2% 33.3% 29.2% 29.2% 100.0% don't know 2 0 0 0 0 2 100.0% 0.0% 0.0% 0.0% 0.0% 100.0% total 10 10 10 10 10 50 20.0% 20.0% 20.0% 20.0% 20.0% 100.0% p=.001 table 6. water source vs. belief if safe to drink chi-square contingency table safe total yes no don't know source pump/tap/well 11 15 0 26 42.3% 57.7% 0.0% 100.0% piped into home 6 8 0 14 42.9% 57.1% 0.0% 100.0% water truck 6 1 2 9 66.7% 11.1% 22.2% 100.0% other 1 0 0 1 100.0% 0.0% 0.0% 100.0% total 24 24 2 50 48.0% 48.0% 4.0% 100.0% p=.026 discussion water is essential for life. we all have knowledge and instinct of its necessity for drinking, producing food, washing, and maintaining our health. 2 the 2011 census of india reveals that 17.4% of urban households in india live in slums. the increasing number of slum-dwellers poses serious challenges to the provision of basic urban water services. 18 the water supply in kolkata and most other indian cities is only available for a few hours per day, pressure is irregular, and the quality 53 beistline may 2016. christian journal for global health, 3(1):46-56. of water is questionable. 19 with understanding of the attitudes, beliefs, and knowledge of drinking water in slums, communities can be mobilized to work towards improved drinking water facilities, as well as being taught about drinking water contamination risks at the household level and safe storage of drinking water from unreliable supplies. 2 this pilot study attempted to assess the present situation of clean water and associated knowledge, attitudes, and beliefs within the slums of kolkata, india. based on the results obtained from the questionnaire, there is a lack of motivation associated with clean water in the slum communities of kolkata. ninety percent said they felt it was important to clean their water, almost half (48%) believed their water was not clean, but only 42% used some method to clean their water. many subjects (68%) stated they knew how to clean their water, but 66% were unaware that visible dirt was not an indicator of illness-causing bacteria in water. respondents identified present barriers to clean water as too time consuming (14%) and too much work (40%). based on the questionnaire, information and knowledge about clean water was not lacking for many participants. however, this raises a more difficult challenge of addressing the motivation and will to clean water. perceived susceptibility of disease from contaminated water needs to be addressed as well. there is knowledge of poor water sources and the illness they cause, but perceived susceptibility to disease is not sufficient enough to motivate people to action. there were several limitations of the current study such as small sample size, language barrier, and the use of interpreters. any time a convenience sample is used, it may confound the analysis because subjects were chosen based on availability rather than being representative of the full population. further research should be done on water storage practices and the knowledge associated with water handling, hygiene, and storage contamination. if water is not piped directly into a house whenever needed, it must be stored in containers. this provides a number of opportunities for contamination. 20 problems associated with inadequate water supplies are further complicated by poor sanitation, which can cause water to become contaminated. in urban areas, many slums contain limited, crowded public latrines that are distant from many of the dwellings they serve, causing many people to defecate in the open. 18 additional data should be collected on the practices and attitudes and beliefs associated with sanitation within slum communities as well as different methods of cleaning water. for example, in one conversation with a subject, she stated that she thought her roof was too dirty to effectively execute the solar water disinfection (sodis) method, which is a process that uses solar radiation to heat and disinfect water stored in plastic bottles. 15 eventually, the provision of safe, sustainable, drinking water needs to be achieved within the slum communities of kolkata. movement needs to be made from point-of-use water treatment to more sustainable means. communities need to be mobilized towards creating their own means of sustainable water. a study was performed in kolkata in 2007 that investigated the current water situation and respondents’ willingness to pay for sustainable water. half of the 202 people surveyed in this study were slum dwellers while the other half were apartment dwellers. a weighted average of the willingness to pay for drinkable water was analyzed and compared to the cost of providing potable water. the willingness to pay exceeded the production and maintenance cost for the drinkable water supply scheme suggesting that a water tariff is economically justifiable. 21 this study shows that communities in kolkata are willing to pay and work toward sustainable clean water, but more knowledge and awareness needs to be raised to mobilize communities towards action. conclusion water management solutions exist that can make significant strides in combating both disease and mortality. recommendations based on infor54 beistline may 2016. christian journal for global health, 3(1):46-56. mation gained from this study include creating more awareness of the level of contamination of water in the slums, creating community groups for women to learn about using point-of-use water treatment methods, decreasing pathways of contamination, and mobilizing communities to work towards sustainable clean water systems. further research should be done on water storage practices and the knowledge associated with water handling, hygiene, and storage contamination, as well the practices, attitudes, and beliefs associated with sanitation within slum communities. further research should also be performed regarding the motivation and will to clean water within the slums. in order to reduce child mortality in kolkata, india associated with clean water, the behaviors and barriers of clean water access in urban slums must first be understood. more focus should be directed towards improving the awareness, knowledge, and changing attitudes of motivation and perceived susceptibility to disease from water within slum communities in kolkata, india. references 1. goli s, arokiasamy p, chattopadhayay a. living and health conditions of selected cities in india: setting priorities for the national urban 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http://www.jyi.org/issue/valuation-of-clean-water-supply-by-willingness-to-pay-method-in-a-developing-nation-a-case-study-in-calcutta-india/ http://www.jyi.org/issue/valuation-of-clean-water-supply-by-willingness-to-pay-method-in-a-developing-nation-a-case-study-in-calcutta-india/ 56 beistline may 2016. christian journal for global health, 3(1):46-56. peer reviewed competing interests: none declared. acknowledgments: liberty university, and professor richard lane for the guidance and assistance in each step of the process of this study. correspondence: holly anne beistline, liberty university, habeistline@liberty.edu cite this article as: beistline, ha. understanding the barriers of clean water access in urban slums of kolkata, india. christian journal for global health (may 2016), 3(1):46-56. © beistline, ha this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:habeistline@liberty.edu http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ clinical care april 2020. christian journal for global health, 7(1) the covid-19 pandemic: defining the clinical syndrome and describing an empirical response mandalam s. seshadria and t. jacob johnb a md, phd, frcp, former professor of medicine & endocrinology, department of endocrinology diabetes & metabolism, christian medical college & hospital, vellore; consultant physician & endocrinologist, honorary medical director, thirumalai mission hospital, vanapadi road, ranipet, india b phd (virology), frcp (paediatrics), former professor& head, department of clinical virology, christian medical college & hospital, vellore, india abstract the novel corona virus infectious disease, covid-19, is a pandemic now and is raging through several continents, posing a challenge to health-care systems of all the countries and disrupting lives and livelihoods across the world. the facilities for virus testing are available for only limited numbers in each country and each country excludes a large number of potentially infected subjects because the lab test is done for only certain categories. nearly 80 % of those infected will, therefore, go undiagnosed. there is an urgent need, therefore, to define the clinical syndrome so that practitioners at the primary and secondary levels can make a confident, clinical diagnosis and proceed to manage patients early and effectively. chloroquine and hydroxychloroquine, both antimalarials, have shown promise in limited trials in france and china. they are inexpensive, have been around for several decades in the prevention and treatment of malaria, have well-known side-effects and, in the shortterm, safe for use. we propose that practitioners make a preliminary clinical diagnosis of the covid-19 syndrome based on simple clinical criteria and lab tests and proceed to manage patients and protect other family members and contacts by using isolation measures and short regimens of these anti-malarial and other medications, anticipating results of more clinical trials. key words: covid-19, clinical syndrome, empirical therapy, hydroxychloroquine. introduction the covid-19 pandemic sweeping across the world is continuing to take a heavy toll in terms of human lives and is threatening the global economy. it is currently spreading rapidly across several continents, and the peak is yet to come. the variable sensitivity of the polymerase chain reaction (pcr) based tests employed, different criteria for testing in different countries, limited availability of the testing facilities, and the high 38 seshadri & john april 2020. christian journal for global health, 7(1) cost of testing will result in underdiagnosis.1 therefore, alternative approaches that do not rely on testing everyone with fever and cough with pcr are necessary in lowand middle-income countries. diagnosis in clinical medicine, a syndrome may be diagnosed using specific clinical and commonly available laboratory criteria, especially when the situation is a medical emergency and treatment is urgent. to cite a common example, empirical use of antibiotics, pending culture reports, is standard practice in treating sepsis syndrome, and completion of a course of antibiotics is indicated if there is a clinical response, even if the cultures eventually turn out to be negative.2 in the face of a pandemic, the possibility of contact with infected patients (typical epidemiologic setting) is a very important element for defining the clinical syndrome. when a disease has a high, attack rate, a clinical diagnosis may provide a more sensitive approach than a lab test. further, in the context of resource poor countries, only select patients are tested by pcr. therefore, relying only on laboratory tests for a diagnosis of covid-19 will grossly underestimate the true disease prevalence and incidence. in view of this, it is reasonable to assume that every individual that meets the clinical case definition inclusion criteria is presumptively positive for covid-19 and to treat as such. this will provide a more sensitive approach and ensure that most of those who actually have the disease are detected and treated. such an approach will be in the best interests of both individual patients and the community as a whole. in the public health systems of countries like india, where access to lab tests is more difficult than access to an outpatient consultation, this approach would be easier to implement. while the who case definition3 is simple to use, it does not give adequate importance to fever which is the most common symptom4 and ignores smell and taste disturbances that appear to be unique to this viral illness.5 in the covid-19 clinical syndrome, fever is observed in > 95 % of individuals and selecting this symptom as a criterion will ensure that the clinical definition will have good sensitivity. sudden, otherwise unexplained loss of smell and taste5 occurs in about 34% of covid-19 patients and including this unique symptom will confer greater specificity for the clinical diagnosis. in the light of these arguments, we recommend that the clinical syndrome be defined using criteria as listed below: mandatory criterion: fever of three or more days duration without other obvious localizing symptoms such as dysuria, skin, or soft tissue infections major criteria: 1. dry cough 2. sudden recent onset loss of smell and or taste sensation (anosmia due to nasal block and sinusitis to be excluded) 3. physical findings of crepitations on chest auscultation 4. chest x ray showing peripheral patchy infiltrate (not lobar pneumonia or cavitating lesion) 5. respiratory rate > 25/minute minor criteria: 1. diarrhoea 2. severe headache, body aches (myalgia) 3. fatigue and lassitude 4. normal or low normal total wbc count and lymphopenia (lymphocytes < 20 % on differential count) 39 seshadri & john april 2020. christian journal for global health, 7(1) epidemiologic setting: (when there is community spread this criterion may not be useful): 1. travel within the past four weeks to or from any other country or a big crowded city in the country. 2. visit within the last four weeks to a crowded place such a bus stand, railway station, movie theatre, airport, place of worship, etc., without a mask and or without maintaining a physical distance of two meters 3. contact with a case of covid-19 at home or at work-place. the clinical syndrome can be presumed if, in the presence of the mandatory criterion (fever), the following criteria are met: 1. presence of one epidemiologic setting along with two major criteria or one major criterion and two minor criteria 2. even in the absence of the epidemiologic setting, the presence of three major criteria and two minor criteria or two major criteria and three minor criteria where available, a positive pcr lab test, in combination with the clinical syndrome criteria, offers confirmation of diagnosis while a negative pcr test does not necessarily negate the diagnosis due to less than optimal test sensitivity. in fact, pcr and ct thorax combined have higher sensitivity than either test alone for diagnosing serious covid-19 infection.6 therefore, in resource poor settings, we can consider two groups of subjects: a) those having the covid-19 clinical syndrome (large numbers) b) cases confirmed by pcr testing (smaller numbers) for those with the clinical syndrome, if feasible, nasopharyngeal swabs, or even throat swabs can be sent to a regional laboratory for confirmation. in endemic malarial zones, malaria should be excluded by a rapid test and peripheral smear. isolation and prevention of spread pending results, clinical management should be initiated as set out below: isolate affected subjects at home for a period of 21 days (three weeks). get a younger member of the family aged less than 45 to be the primary care-giver. a detailed isolation procedure at home, as spelt out below, has to be strictly followed to prevent within family spread. other family members, in particular, the elderly, those with diabetes, and cardiac disease should also home quarantine for four weeks (to allow for incubation period and duration of viral shedding) to prevent serious disease in them. younger family members can go out to get essential requirements but wear a mask when they do so and maintain a physical distance of two meters from others to prevent community spread. (see appendix a for our example of home isolation procedure). any member of any family that develops a fever, cough, and cold should not panic and go to hospital unless there is significant breathing difficulty. other respiratory viruses such as influenza (5-20 % of the population each year)7 and the common cold are highly prevalent and must be considered in the differential diagnosis. the hospital may be crowded with other sick patients who may have covid-19. it is essential that every household has simple medications such as paracetamol for fever and an antihistamine such as pheniramine or cetirizine which may minimize sneezing and limit nasal discharge. these supplies are better issued to individual households by the local civil administration and or by local nongovernmental agencies with instructions for use, so that crowding at hospitals and medical shops is avoided. the mobile phone number of an 40 seshadri & john april 2020. christian journal for global health, 7(1) individual in the family can be made available to the proximate primary or secondary level hospital so that the lab test reports, when they arrive, can be communicated. a designated mobile number at the health care facility can be provided to the family. the family can contact this number in the event of any worsening or questions. the follow up information can be recorded on spread-sheet. with the crowded living conditions in most middleand low-income households, these quarantine measures will prove to be major challenges; isolation may not be possible in poor households living in one or two rooms. the local administration needs to face this reality and design isolation facilities near home, such as a school building, if possible. the government and nongovernmental organisations (ngos) should ensure essential supplies to these quarantined families so that they can effectively practice what is recommended. treatment the antimalarial drugs, chloroquine and hydroxychloroquine (hcq), have shown some efficacy in in-vitro experiments. limited observational studies using hcq in infected subjects in france and china have been shown to reduce virus load and also hasten virus clearance from two weeks to six days.8,9 the proposed mechanisms of action of these drugs9, such as interference with adhesion of virus to cell surface receptor, inhibition of viral replication by increasing the ph in the endo-lysosomes, and an anti-inflammatory action (to reduce cytokine production and immunologically mediated inflammation), imply that the drugs may be of use early in the course of infection as well as in the delayed cytokine storm. 10 however, in the absence of controlled clinical trials in severe cases of covid-19 pneumonia, some suggest that these drugs should only be used in randomized controlled clinical trials.11 major clinical trials have just started, and the results will probably be available only after about 12 weeks by which time the pandemic may be waning. 12 physicians working in endemic malarial zones have good experience with these drugs. however, in non-endemic zones, hcq is commonly used for rheumatological disorders and for malaria prophylaxis in travellers. in new york and other hot spots for covid-19, physicians have started using these drugs on an empirical basis for treating severe covid-19 pneumonia. in countries such as india, adequate supplies of chloroquine and hcq are available, and the government and ngos can cope with the demands for these drugs during this pandemic without compromising supplies of the drug for patients with rheumatological disorders who need the drug. in rural settings, for reasons mentioned earlier, physicians may need to resort to syndromic diagnosis and institute empirical management protocols for sick patients, and if there is good clinical improvement, complete the course of hcq. perhaps based on the safety profile of once weekly doses of the drug in malaria prophylaxis, the relatively short duration of time for which chemoprophylaxis may be required, the suggested dosage schedules, which are similar to doses used for malaria (treatment and prophylaxis), and the potential for reduction of infectivity, the indian council of medical research (icmr) has recommended prophylaxis with hcq for frontline health care workers and household contacts of sars-cov-2 positive subjects.13 when a physician chooses to use hcq for either empirical treatment for covid-19 or chemo-prophylaxis as per government guidelines, due precautions are mandatory for the elderly, those with diabetes and cardiac disease, in whom dosing has to be modified to avert potential side effects of the drug. an outline of suggested empirical treatment, chemoprophylaxis, monitoring, and precautions is detailed below: 41 seshadri & john april 2020. christian journal for global health, 7(1) empirical hcq treatment (effective dose for treatment derived from pharmacokinetics-based computer assisted modelling)14 hydroxychloroquine 200 mg, 2 tablets, q12h (total 800 mg) on day 1 followed by 200 mg, 1 tablet, q12h (total 400 mg per day) for 4 more days. a. youngsters without any risk factors: monitor progress of clinical illness daily (over mobile phone). maintain a database on a spread-sheet, and avoid hcq in mild to moderately severe disease. b. avoid hcq in those with chronic renal or liver disease. c. in subjects with diabetes mellitus: • while on hcq, treatment, reduce dose of anti-diabetic drugs by 25 -30% in order to avert hypoglycaemia. • institute home monitoring or field monitoring of blood sugars by glucometer during hcq treatment. further dose adjustment of anti-diabetic drugs can be based on plasma glucose values • once the treatment course is finished, over the next 3-7 days get back to the previous stable dose of oral anti-diabetic drugs and or insulin d. those with cardiac disease on medication: look at the drug list, check for potential drug interactions, and make a considered decision in consultation with the attending cardiologist. baseline ecg (focus on corrected qt interval) and ecg on alternate days until course is over would be useful; however, this may necessitate hospital admission. monitor serum electrolytes and magnesium and correct hypokalaemia and hypomagnesemia when detected. zinc supplementation in vitro studies have shown that intracellular zinc, when present in sufficient concentration, inhibits viral replication and chloroquine acts as an ionophore, facilitating transport of zinc from extracellular to intracellular compartment. therefore, elemental zinc of 50 mg per day, orally, once daily can be co-prescribed with hcq.15,16 use of antibiotics in order to treat secondary bacterial infection which occurs in about 50 % of covid19 cases, azithromycin 500 mg, once daily, for 5 days or amoxicillin/potassium-clavulanate 625/125mg q12 hourly, for 5 days (common antibiotics used for treating community acquired pneumonia) may be added at the discretion of the treating physician based on a persistent fever > 38 degree celsius and productive cough persisting beyond 5 days. convalescent plasma for severely ill covid19 patients encouraging observational reports in small numbers of patients have aroused wide-spread interest in the use of convalescent plasma for severely ill covid-19 patients on ventilators.17. randomized controlled clinical trials have commenced with this treatment approach. in general, in viral illnesses antibody response is much brisker in those who have a clinical illness than in those with asymptomatic or subclinical illness.18 patients with clinically diagnosed covid-19 syndrome may be the ones with the highest titres of antibodies. utilising the syndromic approach may help identify potential plasma donors in resource poor settings. since those with the clinical syndrome will be the larger number than those with pcr-proven sars-cov2 infection, a physician can select willing individuals who have recovered from the clinical syndrome for checking on antibody titres prior to plasmapheresis and, thus, reduce costs. 42 seshadri & john april 2020. christian journal for global health, 7(1) preventive treatment house-hold contacts of the subject with clinical diagnosis of covid 19 syndrome (during the lock down period in india, household members will predominate), those working or interacting closely with the index case in the workplace (such as grocery store, post office, bank, etc. ) and those in migrant groups amongst whom one individual has been presumptively diagnosed to have covid-19 clinical syndrome or confirmed to have covid-19 by pcr will be the contacts. regimen for household and other contacts (as per icmr advisory13): hcq 200 mg, 2 tabs, twice daily (800 mg per day) for day 1 followed by 200 mg, 2 tabs, once a week (400 mg per week) for the next several weeks preventive treatment for contacts starts as soon as the clinical case is diagnosed. if not, it can be started any time up to day 14 of presumptive diagnosis in the index patient. long-term side effects, like retinopathy, are dose and duration dependent and are unlikely during these short-term treatment protocols. conclusion protocols by the kerala, tamil nadu, maharashtra state governments, and the guidelines from the all india institute of medical sciences, new delhi, adequately cover management of confirmed cases. we highlight the need to address the clinical covid-19 syndrome, where pcr testing may not be performed because of the restrictive selection criteria for pcr testing or lack of availability. for such a syndromic approach to be effective would require a quick nation-wide implementation during the shelter or lock-down period. governments and ngos in other middleand low-income countries involved in responding to the health care challenge posed by covid-19 should consider implementing the syndromic approach. they should mobilize material and human resources and medication to do this quickly through their networks of healthcare professionals. we note the use of hcq has not yet been established in clinical trials and in the results of the multinational and multi-centric clinical trial “solidarity”12 will probably not be available until after the pandemic. we should be closely monitoring the latest evidence for hcq, but in the absence of data from controlled clinical trials and given the expected burden of mortality from covid 19, the treatment of the clinical syndrome and use of chemoprophylaxis for contacts of the presumed covid-19 syndrome (rather than only confirmed cases and their contacts) seems important in countries and settings with resource constraints. references 1. patel r, babady e, theel es, storch ga, pinsky ba, st. george k, et al. report from the american society for microbiology covid-19 international summit, 23 march 2020: value of diagnostic testing for sars-cov-2/covid-19. 2020. mbio 11:e00722-20. available from: https://doi.org/10.1128/mbio.00722-20 2. hotchkiss rs, moldawer ll, opal sm, reinhart k, turnbull ir, vincent j-l. sepsis and septic shock. nat rev dis primers. 2017;2:16045. https://doi.org/10.1038/nrdp.2016.45 3. world health organization. health topics: coronavirus [internet]. available from: https://www.who.int/healthtopics/coronavirus#tab=tab_3 4. wang d, hu b, hu c, zhu f, liu x, zhang j,wet al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in wuhan, china. jama. 2020. 323:1061-69. https://doi.org/10.1001/jama.2020.1585 5. giacomelli a, pezzati l, conti f, bernacchia d, siano m, oreni l, et al. self-reported olfactory and taste disorders in sars-cov-2 patients: a cross-sectional study. clinical infectious diseases. 2020 mar 26;ciaa330. https://doi.org/10.1093/cid/ciaa330 https://doi.org/10.1128/mbio.00722-20 https://doi.org/10.1038/nrdp.2016.45 https://www.who.int/health-topics/coronavirus#tab=tab_3 https://www.who.int/health-topics/coronavirus#tab=tab_3 https://doi.org/10.1001/jama.2020.1585 https://doi.org/10.1093/cid/ciaa330 43 seshadri & john april 2020. christian journal for global health, 7(1) 6. ren x, liu yan, chen, h, liu w, guo z, zhang y, et al. application and optimization of rt-pcr in diagnosis of sars-cov-2 infection. preprints with the lancet. 2020 mar 3. https://doi.org/10.2139/ssrn.3546086 7. thomas j. the flu: facts, statistics, and you [internet]. healthline. 2018 nov 19. available from: https://www.healthline.com/health/influenza/facts -and-statistics#1 8. gautret p, lagier jc, parola p, hoang vt, meddeb l, mailhe m, doudier b, et al. hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial. int j antimicrob agents, 2020 mar 20:105949. 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from: https://www.who.int/emergencies/diseases/novelcoronavirus-2019/global-research-on-novelcoronavirus-2019-ncov/solidarity-clinical-trialfor-covid-19-treatments 13. indian council of medical research, national task force for covid-19. advisory on the use of hydroxyl-chloroquine as prophylaxis for sarscov-2 infection [internet]. available from: https://www.mohfw.gov.in/pdf/advisoryontheuse ofhydroxychloroquinasprophylaxisforsarscov 2infection.pdf 14. yao x, ye f, zhang m, cui c, huang b, niu p, et al. in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2). clinical infectious diseases. 2020 mar 9;ciaa237. https://doi.org/10.1093/cid/ciaa237 15. aartjan jw, te velthuis ajw, van den worm she, sims ac, baric rs, snijder ej, et al. zn2+ inhibits coronavirus and arterivirus rna polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture. plos pathogens. 2020 nov. https://doi.org/10.1371/journal.ppat.1001176 16. jing xue j, moyer a, peng b, wu j, hannafon bn, ding w-q. chloroquine is a zinc ionophore. plos one 9(10): e109180. https://doi.org/10.1371/journal.pone.0109180 17. duan k, liu b, li c, zhang h, yu t, qu j,et al. effectiveness of convalescent plasma therapy in severe covid-19 patients. pnas. 2020 apr 6. https://doi.org/10.1073/pnas.2004168117 18. ganem d, prince am. hepatitis b virus infection: natural history and clinical consequences. n engl j med. 2004;350:1118-29. https://doi.org/10.1056/nejmra031087 peer reviewed: submitted 3 apr 2020; accepted 21 apr 2020; published 27 apr 2020 competing interests: none declared. acknowledgements: thirumalai mission hospital, ranipet, india. correspondence: dr. seshadri, india. mandalam.seshadri@gmail.com https://doi.org/10.2139/ssrn.3546086 https://www.healthline.com/health/influenza/facts-and-statistics#1 https://www.healthline.com/health/influenza/facts-and-statistics#1 https://doi.org/10.1016/j.ijantimicag.2020.105949 https://doi.org/10.1016/j.dsx.2020.03.011 https://doi.org/10.1016/s1473-3099(03)00806-5 https://doi.org/10.7326/m20-1334 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments https://www.mohfw.gov.in/pdf/advisoryontheuseofhydroxychloroquinasprophylaxisforsarscov2infection.pdf https://www.mohfw.gov.in/pdf/advisoryontheuseofhydroxychloroquinasprophylaxisforsarscov2infection.pdf https://www.mohfw.gov.in/pdf/advisoryontheuseofhydroxychloroquinasprophylaxisforsarscov2infection.pdf https://doi.org/10.1093/cid/ciaa237 https://doi.org/10.1371/journal.ppat.1001176 https://doi.org/10.1371/journal.pone.0109180 https://doi.org/10.1073/pnas.2004168117 mailto:mandalam.seshadri@gmail.com 44 seshadri & john april 2020. christian journal for global health, 7(1) cite this article as: seshadri ms, john tj. the covid-19 pandemic: defining the clinical syndrome and describing an empirical response. christian journal for global health. april 2020;7(1):37-44. https://doi.org/10.15566/cjgh.v7i1.365 © authors this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ appendix a: home isolation procedure (from thirumalai mission hospital) the clinically diagnosed covid-19 patient should wear a mask, wear full sleeves, and cough or sneeze only into a disposable tissue or into the crook of the elbow and not into the hand. he should be in a wellventilated single room preferably with an attached bathroom, not shared with others. where there is a need to share a bathroom, the surfaces that the patient has touched should be cleaned with dilute bleach or soap and water and mopped dry after use by the affected person. the patient’s toilet kit (tooth-brush, shaving kit, etc.) should be kept separate and other house-hold members avoid coming in contact with these items of personal use. the patient’s clothes should be washed thoroughly with soap and water daily, dried, and kept separate for him/her to re-use. bed linen should be similarly washed and dried at least once in 3 days and kept separate. if the patient is using a mobile phone, it should not be shared with others and the surface wiped clean carefully with tissue moistened with hand sanitizer 3-4 times per day. other family members also use a mask all the time at home and maintain a physical distance of two meters from the patient, avoiding physical contact such as shaking hands, patting on the back, hugging, etc. the household members should avoid visiting others and not allow visitors until the quarantine period is over. communication with others outside the family should be by phone or messages (sms). if there are people above age 65 in the household, ensure that they follow all the precautions that have been advised for the affected patient. only younger unaffected members of the family (age <45) should go out for buying provisions, wearing a mask when going out to shops, maintaining the critical physical distance of two meters from other people on the road and in the shop, and avoiding standing in groups to talk. children in the house can play indoor games with other family members, read, paint, and listen to or play music for pastime. children should also wear masks and maintain a physical distance of 2 meters from the affected individual. every member of the household should practice frequent and thorough hand washing with soap and water after they come in contact with door knobs, lift buttons, and other potentially contaminated surfaces. if there is a care-taker for the elderly, it is the responsibility of the residents of the house to instruct the care-taker to wear a mask all the time, to use a pair of gloves while working, to sanitize gloves at the end of the work, to practice thorough hand washing with soap and water after they have finished their work and before they help elders, to avoid unnecessarily hanging around in common areas, and to abstain from work for 3 weeks if the care taker or his or her family member has a febrile illness. it is important that care-takers are paid their wages when they or their family members fall sick. https://doi.org/10.15566/cjgh.v7i1.365 http://creativecommons.org/licenses/by/4.0/ references lettter to the editor april 2020. christian journal for global health, 7(1) revised clinical criteria for covid-19 clinical syndrome mandalam s. seshadria , t. jacob johnb a md, phd, frcp, former professor of medicine & endocrinology, department of endocrinology diabetes & metabolism, christian medical college & hospital, vellore; consultant physician & endocrinologist, honorary medical director, thirumalai mission hospital, vanapadi road, ranipet, india b phd (virology), frcp (paediatrics), former professor& head, department of clinical virology, christian medical college & hospital, vellore, india we had recently published clinical criteria for diagnosing covid 19 syndrome1 in lowand middle-income countries. since then, community transmission has become wide-spread in many countries. therefore, the epidemiologic setting has become less relevant, and it should be assumed that everyone is exposed. further some additional common ocular and cutaneous features have been described.2,3 elderly subjects and those with comorbidity may have a different clinical presentation,4 requiring modification of criteria. based on these arguments, we have revised the clinical criteria for diagnosing covid 19 syndrome as set out below. revised diagnostic criteria the following criteria are applicable for otherwise healthy young adults and middle-aged subjects. in other categories of adults (elders and those with co-morbidity), these criteria may be present; frequently, they are not present. they may need fewer and different criteria (lower threshold) for diagnosis. paediatric covid 19 diagnostic criteria are not included. major criteria: group a 1) fever ≥ 3 days 2) persistent dry cough 3) sudden onset loss of smell with or without loss of taste group b 4) on chest auscultation, crepitations 5) resting respiratory rate of ≥25 per minute 6) pulse oximeter showing oxygen saturation ≤ 94 % on room air group c 7) ct scan or chest x ray showing patchy peripheral infiltrates or bilateral ground glass appearance, without lobar consolidation or cavitary lesion minor criteria: 1. headache/body aches/myalgia 2. severe fatigue/lassitude 3. diarrhea 4. conjunctival irritation — pink eye with or without secretions 5. skin lesions — maculopapular erythematous, urticarial or vesicular nonpruritic 6. wbc count: normal or low normal total count; but lymphocytes ≤20% diagnosis using the above criteria: either: three major criteria, if they include at least one each from group a, group b, and group c. or: in the absence of, or non-availability of, chest imaging criterion (group c), at least two major 62 seshadri & john april 2020. christian journal for global health, 7(1) criteria from group a, at least one major criterion from group b, and at least two minor criteria clinical features of covid-19 may be altered and may be subtle, in: 1. elderly, age > 70 years 2. immunosuppressed individuals 3. poorly controlled diabetics 4. cardiovascular disease with or without cardiac failure 5. chronic renal failure on, or not on, dialysis 6. those on corticosteroids and/or other immune-suppressants these subjects may have any of the clinical features listed under major or minor criteria or may have only subtle features of low-grade fever, delirium, postural instability, and drowsiness. if any of these subtle features occurs, it is mandatory to do pulse oximetry (major no. 6) and a chest ct scan or x ray (major no.7) and if either is positive, to assume the diagnosis of covid-19 and initiate treatment in a hospital. references 1. seshadri m, john tj. the covid-19 pandemic: defining the clinical syndrome and describing an empirical response. christ j global health. 2020 apr;7(1):37-44. https://dx.doi.org/10.15566/cjgh.v7i1.365 2. wu p, duan f, luo c, liu q, qu x, liang l, et al. characteristics of ocular findings of patients with coronavirus disease 2019 (covid-19) in hubei province, china. jama ophthalmol. 2020 [cited 2020 aug 6];138(5):575–8. http://dx.doi.org/10.1001/jamaophthalmol.2020.1 291 3. recalcati s. cutaneous manifestations in covid19: a first perspective. j eur acad dermatol venereol. 2020 may [cited 2020 aug 6]; 34(5):e212-3. http://dx.doi.org/10.1111/jdv.16387 accessed on 08-06-2020 4. lithander fe, neumann s, tenison e. covid-19 in older people: a rapid clinical review. age ageing. 2020 [cited 2020 aug 6];1–15. http://dx.doi.org/10.1093/ageing/afaa093 submitted 9 june 2020; accepted 20 july 2020; published 9 nov 2020 competing interests: none declared. acknowledgements: thirumalai mission hospital, ranipet, india. correspondence: dr. seshadri, india. mandalam.seshadri@gmail.com cite this article as: seshadri ms, john tj. revised clinical criteria for covid-19 clinical syndrome. christ j glob health. october 2020;7(4):61-62. https://doi.org/10.15566/cjgh.v7i4.401 © authors this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://dx.doi.org/10.15566/cjgh.v7i1.365 http://dx.doi.org/10.1001/jamaophthalmol.2020.1291 http://dx.doi.org/10.1001/jamaophthalmol.2020.1291 http://dx.doi.org/10.1111/jdv.16387%20accessed%20on%2008-06-2020 http://dx.doi.org/10.1111/jdv.16387%20accessed%20on%2008-06-2020 http://dx.doi.org/10.1093/ageing/afaa093 mailto:mandalam.seshadri@gmail.com https://doi.org/10.15566/cjgh.v7i4.401 http://creativecommons.org/licenses/by/4.0/ references review article nov 2014. christian journal for global health, 1(2):63-70. working together for global health goals: the united states agency for international development and faith-based organizations clydette l powell a a md, mph, medical officer, united states agency for international development; associate professor of pediatrics (neurology), the george washington university school of medicine and health sciences, washington, dc abstract for many years, and before the term “fbo” was used for faith-based organizations, the united states agency for international development (usaid) has supported the work of fbos in global health and development. the agency has long recognized the impact of fbos within that development space, because these organizations are often well positioned to reach the hard-to-reach and to go the last mile because of their strong ties to the community. moreover, fbos deliver a substantial percentage of the health services in some developing countries. faith partners, whether catholic, protestant, buddhist, hindu, muslim, or other, have an important role to play as implementers in global health and to support global efforts towards achieving the millennium development goals (mdgs) in health. in addition, partnerships at national and international levels are key to the success of us presidential initiatives in the developing world, such as president’s emergency plan for aids relief (pepfar) and president’s malaria initiative (pmi). fbos also have an important voice in policy and strategy formulation. among other international donors, usaid support has been of great importance to the work of fbos, thereby helping host nations to achieve goals in ending preventable child and maternal deaths, improving communicable disease control and prevention, and by supporting the construction and renovation of hospitals and health facilities where service delivery is most needed. the development literature is replete with examples of the work of fbos made possible through access to resources. this paper focuses on some of the work supported by usaid in global health initiatives in order to reach complementary goals and achieve significant public health advances. given the vastness of the topic, not all the global health initiatives involving fbos supported by usaid are included here; the reader is encouraged to access the usaid website and usaid implementing partners for further information. introduction collaboration with faith-based organizations (fbo) has been integral to the work of the united states agency for international development (usaid) for more than fifty years. within the health sector, this partnership spans both time and geography to serve the health needs of vulnerable populations and communities in the developing world. faith leaders and faith organizations are 64 powell nov 2014. christian journal for global health, 1(2):63-70. closely linked with the communities they serve culturally, spiritually, and physically. they often represent and are composed of trusted individuals whose lives, beliefs, and cultural values are aligned with their beneficiaries. they know intimately the networks – both formal and informal – as well as the opinion leaders, the history, the behaviors, and the practices which have strengthened or weakened the communities they seek to serve. they are often rich in experience and knowledge, but may be lacking in sufficient resources to do their work. they are mobile and adept but may not be able to wield the necessary influence for change at the upper echelons of a ministry of health, which can be far removed from the details of community life and common people’s struggles. therefore, the partnership of a large donor with fbos as implementers can be a significant advantage to mutual goals and objectives. the development literature is replete with examples of the work of fbos made possible through access to resources. this paper focuses on some of the work supported by usaid in global health initiatives in order to reach complementary goals and achieve significant public health advances. given the vastness of the topic, not all the global health initiatives involving fbos supported by usaid are included here; the reader is encouraged to access the usaid website and usaid implementing partners for further information. 1 usaid’s overall approach to fbos in the selection of its partners, usaid neither discriminates for or against organizations based on their faith-based character or affiliation. 2 however, usaid regularly partners and works with fbos and religious leaders, and those partnerships are, in fact, key to the agency’s work. 3 many such organizations are among usaid's largest implementing partners. 4 in 2002, to coordinate outreach to, and engagement with, the broad range of faith and community organizations and to ensure a level playing field for these organizations, the center for faith based and community initiatives (cfbci) at usaid was established by a presidential executive order. 5,6 as with the bureau for global health (bgh), the cfbci supports engagement with the faith-based community through published evidence and case examples, and mutual learning among usaid’s bureaus and field missions. under usaid forward, an agencywide initiative for better management and business practices, the cfbci opened up new ways to partner with faith-based organizations on the ground, including innovative business models headed by business leaders who are faithaffiliated. 7 even before the establishment of cfbci, christian connections for international health (ccih) had engaged in development dialog with usaid. over the years, ccih has represented its member organizations by raising the visibility and voice of fbos working in global health, thereby reflecting the unique quality that faith can bring to addressing development challenges. 8 . . usaid’s global health engagement with fbos usaid’s engagement in global health with fbos takes many forms. the agency aims to make progress towards the millennium development goals (mdg) 4 and 5, to save children’s lives and to improve the health and welfare of mothers and families. it works to mitigate the impact of malaria and of hiv/aids on families, orphans, and vulnerable children. it helps to support the reconstruction and rehabilitation of schools and hospitals abroad, thereby improving access and quality of health services to remote or marginalized populations. usaid also has less structured interaction, for example with us churches, as well as the music/arts community. 9, 10 child survival since 1985, the child survival and health grants program (cshgp) has evolved to address the major strategic needs of usaid, national 65 powell nov 2014. christian journal for global health, 1(2):63-70. governments, and vulnerable communities. of the 457 projects supported through the cshgp since 1985, approximately 30% have been awarded to fbos and have strengthened their technical capacity and leadership role in global health. 11 in june 2012, usaid hosted the child survival call to action with the governments of ethiopia, india, and the us, in conjunction with unicef. leading up to that summit, the white house office of faith based and neighborhood partnerships, along with usaid’s bgh and cfbci, organized a conference call with over 150 faith leaders on usaid’s efforts on child survival and urged their support for this work. in october 2013, usaid co-sponsored an all-day meeting with over 500 fbos and leaders to launch the lifesaving pledge, “ten promises to our children”. 12 more than 290 faith leaders and 90 fbos from over 50 countries signed the pledge – a pledge that will reach more than 260 million people. women’s health usaid’s office of population and reproductive health (prh) within the bureau for global health has a long history of support for and collaboration with catholic, protestant, and muslim fbos to expand family planning (fp) options to underserved populations. one such example is usaid’s support to georgetown university’s institute for reproductive health (irh) through the fertility awareness-based methods (fam) project. 13, 14 fertility awarenessbased methods are favored by some fbos promoting natural fp (nfp). 15 in the democratic republic of congo, 16 honduras, 17 and india, 18 collaboration has led to nfp acceptance and promotion by religious leaders. 19 in 2011 usaid began collaborating with the organization of islamic conferences (oic) to promote advocacy, training, and community services in maternal and child health (mch), as well as to revise national mch strategies, e.g., in bangladesh and mali. 20, 21 hiv/aids created under the u.s. president’s emergency plan for aids relief (pepfar), and launched in 2005, the new partners initiative (npi) was pepfar’s signature effort to help new and diverse partners build their capacity to fight hiv/aids at the local level in pepfar focus countries. 22 through npi, usaid supported 14 fbos and more than 60 sub-grantees to provide services to orphans and vulnerable children (ovcs) in eight countries. 23 in cambodia, usaid funding to the khmer hiv/aids ngo alliance facilitates some fbos to implement the hiv home and community based care as part of its response to hiv/aids in cambodia. within this alliance, the salvation centre cambodia, 24 buddhism for development, 25 and buddhism for social development action 26 work with teams of buddhist monks, nun trainers, and field volunteers to implement hiv/aids prevention and care activities, improve living conditions of people living with hiv/aids and ovcs, and reduce hiv transmission, deaths, and discrimination. in zambia, the steps ovc project provides standardized and sustainable hiv prevention, care, and support services, through seven fbos. 27, 28 in namibia, the church alliance for orphans (cafo) mobilizes community-based responses to the needs of ovc as part of the pepfar partnership framework. 29 malaria control and prevention partnerships at national and international levels are key to the success of the president’s malaria initiative (pmi). pmi’s investments are strategically targeted to support each focus country’s malaria control strategy and plan and coordinate with many international, national, and local partners, including fbos working in underserved, rural areas where malaria is a major public health problem and where formal health services may be limited. 30 by the end of 2013, pmi had supported 66 powell nov 2014. christian journal for global health, 1(2):63-70. malaria activities through more than 200 local and international nonprofit organizations in all pmi focus countries, approximately one-third of which are fbos. some country examples include social and behavioral changes in mozambique, 31 rapid diagnostic testing in madagascar, 32 extensive insecticide-treated nets (itn) distribution campaigns in ghana, 33 collaboration with koranic schoolmasters in senegal, 34 and a national voucher scheme in tanzania. 35 pharmaceutical systems formed in 1981, the ecumenical pharmaceutical network (epn) is a faith-based organization in africa that supports its constituency with equitable and compassionate quality pharmaceutical services. epn has a constituency of more than 80 anglophone and francophone members from over 30 countries. usaid’s technical support to epn has strengthened the procurement function of its member drug supply organizations, promoted good governance and operations efficiency, and helped to contain antimicrobial resistance. in addition, epn is a resource partner on the usaidfunded systems for improved access to pharmaceuticals and services program and serves as a liaison to usaid field missions in developing countries. 36 health facility construction and renovation usaid’s american schools and hospitals abroad (asha) program provides assistance to secondary schools, universities, libraries, and medical centers outside the us that serve as study and demonstration centers for american ideas and practices. asha awards support construction, renovation, and the procurement of scientific, medical, and educational equipment. since asha’s inception in 1947, usaid has assisted more than 250 institutions in over 70 countries and currently manages a worldwide portfolio of over 100 awards. many of the partners asha works with are faith-based, since missionaries established numerous hospitals and schools in the nascent years of american foreign aid. prime examples include the christian medical college and hospital, in vellore, india and cure international’s network in ethiopia, afghanistan, zambia, uganda and the philippines. 37, 38 conclusion for many years, and before the term “fbo” was defined, usaid has supported the work of fbos in global health and development. the agency has long recognized the impact that fbos have within that development space, because these organizations are often well positioned to reach the hard-to-reach and to go the last mile because of their strong ties to the community. moreover, fbos deliver a substantial percentage of the health services in some developing countries. faith partners, whether catholic, protestant, buddhist, hindu, muslim, or other, have an important role to play as implementers in global health and to support global efforts towards achieving mdgs in health. in addition, partnerships at national and international levels are key to the success of us presidential initiatives in the developing world, such as pepfar and pmi. fbos also have an important voice in policy and strategy formulation. among other international donors, usaid support has been of great importance to the work of fbos, thereby helping host nations to achieve goals in ending preventable child and maternal deaths, improving communicable diseases control and prevention, and supporting the construction and renovation of hospitals and health facilities where service delivery is most needed. references and endnotes 1. http://www.usaid.gov/what-we-do/global-health 2. usaid also does not track funding in this way. the laws governing its work do not permit usaid to http://www.usaid.gov/what-we-do/global-health 67 powell nov 2014. christian journal for global health, 1(2):63-70. track data on whether an organization is “faith-based”, as such organizations are exempt from reporting that fact during the registration process. 3. http://www.usaid.gov/work-usaid/partnershipopportunities/faith-based-communityorganizations/faith-based-organizations 4. catholic relief services (crs) and world vision are among usaid's top 20 implementing partners, receiving hundreds of millions of dollars per annum. in addition, over a third of the american schools and hospital abroad grantees for the past few years have been faith-based or faith-inspired organizations. 5. current priorities of the cfbci include key us government (usg) and usaid initiatives, such as child survival and maternal health, counter-trafficking in persons, food aid reform, and the interagency strategy for global faith leader engagement. in addition, cfbci seeks to leverage faith and community ties to secure increased support for usaid from congress and to support the agency administrator’s actions on key initiatives and priorities to advance the mdgs. 6. as an independent office within the usaid administrator’s office, cfbci is a part of the network of 13 faith-based centers within federal departments and agencies coordinated by the white house office of faith-based and neighborhood partnerships. 7. for example, in 2012, usaid rwanda signed grants with three civil society organizations (caritas rwanda, african evangelistic enterprise rwanda, and fxb rwanda), two of which are faith based. at usaid's local capacity development summit in 2012, catholic relief services (crs) shared how they work to develop capacity of local organizations. another example is a business franchise model, represented by an integrated platform in the democratic republic of congo, and designed to save lives through health care, nutrition, and clean water. with an $800,000 grant to support development of the model and proof of concept, asili is backed by a consortium of non-profits and businesses led by the american refugee committee. it will be open for business in 2014. many of those involved are faith-affiliated business leaders. 8. in a forward thinking way, ccih took the step of entering into the sensitive area of family planning around 2006. it received grants from the usaid’s flex fund and worked with usaid to obtain flex funding for other member organizations. over the years, usaid assistant administrators and staff have been invited to speak at ccih annual conferences, and former usaid staff have served on ccih’s board. the executive director (ed) of ccih had been a usaid foreign service office for 25 years before his service at ccih; he served as ccih’s first ed for 14 years. 9. usaid staff has been working with saddleback church in southern california in two areas: (1) saddleback's development and deployment of over 6,500 community health volunteers (peace servants) in rwanda; and (2) the saddleback orphan care initiative. the saddleback orphan initiative provided ongoing guidance and support to the development of the u.s. government plan of action on children in adversity which was launched in december 2012. 10. grammy award winning band jars of clay, which also founded the ngo, blood:water mission, to address needs in africa around water and aids, endorsed the usg's global water strategy and provided a video in support of its launch from their tour in europe. in march of 2014, jars members met with staff at usaid's washington offices to discuss their efforts and hear of usaid's current work on water and aids. they promoted the visit to their fans via social media. jars' facebook following is over 500,000 individuals, and their twitter following is close to 100,000. 11. the cshgp’s current active portfolio leverages the leadership of four fbos in six countries through five innovative projects by catholic relief services, world renew (formerly christian reformed world relief committee), world relief, and world vision. 12. these focused on actions that parents and communities could do, such as making sure young children were vaccinated, that they slept under bed nets, that they received timely health services, and that children were taught to wash their hands. 13. http://irh.org/resource-library/faith-basedorganizations-as-partners-in-family-planning-workinghttp://www.usaid.gov/work-usaid/partnership-opportunities/faith-based-community-organizations/faith-based-organizations http://www.usaid.gov/work-usaid/partnership-opportunities/faith-based-community-organizations/faith-based-organizations http://www.usaid.gov/work-usaid/partnership-opportunities/faith-based-community-organizations/faith-based-organizations http://irh.org/resource-library/faith-based-organizations-as-partners-in-family-planning-working-together-to-improve-family-well-being/ http://irh.org/resource-library/faith-based-organizations-as-partners-in-family-planning-working-together-to-improve-family-well-being/ 68 powell nov 2014. christian journal for global health, 1(2):63-70. together-to-improve-family-well-being/ from the institute for reproductive health, georgetown university, august 2011 14. http://irh.org/projects/fam_project/ 15. standard days method, twodaymethod, and lactational amenorrhea method. other fam includes billings method and the sympto-thermal method. 16. irh’s collaboration with mamans an’sar, a group of muslim women, led to endorsement of nfp by muslim religious leaders. similar collaborative work was done by conduite de la fecondite, a catholic ngo in drc. 17. in honduras, a catholic-based organization now serves as a national resource on nfp to the ministry of health. 18. in india, world vision integrates nfp into their child survival and birth spacing projects. the catholic bishops conference of india oversees the country’s catholic health facilities, which account for nearly onequarter of health facilities in india, serving rural, hardto-reach areas. collaboration with irh led to advocacy, training, and development of educational materials on nfp. 19. in similar fashion, irh work in kenya, rwanda, mali, and timor-leste has led to sensitization of catholic, protestant, and muslim leaders with regard to nfp. 20. collaboration between the oic, usaid, and the ministry of health and family welfare (mohfw) in bangladesh led to revision of the national maternal health strategy. unicef, who and usaid’s mchip program provided the necessary financial, technical and coordination support that facilitated a national participatory and consultative process that involved more than 100 professionals from government, un, ngos, fbos, and other stakeholders. 21. in mali, a joint usaid-oic communication initiative resulted in religious leaders’ support for postpartum family planning (ppfp) and healthy timing and spacing of pregnancy. additionally, usaid’s health policy project strengthened the capacity and support of religious leaders at national and district levels for ppfp. nearly 200 islamic leaders were also trained on advocacy tools regarding malaria, pregnancy, and hiv/aids. with the support of religious leaders, women’s groups and messages through local radio stations mobilized women on reproductive health issues for family well-being. 22. the npi selected ngos and fbos which were capable of reaching people who needed hiv/aids services but who lacked the experience in working with the usg. 23. the partners served more than 200,000 ovc between 2007 and 2012 and received technical and organizational capacity-building not only to improve services, but also to provide services over the long term. currently usaid serves over 3 million children and their families through thousands of local and international faith-based partners throughout the world. 24. scc has helped more than 400 poor families with its services, along with 700 plhiv and more than 2,000 ovc. 25. buddhism for development (bfd) has achieved significant milestones since 1992 in collaboration with their field-based monks and nuns. 26. since 2005, buddhism for social development action (bsda) provides integrated hiv prevention and hcbc, education and vocational training for ovc; and community and democracy development. bsda is currently providing hiv/aids care, support, and counseling to over 600 plhiv and more than 600 ovc. 27. steps is a three-year usaid-funded grant. by 2012, steps ovc scaled up quality, comprehensive care, and support to 320,000 ovc. 28. these included catholic relief services, expanded church response, and salvation army. by 2012, steps ovc scaled up quality, comprehensive care and support to 320,000 ovc. world vision international was the lead partner. 29. cafo targets ovc and their caregivers in 12 regions in namibia. an indigenous civil society http://irh.org/resource-library/faith-based-organizations-as-partners-in-family-planning-working-together-to-improve-family-well-being/ http://irh.org/projects/fam_project/ 69 powell nov 2014. christian journal for global health, 1(2):63-70. organization of over 500 member congregations, and formed as an inter-denominational umbrella organization, cafo promotes local action by church congregations and communities to mitigate the impact of hiv on children. 30. pmi support is improving community-level access to critical malaria prevention and treatment services while also building local capacity and ensuring program sustainability. 31. starting in 2007, pmi has provided support to improve the organizational and management capacity of an interfaith network in mozambique, the programa inter-religioso contra a malaria (pircom). pmi’s technical assistance to pircom for a social behavior change and communication program ensured that in four provinces 95 % of the population received key messages on malaria prevention, diagnosis, and treatment. during fy 2012, pircom trained more than 6,000 religious leaders on key malaria messages. these religious leaders in turn have reached approximately 100,000 people in 35 districts. 32. pmi supported madagascar’s ngos and fbos in their implementation of the national strategic plan for malaria control. moreover, these groups introduced and expanded malaria case management, including rapid diagnostic testing and supply chain management, in health facilities operated by local ngos and fbos in all 22 of the country’s regions. a formal agreement was established in which organizations agreed to provide rapid diagnostic tests (rdts) free-of-charge to patients and to report cases in exchange for a supply of rdts procured by pmi. this support occurred after madagascar’s coup d’etat in 2009. 33. in 2010, under the leadership of ghana’s national malaria control program, pmi partnered with malaria no more, comic relief, unicef, who, nets for life, the anglican diocesan development and relief organization, and others to launch the first in a series of long-lasting insecticide-treated nets (itn) distribution campaigns designed to reach every region in ghana. pmi’s contribution included providing more than 950,000 long-lasting itns, logistics support, training, technical assistance, and post-campaign evaluation. through diligent door-to door work in 2010, some 10,000 volunteers distributed and hung more than 560,000 long-lasting itns to cover children under five and pregnant women. as a result, household ownership of at least one itn increased from 28% in 2008 to 82% in 2010, itn use among children under five years old increased from 11% to 52%, and itn use among pregnant women increased from 7 to 39%. 34. pmi works with koranic schoolmasters to extend community-based treatment for malaria to vulnerable populations. 35. pmi supports the distribution of itns through the tanzania national voucher scheme in partnership with the fbo mennonite economic development associates. sources: 6th, 7th, and 8th pmi annual reports, usaid 36. epn’s role also includes coordination and networking, development and provision of technical assistance on pharmaceutical policy and services, human resources capacity development, and consumer/patient education related to pharmaceutical management and medicines use. 37. founded in 1900 by an american missionary, cmc vellore has served more than 23 million patients, and enrolls nearly 2,000 students annually. cmc vellore is one of best hospitals and one of the top ranked medical colleges in india. asha funding to vellore helped to procure equipment to improve the hospital’s efficiency and quality of care, including an electronic medical record system and a new library for the college of nursing. over the last decade asha has provided cmc vellore with more than $2 million dollars. 38. cure international is a network of charitable hospitals and surgical programs which deliver medical care and christian values to children and families. since 1998, cure has helped more than 2 million patients, performed over 167,000 surgeries, and trained over 7,200 medical professionals in more than 30 countries. over the last five years, asha has worked with cure to procure medical equipment, build and renovate hospitals in ethiopia, afghanistan, zambia, uganda and the philippines. most recently, asha provided cure with $379,000 to procure commodities to support surgical services and training at tebow cure hospital in davao, philippines. 70 powell nov 2014. christian journal for global health, 1(2):63-70. disclaimer: the author’s views expressed in this article do not necessarily reflect the views of usaid or the us government. peer reviewed competing interests: none declared. acknowledgments: staff at usaid, as well as ccih, contributed information and case examples. special thanks to usaid’s victoria graham for encouragement to write this article, and for her long-standing leadership and support to fbos. jeffrey spieler generously served as a reviewer prior to formal peer review. correspondence: clydette powell. usaid. cpowell@usaid.gov cite this article as: powell cl. working together for global health goals: the united states agency for international development and faith-based organizations. christian journal for global health (nov2014), 1(2):6370. http://dx.doi.org/10.15566/cjgh.v1i2.36 © powell cl. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:cpowell@usaid.gov http://dx.doi.org/10.15566/cjgh.v1i2.36 http://creativecommons.org/licenses/by/3.0/ capacity building nov 2020. christian journal for global health 7(4) low cost training during lockdown: homemade training for gas insufflation less laparoscopic surgeries jesudian gnanaraja a mbbs, ms, mch (urology), fics, fiages, farsi (rural surgery), director of medical services, surgical services initiative, association of rural surgery, india abstract: given the covid-19 global pandemic, there are severe restrictions on travel in india and other countries. the indian government has issued an advisory for postponing nonessential or elective surgeries. surgeons, especially those working in rural areas, have more time at hand to learn new skills. unfortunately, due to the lockdown, purchasing new equipment has been difficult. we describe how fellowship of laparoscopic surgery course skills for gas insufflation less laparoscopic surgeries could be practised at home with easily available materials to make use of the time and build surgical skill capacity. key words: low cost simulator, gas less laparoscopic surgery, fls tasks introduction corona virus disease 2019 (covid-19) is a global pandemic and has brought in severe restrictions on travel in india and other countries.1 the indian government has also issued an advisory for postponing non-essential or elective surgeries.2 this essentially means that surgeons, especially those working in rural areas, have a lot of time at hand. it has been a good time to learn new skills. unfortunately, due to the lockdown, purchasing new equipment has been difficult. we describe how skills for gas insufflation less laparoscopic surgeries (gills) could be practised at home with easily available materials. learning minimally invasive surgery (mis) skills for mission and rural hospitals is important because after the pandemic, the surgical and other services would be decentralized and offering mis would make these hospitals relevant once more. the fellowship in laparoscopic surgery (fls) course is a validated course for teaching and evaluation. it has a list of tasks to perform and methods of evaluation.3 the fls improves intraoperative laparoscopic skill and predicts performance.4 even those not routinely doing laparoscopic surgeries can learn these skills and become proficient in them.5 the training box a variety of trainer boxes are available.6 unfortunately, none of them could be delivered during the lockdown. a simple training box can be made with easily available items in the house like a cardboard box and two cell phones as shown in figure 1. 40 gnanaraj nov 2020. christian journal for global health 7(4) figure 1. cardboard box trainer using 2 cell phones one of the phones is kept inside the box to provide sufficient light, and the other one is used as a camera. maryland forceps and needle holders are necessary for practice. one more hole could be made in the front for practising single incision surgeries. figure 2. for single incision laparoscopic surgery (sils) practise the skills the fls program assesses the skills for peg transfer, precision cutting, ligating loop, and extra/intra corporeal knotting.7,8 for a clearer picture, we show the skills from the larger monitor of the endo-trainer box we use. however, practice for all of the skills are possible using the cardboard box. if the commercial pegs are not available, as shown in figure 3, colour threads and holders can be used instead. the thread is picked up with the 41 gnanaraj nov 2020. christian journal for global health 7(4) maryland forceps, transferred to the needle holder, and placed on the slot for holding the thread. this gives an excellent opportunity for converting the 2 d image to 3 d actions. further practice is possible by changing the hands holding the instruments, placing the box at different places and angles. figure 3. thread and holder for peg transfer the commercial endo loops are expensive. a low-cost endo loop can be made using the pusher of the dj stent and prolene suture.9 glove fingers can be used for practising knotting and cutting. some cotton pieces or gloves can be placed inside the fingers of the gloves to make them a little more realistic. figure 4. homemade endo – loop with pusher for extracorporeal knotting, either the regular knot or modified roeder’s knot can be used. homemade pushers are shown in figure 5. figure 5. homemade pusher versions several techniques of intracorporeal knotting is described.10 suturing is another skill that needs practice. to practice suturing, it is easy to use a gauze piece that is going across the field as shown in figure 6. figure 6. suturing with a gauze piece a reusable needle and ordinary thread can be used for practice. this could be used many times and the thread used costs very little. (figure 7) figure 7. thread and reusable needle 42 gnanaraj nov 2020. christian journal for global health 7(4) the readymade material for precision cutting would be expensive. a simple but perhaps even better way would be to pack some gauze pieces inside the glove and mark the place for cutting on it with a marker pen (figure 8). unlike the readymade ones, the line would be in different depths, and also, we can learn to pull out the single gauze piece below it without disturbing the others to practice dissection using the instruments with both the hands. figure 8. practising dissection with glove, marker, and gauze summary gas insufflation less laparoscopic surgeries (gills) are ideal for rural areas as they are possible under spinal anaesthesia.11 the above methods help to prepare for gills using locally available materials during the lockdown except possibly for the maryland forceps and laparoscopic needle holder. if these are not available, ordinary long needle holders and kelly clamps could be used with smaller boxes. references 1. ministry of health and family welfare, india. travel advisories [internet]. 2020 [cited 2020 apr 25]. available from: https://www.mohfw.gov.in/ 2. ministry of health and family welfare, india. advisory for hospitals and medical institutions [internet]. 2020 [cited 2020 apr 25]. available from: https://www.mohfw.gov.in/pdf/advisoryforhospitals andmedicalinstitutions.pdf 3. vassiliou mc, dunkin bj, marks jm, fried gm. fls and fes: comprehensive models of training and assessment. surg clin north am. 2010 jun;90(3): 535–58. http://dx.doi.org/10.1016/j.suc.2010.02.012 4. mccluney al, vassiliou mc, kaneva pa, cao j, stanbridge dd, feldman ls, et al. fls simulator performance predicts intraoperative laparoscopic skill. surg endosc. 2007 ;21(11):1991–1995. http://dx.doi.org/ 10.1007/s00464-007-9451-1 5. rooney dm, santos bf, hungness es. manual skills assessment: surgeon vs. non-surgeon raters. j surgical educ. 2012 sept-oct;69(5):588-92. 6. indiamart. laparoscopic virtual endo trainer. n.d. [cited 2020 apr 25]. available from: https://dir.indiamart.com/impcat/laparoscopicvirtual-endo-trainer.html 7. society of american gastrointestinal and endoscopic surgeons. fls [internet]. n.d. [cited 2020 apr 25]. available from: https://www.sages.org/projects/fls/ 8. society of american gastrointestinal and endoscopic surgeons. fls [internet]. 2020 [cited 2020 apr 25]. available from: https://www.flsprogram.org/ 9. gnanaraj, j. (2017). low cost endo-loop for rural surgeons. trop doct. 2017 jan 6;47(3),275–8. https://doi.org/10.1177/0049475516686540 10. croce e, olmi s. intracorporeal knot-tying and suturing techniques in laparoscopic surgery: technical details. jsls. 2000;4(1):17–22. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc30 15354/ 11. j gnanaraj, m rhodes. laparoscopic surgery in low and middle income countries: gasless lift laparoscopic surgery. surg endosc. 2016 may;30(5): 2151-4. available from: https://pubmed.ncbi.nlm.nih.gov/26275541/ https://www.mohfw.gov.in/ https://www.mohfw.gov.in/pdf/advisoryforhospitalsandmedicalinstitutions.pdf https://www.mohfw.gov.in/pdf/advisoryforhospitalsandmedicalinstitutions.pdf http://dx.doi.org/10.1016/j.suc.2010.02.012 https://doi.org/10.1007/s00464-007-9451-1 https://dir.indiamart.com/impcat/laparoscopic-virtual-endo-trainer.html https://dir.indiamart.com/impcat/laparoscopic-virtual-endo-trainer.html https://www.sages.org/projects/fls/ https://www.flsprogram.org/ https://doi.org/10.1177/0049475516686540 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3015354/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3015354/ https://pubmed.ncbi.nlm.nih.gov/26275541/ 43 gnanaraj nov 2020. christian journal for global health 7(4) peer reviewed: submitted 27 april 2020, accepted 10 sept 2020, published 9 nov 2020 competing interests: none declared. correspondence: dr. jesudian gnanaraj, india. jgnanaraj@gmail.com cite this article as: gnanaraj j. low cost training during lockdown: homemade training for gas insufflation less laparoscopic surgeries. christ j for global health. nov 2020; 7(4):39-43. https://doi.org/10.15566/cjgh.v7i4.385 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:jgnanaraj@gmail.com https://doi.org/10.15566/cjgh.v7i4.385 http://creativecommons.org/licenses/by/4.0/ introduction the training box the skills summary references commentary may 2016. christian journal for global health, 3(1): 57-72. developing cross-cultural healthcare workers: content, process and mentoring mark a strand a , alice i chen b , lauren m pinkston c a phd, professor, school of pharmacy and department of public health, college of health professions, north dakota state university, fargo, nd, usa b md, mar, medical department, shanxi evergreen service, taiyuan, shanxi, china c doctoral candidate, institute of family and neighborhood life, clemson university, clemson, sc, usa abstract career service in cross-cultural healthcare mission work is the ambition of many people around the world. however, premature termination of this expected long-term service mitigates against achieving the goals of the individual and the organization. the lingering challenge of high rates of missionary attrition impacts the long-term effectiveness of the work and the health and well-being of the workers. one of the keys to reducing premature attrition is cross-cultural training for these individuals, provided it offers the right content, through the best medium, at the time of greatest perceived need by the missionary. this paper applies the dreyfus model of skills acquisition to the process of mentoring career healthcare missionaries in a progressive manner, utilizing a mentoring method. these missionaries can flourish in their work and more effectively achieve their individual and organizational goals through strategic mentorship that clearly defines a pathway for growing their cross-cultural skills. background it is estimated that there are 400,000 cross-cultural christian missionaries serving around the world, 127,000 of them from the united states and 42,000 of them serving four or more years. 1,2 healthcare professionals are a part of this workforce. every year, hundreds of healthcare professionals relocate to a new country to begin language learning in preparation for a career in missionary service. 3,4 at the cmda medical missions summit in atlanta in 2012, it was determined that 6.4% of the missionaries in the eight organizations attending were involved in healthcare. 5 of the 66 organizations studied in the global healthcare workers needs assessment (ghwna) study in 2013, 24% of new missionary candidates were healthcare workers. 6 however, even as these new recruits are moving out, an approximately equal number of missionaries are relocating back to their home countries and ending their healthcare careers abroad. 7 some of these departures are due to retirement, others are planned upon completion of a contracted term of service, but many are premature, with workers never fulfilling the full vision and expectations once held of a long and 58 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. productive career. premature return from crosscultural service is considered preventable in many circumstances. 7,8 this paper seeks to discuss the current state of missionary attrition, as well as to make recommendations for a cross-cultural training model that promotes longevity and success in overseas healthcare work. duration of intended healthcare missionary service is evolving. younger generations of cross-cultural healthcare missionaries are shifting toward shorter terms of service. 9 this includes short-term missions (10-14 days duration), extended short-term missions (1-2 years), and one-term long-term missions (four years). the focus of this paper is service longer than four years, but it takes seriously the importance of each of the shorter durations of service as preparation for potential long-term service. this is based on evidence that shortterm service has a significant impact on those going and, thus, can serve as an exploration into longer term service and an opportunity to grow in one’s cross-cultural competence. 12 in contrast, most short-term service has limited impact on the intended beneficiaries. 10,11 for one, neither individuals nor communities change quickly; furthermore, conversion occurs through strong and culturally embedded relationships, not short-term encounters. 12-14 therefore, the proposal of this paper for incountry training through a mentoring process can be implemented even for short-term mission experiences and, thus, begin an individual on the road to career missionary service. 15 this mentoring model, even for individuals initially reluctant to make a longterm commitment, is particularly important for the millennial generation, as is described below. the millennial generation (those born between 1980-2000) represents 77.9 million americans, the largest generational cohort in american history. 16 as the mission leaders of tomorrow, they bring many assets to this challenge. the millennial generation represents the most culturally diverse american generation to date, with 38% of 18-24 year olds coming from minority ethnic backgrounds. 17 this has the potential to make cross-cultural acclimation smoother and faster for them. millennials also gravitate toward holistic approaches to mission, which is an essential element of healthcare missions. 18 millennials expect to maintain a close relationship with their parents and to seek their advice. 19 therefore, they expect mentoring from someone when they assume a new role, but from an egalitarian perspective, not a hierarchical one. 18 they also respond favorably to small tasks, with clear expectations and of limited duration, as a way of testing out their interest in, or ability to perform that task. 18 each of these attributes prepares the millennial generation to thrive in the kind of healthcare missionary development process introduced in this paper and to be up to the challenge of leading in healthcare missions in the future. 20 challenges facing healthcare missionaries it has been reported that religious expatriates in general are highly resilient, with a uniquely high capacity for coping with stress and trauma. 21 healthcare missionaries have completed challenging undergraduate coursework, undergone stringent graduate-level training, endured rigorous workloads, and sacrificed high salaries to serve under difficult circumstances. this selects individuals with a high capacity for facing challenging circumstances. still, no matter how capable and resilient healthcare missionaries may be, cross-cultural service requires a set of skills and knowledge that is different from what can be learned in a classroom. mccrae and costa claimed that 59 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. there are five major personality traits that can predict expatriate effectiveness: extroversion, agreeableness, conscientiousness, neuroticism, and openness. 22 cultural intelligence, a multifaceted individual attribute that assists a person in adapting effectively to a new cultural context, may also contribute to cross-cultural success. adjustability, 22-27 cultural sensitivity, 28,29 self-efficacy, 30 previous international experience, 26,27,30 and family adjustment dynamics 31 also play major roles in contributing to the effective functioning of the cross-cultural professional. so, a number of factors have been identified which can help the healthcare missionary become successful; yet, many crosscultural workers are surprised by the difficulties they face once established in their cross-cultural living situations. without proper cross-cultural training (cct), healthcare missionaries are likely to struggle to understand cultural, relational, or systematic reasons for the apparent lack of efficiency, the slow pace of change, or the unique way in which people behave in a different country. frustration with conflicts between the values of their home and host culture may be compounded by trouble with language learning, team conflict, or culture shock. after spending so many years preparing to be a professional in the field of medicine in their home country, healthcare missionaries may struggle with role deprivation or be discouraged or fatigued by having to face yet another season of training, cross-cultural training. therefore, it is important that this critical process be encouraging and helpful to the missionaries, not onerous or perfunctory. missionary attrition missionary attrition among organizations has been reported to be on average 5% per year. 32 the top reason for attrition is children’s needs. five of the next eight most frequently reported reasons for attrition were: change in role, physical and mental health, problems with peers, disagreements with their agencies, and poor cultural adaptation. 32 these reported reasons for attrition reflect the absence of some of the key factors reported above that predict cross-cultural success, such as cultural intelligence, adjustability, cultural sensitivity, previous international experience, and family adjustment dynamics. ineffective attempts to help healthcare missionaries with the challenges they face contribute to missionary attrition. the progressive mentoring model proposed in this paper is well-suited to address these shortcomings. one of the authors conducted a survey called the global health workers needs assessment survey (ghwna) of current and former healthcare missionaries associated with the organization medsend. 6 the purpose was to determine some of the key factors contributing to missionaries remaining in service on the field. the ghwna survey found that the average length of service for those who left the field was 4.77 years. although the intended length of service of these missionaries was not reported, this attrition can exact a considerable toll on missions— financially, personally, and spiritually. the cost of supporting an american missionary family of five on the field varies by organization and field of service, but is estimated by the authors to be approximately $395,000 usd for a five-year term. a the personal and spiritual toll of these premature departures is also significant. respondents to the ghwna survey reported that a. this includes start-up costs of $20,000 for fundraising, overseas travel, and home set-up expenses on the field such as for furniture and appliances, and also includes $75,000 a year for living allowance, rent, children’s education, mission administration fees, pension and federal insurance contributions act (fica). this does not include the full cost of support services incurred by the sending organizations and churches through the entire application process and after the family has left for the field. 60 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. they experienced “great difficulty” in departing from the field and in resettling back in their home country. parting ways with colleagues and national friends and coworkers can be very painful. the nature of mission work results in forming deep interpersonal relationships with mission colleagues and national coworkers, who all suffer when these bonds are severed, and even more so when the departure is premature. and, of course, seeing one’s spiritual calling come to an end can be both painful and spiritually confusing. furthermore, a cross-cultural health-care worker needs at least two years of dedicated language and culture learning, and usually only begins to have a significant impact during years three and four, so that many departing missionaries are just beginning to enter a time of cultural belongingness and ministry effectiveness at the time they leave the field. david frazier suggests that the attrition seen today may be caused in part by an old mission system trying to challenge, guide, and equip a new generation of missionaries who have different expectations. 9 he reports that the top issues leading to preventable attrition have to do with character and relationships. other major causes are a misunderstanding of calling, incorrect fit with one’s skills, poor relational skills, and insufficient language progress. this paper fits the expectation of the millennial generation to seek mentors, who partially fill the role they had previously valued in their parents. 18 underlying these myriad issues is a frequently encountered uncertainty about who is responsible for training the healthcare missionary. mission boards rely on churches to refer and fund missionaries, and churches then rely on mission boards to train and screen missionaries for cross-cultural readiness. but once missionaries are on the field, they can be neglected and forgotten in their most difficult and crucial days of adjusting to a new culture and lifestyle. sixty percent of mission organization leaders reported no specific training for healthcare missionaries, other than the training provided to all missionaries. 6 it is the purpose of this paper to introduce a model for healthcare missionary training that is progressive and mentor-driven, but first, the general concept of cross-cultural training will be explained. the role of cross-cultural training cross-cultural training (cct) is defined as educational processes that improve intercultural learning via the development of cognitive, affective, and behavioral competencies needed for successful interactions in diverse cultures. 33,34 cct is traditionally designed for preparing international trainees by targeting cultural issues. 33 cct aims to develop the skills and knowledge needed to interact appropriately and effectively with host-country nationals (hcns) 34,35 and with members of multicultural teams. 35 researchers have identified three goals for cct. the first is to assist expatriates in determining acceptable cultural behaviors and appropriate ways to complete tasks in a new environment. a second goal is to equip field staff with coping strategies to deal with unexpected situations in the host country. the third goal of cct is to help the expatriate define realistic expectations for life and work in a new country. 33,35 ultimately, cct aims to predispose members of one culture to rapid adjustment in their host culture. 26 however, some studies have found that cross-cultural training may not provide significant benefit for expatriate adjustment. 24 morris and robie conducted a meta-analysis of 16 studies (total n=2,270) and found that the overall effectiveness of ccts was weaker than expected in light of the wide use of training. 24 chang was also skeptical about the impact of cct, arguing that living in a foreign culture impacted people differently, so measuring expatriate adjustment based on cct was too 61 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. difficult. 29 other research has reported the benefit of cct. brewster and suutari reported that crosscultural training was linked to an improvement in the relationships between expatriates and local people. 36 likewise, littrell et al. reported that cct was positively related to the development of self-confidence and overall feelings of well-being, interpersonal skills, and cognitive skill development. 35 they wrote that cct was positively correlated with adjustability and cross cultural adjustment, while negatively correlated with early return rates. 33 recommendation: on-field cct and mentoring while cct likely plays a role in helping a missionary adjust to his or her new life, the increase in cct in recent years has not decreased missionary attrition appreciably. it is not that cct is unable to help with the key predictors of success such as cultural intelligence, adjustability, cultural sensitivity, and family adjustment dynamics, but it is the concern of the current authors that cct is being delivered in a didactic method and prior to the time of perceived need and, thus, is less effective than it could be. extensive pre-field training can mediate against worker effectiveness on two planes. first, it postpones language learning and culture adaptation. second, it inadvertently mis-prepares a person because the needs of the field or team and the needs of the country will seldom be a perfect match with the pre-field training they received and may not be optimally addressed in the cct. the ghwna study respondents reported preferring on-field to pre-field training. 6 age is also a factor; seldom do healthcare workers arrive on the field before the age of 32, so adding more years of pre-field training can further delay their arrival. the concern of this paper is that a didactic, front-loaded cct process does not fit with the needs of current healthcare missionaries. these needs can be characterized as being adult learner-focused, with great diversity by country and culture, a preference for real-time training, and a desire for personal on-site support and mentoring in the new culture. therefore, while pre-field training is important, and in the absence of an on-site mentoring model as proposed in this paper, is essential, it has possibly been excessively relied upon and fallen short of expectations in the past. as will be explained below, training of healthcare missionaries through mentoring, coaching, and teaching after they begin their work on the field may better fit current needs. it will also allow for a guided, progressive process of finding a role for the missionary that has meaning and value and, thus, increases role satisfaction. 37-39 this means making the development of people an integral part of organizational culture, not an activity to be inserted into the organization. 40-41 finally, real-time training is a way to assist the expatriate through cultural adjustment. real-time training can improve communication, leadership, and problemsolving skills. common sources of real-time training are face-to-face or internet-based interactions with other expatriate workers, repatriates, or local nationals. materials provided by their organization can also be helpful as an asynchronous learning tool. 24 eschbach, parker, and stoeberl argue that highrigor cct, beginning during the pre-departure phase and continuing intermittently through-out the posting, is the most effective type of delivery. 42 effective cct teaches expatriates how to process the many new experiences they are having. 35 cross-cultural training should be provided over several years, according to the missionary’s need, and through a mentoring relationship. the process of moving from 62 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. being a novice to expert is a long process, requiring at least eight years, and involves the mastery of specific subject areas, as shown in table 1. just as healthcare professionals are expected to practice evidence-based medicine and to engage in lifelong learning through continuing education, so missionaries should practice evidence-based ministry and engage in lifelong learning commensurate with the enormity and importance of the task. therefore, cross-cultural training for successful healthcare mission service should be delivered over a ministry life cycle through a diversity of educators and trainers. the dreyfus model shows the progression of an expatriate worker in five stages from novice to expert. 43 it has been well-utilized in other healthcare disciplines and can be aptly applied to crosscultural healthcare workers. 44 the dreyfus model is shown in figure 1 and explained below. 45 figure 1. time and skill progression of healthcare missionary from novice to expert. a process of progression into effective missionary service stage 1: novice the novice stage involves formal learning and lasts approximately two years. the learner is given rules for determining actions much like data entry into a computer. the learner is guided and instructed within a narrow set of expectations that may be communicated through assigned reading or other academic formats. at this stage, the missionary seeks to learn basic concepts and establish routines. for the healthcare missionary, this includes learning basic language skills to communicate essential concepts with local people, such as ordering food and finding one’s way around, and learning how to connect with and know one’s neighbors by name. if the missionary is involved in patient care, he or she will be dependent on an interpreter to understand the patient’s language and also to begin to recognize the cultural factors and nuances at play. it requires significant effort, and can be quite stressful as the learner seeks to grasp new information and new skills. a young couple that arrived in an asian country to study language in a university setting offers a real-life example of this stage of learning. before arriving, they had completed assigned readings that described asian etiquette and how to give face to their superiors. upon arriving at their university, they were visited in their fifth-floor apartment by the head of the language department, their new supervisor. 63 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. after his short cordial visit, he got up to leave and the couple, recalling from their reading the importance of “sending off” their guest, then proceeded to follow this rule. without the benefit of having seen it actually modeled, they accompanied the professor down each floor of their apartment building, despite the professor’s vigorous protestations. the next day, the news on campus was that these newcomers were the most excellent and suitable of all foreigners that had ever come to this university, because they had gone to such lengths to send off their guest, despite the fact that they didn’t fully understand the meaning of what they were doing. gradually, the learner is able to understand the situations that had previously escaped, confused, or frustrated him or her. by following the rules and established routines, they begin to feel more comfortable and function more effectively. thus, the healthcare missionary becomes a beginner. stage 2: beginner after seeing and experiencing a sufficient number of examples, the learner begins to recognize principles and patterns and identify further aspects and levels of meaning from what they have observed. this marks a movement beyond novice to beginner. it generally happens during years three and four (figure 1). the beginner is able to compare personal experience with rules learned while a novice. informed reflection allows the beginner to form principles and generalizations to further their understanding of their host country. specifically, the beginner healthcare missionary will begin to develop cultural competence, including appropriate interpersonal physical contact, the use of greetings according to individuals’ social status, and the recognition of the role of traditional world-views regarding well-being and illness. thus the beginner starts to form mental models through practice and feedback. 46 for example, in china, traditional chinese medicine (tcm) continues to be widely used. for the new healthcare worker in china, gaining a basic understanding of the theoretical basis of tcm as well as commonly prescribed herbal medications is essential. learning how to take a patient’s history using tcm terms and familiarizing oneself with the side effects and interactions of tcm with western medications will also become necessary skills for practicing medicine in china. even more important, however, is grasping the cultural significance of tcm as a deeply-engrained worldview that embraces not only physical diagnosis and treatment but also the patient’s overall well-being and interaction with one’s environment. cultural learning and adjustment continues to be stressful, but as one’s language and cultural competency improves, one feels increasing confidence in his or her knowledge and ability to access the information needed. reliance on rules and routines begins to lessen, while reliance on the context becomes more important. this model explains why mission organizations previously treated the first three years of service as probationary, as it takes that long to become functional in that setting. a career missionary named emily, serving in south asia, illustrated the model proposed here in her article, “year 4,” where she described the yearly progression she made in language, dress, food, shopping, and “normalcy” through her first four years of service. with regard to “normalcy,” she described her progression as follows: year one, “we’re going to settle in here and find out what normal is like,” progressing in year three to, “we’re still trying to figure out what normal is like,” and by year four concluding, “well, i guess this is normal.” 47 she had moved past searching for rules to beginning to accept the local context and seek to work within it. this is evidence that emily had achieved substantial 64 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. cultural competence and was on her way to becoming highly effective as she moved toward proficient or expert missionary competence over time. stage 3: competent missionary by the end of their first four years, healthcare missionaries have struggled through cultural and ministry dissonance. if they have been properly mentored, they will have begun to organize their experiences into patterns and models which go beyond the simple, more unambiguous rules they learned as a novice or beginner. in diverse situations, they are increasingly able to decide for themselves what plan to choose and when to choose it and to identify and negotiate the nuances that distinguish different situations from each other. they are able to cope with uncertainty and maintain a degree of psychological balance in doing so. this occurs at about year five, as they prepare for and experience home assignment. (note the fading color intensity of the years shown in figure 1, intended to depict that the time at which healthcare missionaries achieve the levels of competency is harder to predict with time.) in addition to knowing local terms for symptoms, the competent healthcare missionary will be aware of culturally embedded disease descriptions, the impact of various practices upon local medical practitioners, and be able to read non-verbal cues of patients. for the healthcare missionary to proceed to competence, he or she benefits from being independently immersed in work situations, with a mentor to debrief them afterwards. the process of becoming a competent missionary is a long-term proposition. it has been observed that, frequently, it isn’t until into their fifth year of service that missionaries are able to pursue tasks more in line with their skills and interests. with average term of service around five years, they frequently leave just as they are becoming competent. this is why it is so important for the missionary to be patient, knowing that they will be able to move toward more suitable roles with time, and for the organizational leadership to provide personal mentoring for the missionary. an example experienced by one of the authors occurred in her fifth year of service in china. a 30-year-old man presented with a ruptured esophagus. his family requested financial assistance for his care through a charitable program for needy families. assistance was not provided, as the patient did not meet the program’s criteria. the patient was under the charge of a local senior internist who treated him extremely conservatively, choosing not to take him to surgery, but sought to reduce his pneumothorax with daily manual aspirations of air from his pleural cavity with a 30 cc syringe versus the insertion of a chest tube, a more conventional and effective therapy by western standards. the pneumothorax did not resolve, the esophageal rupture was not treated surgically, and the patient deteriorated steadily and rapidly. eventually the patient developed an abscess in the area of the rupture, descended into respiratory failure, and died of sepsis a week after admission. for a foreign doctor working in this setting, acute distress was created by a number of factors in this case: the age and previous good health of the patient, the excessively conservative treatment provided, and the seniority of the attending physician who was generally respected and would not have been appropriate to contradict. it was tempting to circumvent the rules of the assistance program and to use personal funds to provide this patient with surgery, but this option too was problematic and conflicting when considered against how many other patients could be assisted with that significant sum of money. what helped this young expatriate doctor in these ethically challenging situations was the 65 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. input of several veteran missionary doctors, one working in nepal and two in taiwan, who generously shared of their experience and wisdom from decades of caring for patients in under-resourced areas. their thoughtful mentorship helped her to develop lasting and valuable principles for dealing with the inequities of medical care in needy areas, balancing conflicting values, and communicating compassion and care in seemingly hopeless situations. these events, and the role played by mentors, characterize the experience of the healthcare missionary gaining culturally appropriate competency. stage 4: proficient missionary stage four in the dreyfus model represents proficiency. during this stage, the missionary is able to read the context and intuitively determine the right thing to do. the proficient healthcare missionary can discriminate a variety of situations and intuitively suggest plans from his or her experience toolbox. he or she understands the etiology of culturally embedded disease descriptions that patients report. he or she is able to care for patients independently, without a cultural or language interpreter. the proficient healthcare missionary understands the local healthcare system, so that he or she is able to confidently make referrals and fully understands the process the patient will experience in each setting. the proficient healthcare missionary will work for hours without being conscious that he or she is working cross-culturally. work will be less of a struggle and cultural patterns will feel intuitive. he or she will be able to respond to unexpected changes, handle varieties of situations with varied groups of people, and provide healthcare confidently and safely. poor integration of the healthcare and church-planting aspects of the mission organization frequently cause stress and contribute to attrition. sometimes the organizational leaders subconsciously communicate that healthcare work is less important than church-planting work. the proficient missionary can grasp the whole ministry context, appreciating both the medical and the church-planting components of the organization, and how their interaction is mutually beneficial. they can also communicate this integration to their organizational leaders as necessary, as a way of explaining the value of healthcare work for broader organizational goals. proficiency usually comes late in the second term, during years 7-8. without persistence, humility, a stance of lifelong learning, and deep cross-cultural engagement, many healthcare missionaries will not achieve proficiency. it is important to remain persistent in the pursuit of language ability and cultural competence in order to prevent premature plateauing, which can compromise effectiveness and long-term personal flourishing. the proficient missionary is likely prepared for cross-cultural leadership, including relating well with existing national leaders in medicine, politics, and religion. a skill that is essential in many of the cross-cultural healthcare settings that exist today is the skill of developing and maintaining relationships with local and national government leaders and officials. keeping relationships with these individuals well-oiled is necessary to ensure future harmonious acceptance and cooperation. certain knowledge and skills are involved in this process, such as appropriate seating at a formal banquet or where to position oneself while taking photographs with officials, but more important is an understanding of the dynamics of interactions with officials, such as when and how to make recommendations. in many cultures, paying respect by visiting officials and leaders is a necessary, but 66 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. challenging part of the work of the healthcare missionary. few western missionaries are familiar with this practice, so it creates many questions for the expatriate missionary: what do we talk about with these officials? what gift should we bring? will this gift be interpreted as a bribe? over time, and with repeated exposures, individuals can begin to understand the underlying dynamics of such visits, and adjust their expectations. gradually, the humanness of these officials becomes more evident, and the fact of their own personal challenges and limitations emerges. eventually, these visits become not so much a make or break experience, but instead become an opportunity for shared understanding and shared blessing. stage 5 expert missionary the pinnacle of development in the dreyfus model is the expert (figure 1). the expert missionary no longer relies on routines, but functions intuitively and naturally, according to context and situation. the expert sees what needs to be achieved, and due to a vast repertoire of situational discriminations, he or she sees how to achieve the desired goal. the expert missionary is able to make an immediate, intuitive situational response that demonstrates expertise. he is able to take action without conscious analysis, and national coworkers respond to him or her comfortably and naturally. the expert healthcare missionary is bilingual, and functions interchangeably and smoothly in one’s passport and host cultural context. he or she will be able to link culturally embedded disease descriptions with their comparable bio-medical concept and will, thus, be able to provide evidence-based, but locally appropriate, care. the expert healthcare missionary will be expected to participate in local leadership decisions and does so in a culturally appropriate way. the expert missionary will frequently lose sense from what language or culture he or she is working, and those with which he or she is working will feel this naturalness and effectiveness. granted, personal gifting, affinity for language and cultural learning, and individual personality predispose certain individuals for this proficiency, but generally, reaching this level can be achieved after nine or more years of cross-cultural service. the expert missionary possesses an intuitive sense of what is appropriate in a given situation. the expert missionary will not get to that level without the help of many mentors along the way, formal and informal. furthermore, the expert will be expected to likewise serve as a mentor to novice and beginner healthcare and other missionaries. as conceptualized in this paper, the process of moving from novice to expert involves specific content (table 1), a gradual progression through the five stages (figure 1), and guidance along the way by a series of mentors. variations of the dreyfus model have been used effectively in healthcare missions, but they have not been analyzed or reported in a formal way. formal evaluation of a mentoring program should be considered by organizations that currently highly value mentoring, but have not implemented it in a formal way, and even less, have not evaluated its effectiveness. the role of mentoring will be described presently. mentoring cross-cultural training is essential for healthcare missionaries to be effective. this process should happen on the field and under the guidance of a trained mentor or coach. the content can be delivered through reading or viewing high-quality materials, but equally important is guided reflection on real experiences of the missionary with a mentor. just-in-time training, under the guidance of an 67 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. experienced mentor, makes training in areas such as cultural sensitivity, adaptability, and even family adjustment dynamics, more practical and, thus, more highly valued by the healthcare missionary who is in the process of moving through the first three levels of the dreyfus model. although this paper proposes a ten-year process of development to become an expert healthcare missionary, it should be pointed out that the frequency and intensity of mentoring will lessen with time. the first four years through the beginner phase are especially critical and should be relatively formal. after that, the needs of the developing healthcare missionary will be most important in determining the content and nature of the mentoring process. the mission organization is responsible to design a progressive mentoring program and create a culture where mentoring is normative. in the ghwna study, organization leaders reported “mentoring ability” to be the most important area of leadership, but only 18% of them assigned mentors, and only 38% of the missionaries reported having any type of mentor. 6 the study also showed that those who left the field prematurely reported a lower quality of mentoring relationship than those who remained on the field. therefore, mentoring success will require deeper organizational commitment to mentoring, setting clear expectations for the mentoring process, and training mentors and mentees. 48 it also involves providing specific feedback about their performance. mentors can be either expatriate or national coworkers, depending on the situation. mentoring by national colleagues is an incredibly rich source of growth and direction to the learning missionary. it demonstrates respect for local individuals as the true arbiters of what is locally appropriate and shows true humility. while offering advice and specific information about cultural issues is a valuable aspect of mentoring, coaching is an effective adjunct. using a coaching approach, the mentor can offer thoughtful questions to stimulate the learner to reflect upon his or her experiences. reflective listening, expressing empathy, and open-ended questioning can help the individual to process feelings, thoughts, and behaviors, thus, developing the skills necessary to function less rigidly and more according to context and situation in the future. mentoring should be provided throughout the worker’s progression from novice to expert and will contribute to improved interpersonal relationships, effectiveness, and cultural competence. 68 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. table 1. competencies and areas of training designed specifically for healthcare missionaries. medical applications  up-to-date clinical skills  a theology of health and medicine  community health  serving in situations of overwhelming need, death and dying issues, loss  whole health approach, integrating faith and medicine  developing specialty areas, such as hiv care, chronic disease management, mental health, rehabilitation medicine  patient care in a cross-cultural setting, traditional healing practices, culturally specific practices regarding health maintenance, time, stigma, face/shame, etc. politics/policy  compliance with the national health system  working in a secular setting, such as a government hospital  ethics in medical missions  healthcare resource development  organizational/church leadership business/finance  administration  fund-raising  guidelines for the use of finances for charitable care  consideration of donated equipment and supplies personnel  multi-cultural team building  management, especially related to human resource management in healthcare  integration healthcare into the mission strategy  professional and personal development of both expatriate and national colleagues  dealing with conflict and implementation of an effective grievance process education/teaching/training skill  being an effective educator  adult learning theory  participatory training methods  problem-based learning  skills development and assessment  medical education, residencies  mentoring and training local (christian medical) professionals  coaching and mentoring of students, residents, etc.  modeling self-care, professional excellence, lifelong learning  locally-appropriate educational technology note: some baseline competencies required of all missionaries include language and cultural training, bible and theological training, and basic spiritual health and vitality. these are not included in this table because they are already the focus of significant attention by mission organizations. assessment it has been shown in many settings that people are successful in accomplishing those things for which they are being held accountable. therefore, tracking and monitoring of progression in competency in missionary service should be provided. 49 mission organizations should provide clear job descriptions, regular evaluation, and accountability to new workers, so that the missionaries are clear about what is expected. this process should be carried out in a constructive and supportive way, not in an onerous way. healthcare missionaries need to be placed in settings where they have a greater chance of success. furthermore, the mission organization should develop specific health care strategies that contribute to the overall mission, so that the healthcare missionaries do not feel marginalized. as part of the annual evaluation process for healthcare missionaries, the missionary should be assessed for how they are mastering content areas and the degree to which they are 69 strand, chen, pinkston may 2016. christian journal for global health, 3(1):57-72. traversing the stages towards becoming an expert missionary. the assessment can be either process or summative. in order for the assessment to be fair and substantive, the expectations need to be stated clearly at the outset. documentation of progress and barriers is also important so that the annual evaluation takes into account prior experience. limitations this commentary has proposed an approach to the process of developing missionaries that has not previously been implemented in such a way that it could be formally assessed. however, it is based on good evidence from medical education models and from available literature on healthcare missionary development and retention. this is a call for mission organizations deeply committed to healthcare work to redesign their program for developing and training healthcare missionaries along the lines proposed here and then to perform rigorous assessment in order to determine strengths and weaknesses of the model. it is also acknowledged that while the dreyfus model is a good model to explain the acquisition of competencies that fit with intuition and more implicit decision-making required in ambiguous cross-cultural settings, it may not be the best model to explain the acquisition of more explicit skills, such as those listed under the domains of medical applications and business/finance (table 1). for example, up-to-date clinical skills and administrative or finance skills might require more didactic approaches. therefore, while the dreyfus model is seen to be the best and most comprehensive approach to developing longterm healthcare missionaries, it must leave room for other elements of professional development that may not be as effectively delivered through this model. conclusion healthcare missionaries make a large personal and organizational investment in order to prepare for service. they are too valuable to lose to premature attrition. one of the causes of attrition is insufficient and inappropriately timed cross-cultural and professional training. an additional cause is the absence of mentors who are themselves competent or better. yet another cause is the lack of organizational commitment to use mentoring as the core of the missionary development process. more support and accountability for healthcare missionaries from their organizational leaders and local team leaders is needed. one of the ways this can happen is to create a more clearly defined pathway for missionaries to move from novice to expert and then to guide that process with both essential content and a progressive mentoring approach. references 1. johnson t. christianity in its global context, 1970-2020: society, religion, and 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2010. 47. emily. year 4. together in prayer. minneapolis, mn: world mission prayer league; january 2016:12. 48. nelson j. four ways to improve field staff retention. evang miss q. 2015;51(4): 440-5. 49. michael j. mental models and meaningful learning. j vet med edu. 2004;31(1) :227-31. http://dx.doi.org/10.3138/jvme.31.1.1 peer reviewed competing interests: none declared. correspondence: mark a. strand, north dakota state university, united states, markstrand3@gmail.com, alice i chen, shanxi evergreen service, china, alice.chen@evergreenchina.net, lauren m pinkston, clemson university, united states, lmpinkston@gmail.com cite this article as: strand ma, chen ai, pinkston lm. developing cross-cultural healthcare workers: content, process and mentoring. christian journal for global health (may 2016), 3(1):5772. © strand ma, chen ai, pinkston lm this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.3138/jvme.31.1.1 mailto:markstrand3@gmail.com mailto:alice.chen@evergreenchina.net mailto:lmpinkston@gmail.com http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ short communications june 2020. christian journal for global health 7(2) number our days: a reflection on psalm 90, a moses psalm lois joy armstronga a bsc, bmin, mphtm, public health consulting and writing healthy words, australia teach us to number our days, that we may gain a heart of wisdom. psalm 90:12 (niv) i am convinced that this phrase "number our days" means more than assigning a numerical value to our day. i also think it is more than adding another day towards our next birthday. why am i convinced? the outcome of numbering our days is gaining a heart of wisdom, not a numerical age. i am also convinced that is not about productiveness. many of us like to look back at each day and see what we have achieved. we feel proud we have achieved an outcome towards a project. i feel pleased when my friend alison says to me, "you are such a productive person." yet i know that i can do activities and make items, but these do not produce in me a heart of wisdom. "numbering our days" seems to be something we need to be taught; at least here, moses asks god to teach him to "number his days," which means we probably need to do that too. i am hoping in this season, when many are dying all around our world, i learn something more about what it means to "number our days." longevity is something after which many have sought. we have all been advised of the advantages of the mediterranean diet, but when we saw covid19 take on italy, all those dietary advantages seemed to fade as the virus spread rapidly. worldwide, and particularly in the west, we have forgotten the devastation of infectious diseases. this idea of time has especially caught my attention just now. i am reading on hinduism for my phd. hinduism takes a circular view of time, yet, strangely enough, as writers give their understanding of how the hindu religion developed, they take a linear view of time. it seems rather anachronistic to me. moses takes a linear view of time as he begins this psalm saying, "the lord god has been our dwelling place through all generations."(v.1) was this psalm written before or after the building of the tabernacle, a physical dwelling place for god? moses is not talking about a dwelling place for god but instead says god had been the dwelling place for his people. he does not mention canaan, the promised land. this statement of moses includes both space and time. god was their dwelling place, through all generations. i guess moses was between 80 and 120 years old when he wrote this psalm. moses knew about death — he had been saved from death by his mother, he had killed an egyptian then ran to the desert to protect his own life, he had seen the death of all the firstborn in egypt at the final plague, and he saw pharaoh and his army covered in the watery grave of the red sea. now in the desert wanderings, moses watched death after death of those unbelieving people. perhaps, he already knew he must face his own death before the israelites entered the promised land. in my isolation in semi-rural australia, i am with my mother who is about to turn 80. i am wondering what her 80th birthday will look like. as australia's number of cases of covid-19 grow, i have wondered if she will see this 80th birthday. it has been a special privilege to "number our days." we have talked about many things, both serious and funny, but i am glad i am here and can be with her in these days. already this year, i have "counted my days" to 14, twice. my travel to singapore and india before my return to australia had me counting. neither 2 armstrong june 2020. christian journal for global health 7(2) were the compulsory isolations, but having public health training, i was making sure i knew who i might need to contact if i developed symptoms. what a relief it was as i counted off that final 14th day twice. i sit in my warm office looking out at the cold rain landing on a red maple tree, but i often remember other parts of the world. many of my colleagues are facing the onslaught of covid-19 with limited resources. many of their patients do not make it to 70 years of age at the best of times. my colleagues are counting the days until the peak of the virus hits while i am counting those days until the curve flattens. how thankful i am that prayers, and the holy spirit, are not contained by social distancing and lockdowns. moses finishes this psalm by praying in verses 13 to 17. he asks, "relent lord, how long . . . ," a prayer many other prophets and ordinary people have prayed. moses asks for five things. these items have provided me with prompts on what to pray for his people while i am limited to this space in australia. • lord, have compassion on your people. this virus is no respecter of people, but lord have compassion on your creation. • may your people be satisfied with your love each morning. as your people arise this morning, fill them with your love. they may face many difficult decisions; may they be filled with your love to enable them to care for others. • make us glad for the days you have given us. right now, it is easy to think of the losses: yll (years of life lost), financial, freedoms, and hunger. make us all glad for each day you have given us. • may your deeds be shown to your people. grant your people wisdom in making decisions, and may your hand be visible in their situations. may those who do not yet acknowledge you also see your hand at work. • maybe your favour rest on your people and establish the work they do. father, some of your people are at the frontline caring for those sick with covid-19, tracing contacts and testing cases; some are entering data into computers to track epidemiological curves and advise governments; some are educating and making hand sanitizer; some are planning for the recovery phase; and others are continuing routine work like antenatal checks. father, show your favour and establish the work of their hands. submitted 11 may 2020, accepted 14 may 2020, published 22 june 2020 competing interests: none declared. correspondence: lois joy armstrong. loisjarmstrong@gmail.com cite this article as: armstrong l. number our days – a reflection on psalm 90, a psalm of moses. christ j for global health. june 2020; 7(2): ____. https://doi.org/10.15566/cjgh.v7i2.395 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank about:blank short communications nov 2016. christian journal for global health, 3(2):140-142. modern medicine failed me in kenya kathryn l. butler a a md, trauma surgeon, harvard medical school, boston, ma, united states his bottom lip trembled as i leaned in with my stethoscope. although his eyes shimmered with a thin sheen of tears, he did not recoil. as had his toddler sister, he waited, straight, silent, and obedient, and he studied me. i crouched to his level, and we connected for a heartbeat or two. i listened to the cadence of his breath; he searched my face. searched for what? understanding? hope? the missionary leading our team often remarked, “you are the face, and hands, and feet of christ.” as this child scanned my face, i felt the sweat snake down my neck, glimpsed the elongating line of villagers through the paneless window, heard the howls from the procedure room. . . and i realized the profundity of my failure. i wore no face of christ. i wore a grimy white coat, a stethoscope, and other flashy trappings incongruous with the dirt floor and dilapidated benches of the clinic. i considered the hundreds of people piling onto the grass into lopsided queues, stumbling over each other in the hope that we, mzungu, would cure their cataracts, their diabetes, their oozing wounds, and arthritic hips. i met person after person for whom i could prescribe only vitamins, and i watched their hopes crumble. rather than mercy, i offered disappointment. rather than the face of christ, i wore a perpetual air of apology. i journeyed to kenya to devote my skills toward care of god’s poor. in my arrogance, i envisioned myself pouring out mercy like water. i dreamed of dousing villagers in the healing power of western medicine, all the while preaching the love of christ. with the assistance of the local church, we assembled a clinic in a schoolhouse, and giddily set about our calling. patients flocked to the clinic. they left their homes at five o’clock in the morning and rode their bikes or trudged barefoot along muddied roads. volunteers filed entire families into lines and beneath tents, where they waited for hours to talk with us about their back pain, their toothache, their cough, their blindness. one village among many inefficiency drowned our efforts. we had no diagnostics and no referral hospitals. i punctured countless finger pads to test for malaria, dispensed ibuprofen, and fumbled through physical exams, but the tests the patients really needed — the ct scans, the colonoscopies, the biopsies, the blood tests — were unattainable. even acquiring a medical history proved formidable as we haltingly translated between english, to swahili, to the local vernacular, and then back. one after another, patients leaned forward on the rickety table and implored me for help. each time, i winced as i explained that despite my white coat and fancy credentials, i could not cure their advanced disease. they would trudge away crestfallen, with their five children in tow. with each encounter, despondency crept further into my bones. desperate for fortitude, each night i huddled under a mosquito net with a battery-powered headlamp, and read matthew 8 and 9. i pored over passages of healing accounts in jesus’ ministry. when solace came too slowly, i concocted preposterous plans for a mission hospital, to provide 141 butler nov 2016. christian journal for global health, 3(2):140-142. real care. i schemed about radiology wings and operating theaters in the bush. via a spotty internet connection one hour nightly, i forewent writing to my family in favor of researching hospital finances. as i tallied the needs of the patients, my heart — still anchored in the world — became heavy. this is just one village. how many more so direly need help? how can we endure such poverty and suffering? lord, how on earth can i help here? the patient diagnosed me such morose thoughts churned in my mind the day i met j. “i was wondering if you could please help me,” he said. i glanced up and noted he clutched a cane for refinery, not for infirmity. he had cordially removed his hat, and worry creased his brow. “i had an operation for hemorrhoids some time ago,” he continued, “but it’s not fixed anything. i am constantly bleeding. every time i go back, they just give me tablets, but they don’t help. i wish to know what i have. even if it is something that cannot be cured, i just wish to know.” he dropped a tattered booklet of hospital records onto my table. i leafed through the stained pages, and froze upon a word scrawled in pencil. my heart sank. j did not have hemorrhoids. he had rectal cancer. he could not afford the operation that might save his life. patients crowded outside. our clinic measured success according to the number of patients we treated daily. a nurse signaled for me to hurry. “too many waiting!” she mouthed. i searched j’s eyes, and the verse surfaced through the tumult: your faith has healed you. (matt 9:22) i choked back tears. in my brokenness, i had wasted precious reserve lamenting our paucity of technology, as if healing was titratable and mechanical. as if the machinery constituted the heart of the thing. yet god worked in our hearts, and in those of the patients whom we served, in ways subtle and dramatic, indiscernible, and cacophonous, beautiful, and mysterious. i shrugged my colleague an apology, leaned forward, and held j’s hand. we discussed his diagnosis for the next half hour. i drew diagrams. we prayed together. tears blurred our vision. “thank you for explaining to me,” j finally said. the creases had smoothed away from his forehead. “i see you have sympathy and compassion for me, and i am grateful. i am in the lord’s hands now. i must trust in him. he will provide what is best for me.” he squeezed my hand. i still feel the warmth. martha in the mission field the clinic was god’s vehicle, not the ultimate aim. he required no diagnostics; he healed through faith in his power. in my very urgency to serve him, i had supplanted my devotion to him with idolatry of modern medicine. i had relinquished dedication to the lord for adoration of my own pride. when i discarded esteem of my own efforts, in favor of being present for people in the clinic — of being christ’s face, and hands, and feet — narratives arose from the fogginess of our dialogue. they wove stories of rejection and discouragement at local clinics; anecdotes of struggling with ailments for years without an understanding of the cause; and the frequent complaints, “they just give me tablets, and it never gets better.” they received tablets, but no care. no laying on of hands. no consolation. no teaching. no hope. no hint of the gospel. in most instances, i could only give over-thecounter pills for their complaints. yet with the lord’s mercy, i could assure them that i had traveled halfway around the world to be with them, because we are all one in christ. i could reach out my hand and replace the distant white coat with the warmth of my palm. i could listen to the impact of illness on their work, their families, their homes. and i could conclude each encounter with an appeal to god, to remind them that all are without pain and suffering in heaven. to remind all of us, 142 butler nov 2016. christian journal for global health, 3(2):140-142. that any works we achieve of our own volition, pale in comparison to those accomplished through the love of our holy and perfect god, who gave his son for us. competing interests: none declared. acknowledgments: this article was published on-line 13 june 2016 at desiring god and is reproduced with permission of the author http://www.desiringgod.org/articles/modern-medicine-failed-me-in-kenya correspondence: kathryn l butler, harvard medical school, united states. klbutler@partners.org cite this article as: butler lk. modern medicine failed me in kenya. christian journal for global health (nov 2016), 3(2):140-142. © butler lk this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.desiringgod.org/articles/modern-medicine-failed-me-in-kenya mailto:klbutler@partners.org http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ original article health care options and factors influencing health seeking behavior in a rural community in nigeria: a cross-sectional study paul west okojiea, richard laneb a mph student, liberty university, united states of america b md, mph, professor, department of public and community health; program director, master of public health program, liberty university, united states of america abstract introduction: health care resources are disproportionately distributed between urban and rural areas in many developing countries, including nigeria. barriers to health care like cultural beliefs, poor education, and financial constraints make many rural dwellers seek other options of health care available to them. this paper aimed to determine the sociodemographic factors that influence healthseeking practices in a rural community setting. methods: a sample of 380 rural community dwellers in southern nigeria was recruited in a cross-sectional study. an interviewer-administered questionnaire was used to collect socio-demographic, healthcare access, and utilization data. data were analyzed with spss version 25.0 software. a chi-square test was used to find the association between sociodemographic characteristics and their health-seeking practices. results: equal proportions (43.4%, 42.9%) of the respondents fell within the younger age categories of 10–29 and 30–49 years. self-reported factors influencing the choice of health care were: promptness of care (41.8%), cost (22.4%), professionalism (16.8%), distance (15.8%), and cultural belief (3.2%). the patent medicine store was the most utilized source of health care (42.1%), and 36.8% of respondents sought health care in the hospital. the hospital was utilized by 41.8% of respondents with secondary education, 34.9% with tertiary education, 31.7% with primary education, and 26.1% with no formal education. females tended to seek health care from hospitals (40.2%) and patent medicine store (43.7%) compared to males (33.3% and 41.0%, respectively). there was a statistically significant association between education and health care options utilized (p<0.05). conclusion: this study draws attention to the suboptimal utilization of standard health care in a rural community setting mainly due to perceived influences of promptness of health care service (41.8%) and cost (22.4%). it revealed that rural dwellers mainly seek healthcare from patent medicine stores. the health authorities should, therefore, prioritize the eradication of delays at the point of care and expand financial access to health care. these would enable rural 84 okojie & lane june 2020. christian journal for global health 7(2) dwellers to optimize the minimum standard of health care available within their various communities. key words: health-seeking behavior, rural, nigeria, primary health care introduction primary health care (phc) aims to bring health care as close as possible to where people live and work.1,2 to bridge the gap in health service infrastructure and ease inequitable access to health care by the vast majority, the world health organization (who) launched the health for all strategy.3 however, after four decades since the ama atta declaration, many developing countries have yet to fully operationalize phc to the level of their sociopolitical and economic development.4,5 health indices continue to worsen in the affected countries, particularly among the most at-risk groups in the population—women, children, and the elderly.6,7 consequently, attaining a level of health that will facilitate social and economic productivity has been elusive for many individuals, families, and communities in these countries. distributive equity in the allocation of health resources has been hard to realize by many developing countries.8 in many cases, healthcare resources are disproportionately distributed between urban and rural areas.9,10 according to the national demographic and health survey (ndhs), about 64% of nigeria’s population live in rural areas while many have little or no access to quality healthcare.11,12 despite the contribution of rural dwellers to food production and preservation of culture, their quality of life is poorer than that of their urban counterparts.13 to correct this social injustice, nigeria adopted a national health policy that is based on the principle of phc.14 unfortunately, the country appears to have made unimpressive gains due to faulty implementation framework, resource deficit, and lack of political will.15,16 in communities where the minimum standard health facility is present, barriers to health care access such as culture, education level, geographical factors, and poor healthcare financing have been identified.17,18 nigeria is yet to effectively implement universal healthcare coverage, 70% of healthcare spending in the country is out-of-pocket, and rural dwellers are unable to afford exorbitant fees charged in public and private health facilities.19 a sizeable proportion of the nigerian population, the majority of whom live in rural communities, are yet to attain a level of education required to make them appreciate the benefits of utilizing available health resources like health centers and immunization services. data from the 2013 ndhs indicate that literacy is generally higher in urban areas compared to rural areas. while more than 7 in 10 urban women (77%) are literate, less than 4 in 10 rural women (36%) are literate. it further showed that literacy levels decline with age, from 66% among women in the age range of 15–19 to 36% among women in the age range of 45–49.20 this, among other identified factors, affect health-seeking behavior and decision making concerning suitable healthcare options.1719 rural dwellers have been reported to combine traditional african medicine (tam) with standard care or fail to utilize health facilities in their domain due to a perceived clash of western medicine with their cultural beliefs. similarly, the use of patent medicine stores (pms, commonly called a “chemist” by a majority of nigerians) is rampant in most rural nigerian communities.21 there are premises mandated by regulatory bodies such as the pharmaceutical council of nigeria (pcn) to sell patent medicine or over the counter drugs (otc) that are considered safe for unsupervised public use as long as they are sold in their original manufacturer packages. common otcs include pain-relieving tablets, antimalarials, and cough syrups. pms is not permitted to sell and dispense 85 okojie & lane june 2020. christian journal for global health 7(2) prescription drugs such as antibiotics and steroids. also, most pms sell household products such as toilet soap, body creams, and canned foods depending on consumer demand.21 the health-seeking practices of a community influence the utilization of available health resources. a study conducted in wakiso district, uganda identified regular stock-out of drugs, high cost of services, and long distance to health facilities as factors affecting the healthseeking practices of a community.22 findings from a study of the effects of access to primary health care services on the health-seeking behavior of nigerians showed a spectrum of health care options in the community. over 50% of the respondents sought health care at the health centers, 121 (62.7%) pms, 87 (45%) medicine vendors, 100 (51.8%) private clinics, 56 (29%) prayer houses, and 118 (61.1%) traditional healers. the researchers identified accessibility to health-care services as the most common reason for the preferred choice of visit among 79.8% of the study participants.23 the study concluded that limited access and delivery of poor-quality health service at the primary health care level accounted for nigerians seeking nonstandard health care. this study identified the prevailing healthseeking practices of a rural community and the factors responsible for the phenomenon. this information will be useful in developing behavior change strategies to promote better health awareness in the community and enhance health facility utilization. identification of options of healthcare available in the community will aid public health authorities to engage practitioners to train them and correct practices inimical to health. therefore, this paper aimed to determine the sociodemographic factors associated with healthseeking practices in a rural community setting in nigeria. methods a cross-sectional study was conducted over six months from june to november 2017 in utese, a rural community in ovia north east local government area of edo state, nigeria. utese has an estimated population of 1,320, and the people are mostly peasant farmers and smallscale traders. some socioeconomic infrastructure available in the community includes a palace led by a village headman, market, primary/secondary school, and a primary health center. residents who had lived in the community for a minimum of six months before the study were included, while those who did not consent to participate in the study were excluded. the cochrane formula for calculating sample size in a cross-sectional study was used to estimate a total sample size of 345. three hundred and eighty (380) respondents who consented to participate in the study were selected through a systematic sampling technique. a random selection of the palace was carried out, consequently; every third house was also selected and respondents who met the inclusion criteria were interviewed. a structured, interviewer-administered questionnaire was used to collect data on sociodemographic and preferred healthcare choice and health-seeking behaviors of the respondents. data were sorted for completeness, coded, screened, and entered in the spss version 25.0 software for statistical analysis. univariate and bivariate analyses were conducted for appropriate variables. sociodemographic data were presented with summary statistics as means and proportions. a chi-square test was used to find the association between respondents’ sociodemographic characteristics and options for health care. statistical significance was set at p<0.05. approval for the survey was granted by the department of community medicine, igbinedion university, okada, nigeria. permission was sought from the local government chairman, the head of the council of chiefs of utese. the verbal consent of respondents was sought before the administration of the questionnaires. respondents were assured of their right to participate and withdraw from the study at will. confidentiality of data was ensured by deidentifying respondents during data entry with the use of serial coding only. all data were safely 86 okojie & lane june 2020. christian journal for global health 7(2) stored in a secured and password-protected computer accessible only to the researcher. results respondents within the younger age categories of 10–29 years (43.4%) and 30–49 years (42.9%), made up 86.3% of the study sample. of the 380 participants, 51.1% of them were female and 48.9% males. fifty-eight percent of respondents were married while 41.6% were unmarried. fifty-one percent of respondents attained secondary education while 31.6% attained primary education. seventy-two percent of them had lived in the community between 1–29 years and 25.3% earned a monthly income of n 26,000–50,000 ($70–$140) (table 1). table 1. background characteristics of respondents characteristics (n = 380) (%) age group (years) 10–29 165 43.4 30–49 163 42.9 50–69 44 11.6 70–89 8 2.1 mean: 33.8 (13–78) years sex male 186 48.9 female 194 51.1 marital status married 222 58.4 unmarried 158 41.6 level of education none 23 6.1 primary 120 31.6 secondary 194 51.1 tertiary 43 11.3 duration of residence (yrs) 1–29 274 72.1 30–59 88 23.2 60–89 18 4.7 monthly income (n360 =$1) 1,000–25,000 284 74.7 26,000–50,000 96 25.3 forty percent of respondents aged 10–29 years chose hospitals for health-care compared to those aged 30–49 (33.7%). of respondents aged 10–29 years, 44.8% chose patent medicine stores compared to those aged 30–49 (43.6). of those aged 70–89 years, 37.5% chose traditional medicine. a chi-square of independence showed that there was no significant association between age of respondents and choice of healthcare, x2 (12, n =380) = 19.5, p = .07 (table 2). one-third of male respondents used hospitals, while 40.2% of females used hospitals. men chose a patent medicine store (33.3%) and self-care options (5.4%) for healthcare compared to women (40.2%, 5.2%). a chi-square of independence showed that there was no significant association between age of respondents and choice of healthcare, x2 (4, n =380) = 6.26, p = .17 (table 2). respondents with a primary (31.7%), secondary (41.8%), and tertiary (34.9%) level of education used hospitals for healthcare. traditional healers (26.1%) and self-care (13.0%) were reported among those without basic education. of respondents with primary school education, 15.1% used traditional healers. a chisquare of independence showed that there was a significant association between the education of respondents and choice of healthcare, x2 (12, n =380) = 22.19, p = .03 (table 2). 87 okojie & lane june 2020. christian journal for global health 7(2) forty percent of respondents who had lived in the community for 3 to 6 decades used hospitals, while 35.2% of them used patent medicine stores and faith healing. of respondents who had lived in the community for less than 3 decades, 12% used traditional healthcare, while 36.9% of them used hospitals. a chi-square of independence showed that there was a significant association between the amount of time lived in the community by the respondents and their choice of healthcare, x2 (8, n =380) = 16.06, p = .04 (table 2). table 2. background characteristics and healthcare option utilized healthcare option utilized (n=380) traditional hospital pms* faith healer self-care p age (yrs) 10–29 18 (10.9) 66 (40.0) 74 (44.8) 3 (1.8) 4 (2.4) 0.06 30–49 22 (13.5) 55 (33.7) 71 (43.6) 5 (3.1) 10 (6.1) 50–69 8 (18.2) 17 (38.6) 13 (29.5) 0 (0.0) 6 (13.6) 70–89 3 (37.5) 2 (25.0) 2 (25.0) 0 (0.0 1 (12.5) sex male 21 (11.3) 62 (33.3) 90 (48.4) 3 (1.6) 10 (5.4) 0.17 female 30 (15.5) 78 (40.2) 70 (36.1) 5 (2.6) 11 (5.2) marital status married 35 (15.8) 74 (33.3) 91 (41.0) 6 (2.7) 16 (6.8) 0.10 unmarried 16 (10.1) 66 (41.8) 69 (43.7) 2 (1.3) 5 (3.2) education none 6 (26.1) 6 (26.1) 7 (3.4) 0 (0.0) 4 (13.0) 0.02** primary 19 (15.1) 38 (31.7) 49 (40.8) 4 (3.3) 10 (8.3) secondary 20 (10.3) 81 (41.8) 86 (44.3) 3 (1.5) 4 (2.1) tertiary 6 (14.0) 15 (34.9 18 (41.9) 1 (2.1) 3 (7.0) income/month (n) (n360=$1) 1,000–25,000 36 (12.7) 100 (35.2) 128 (45.1) 6 (21.0) 13 (4.6) 0.36 26,000–50,000 15 (15.6) 40 (41.7) 32 (33.3) 2 (2.1) 7 (7.3) duration of residence (yrs) 1–-29 33 (12.0) 101 (36.9) 123 (44.9) 5 (1.8) 12 (4.4) 0.04** 30–59 12 (13.6) 36 (40.9) 31 (35.2) 3 (35.2) 6 (5.7) 60–89 6 (33.3) 3 (16.7) 6 (33.3) 0 (0.0) 3 (16.7) notes: *=patent medicine store **=statistically significant the reasons for the healthcare options utilized included promptness (41.8%), the cost (22.4%), distance from dwelling place (15.8%), professionalism displayed (16.8%), and culture considerations (3.2%). (figure 1) 88 okojie & lane june 2020. christian journal for global health 7(2) figure 1. self-reported factors influencing choice of healthcare the patent medicine store was the most utilized source of health care (42.1%). one hundred and forty respondents (36.8%) sought health care in hospitals, while 13.4% used traditional healers. (figure 2) figure 2. proportion of respondents by self-reported rural healthcare option utilized discussion the demographic profile of the participants in this study reflects nigeria’s young population with over 80% of the study subjects belonging to the age brackets of 10–29 and 30–49 years. according to the data, the younger-aged respondents appeared to use hospitals more than the middle-aged and elderly respondents. in most rural communities, the elderly people are the custodians of traditions and the perceived health benefits of traditional african healing.24 this may explain the observed high user rate of traditional healers among the elderly compared to the younger respondents in the study sample. this study revealed a gender difference in the health-seeking practices of the community. it showed that compared to 40% of women, only one-third of men used hospitals in the community. this relatively poor use of hospitals by the male respondents is not unexpected since beliefs about 89 okojie & lane june 2020. christian journal for global health 7(2) masculinity and manhood, which are deeply rooted in most african cultures, influence healthseeking behavior in many rural communities. the social system in many african communities projects men as strong, dominant, virile, and invulnerable compared to women.25 this, unfortunately, translates into an exhibition of unhealthy attitudes such as fewer encounters with the health system, poor treatment adherence, and a delay or refusal to seek prompt healthcare among men.26, 27 on the other hand, the higher proportion of women seeking hospital care in this study corroborates the finding of previous studies which showed a higher utilization of health services and better health-seeking behavior among women compared to men.28,29 this may not be unconnected with the physiological role of women in childbearing and related childcare functions like infant/child nutrition and immunization which necessitates women to frequent healthcare facilities. in this study, a significant association was found between education and health-seeking practices. a higher proportion of respondents with secondary and tertiary education were more likely to report the use of hospital care compared to those with primary or no education. this finding is in keeping with the well-documented role of education as a determinant of health.30,31,32 education has been linked to the social and psychological factors that affect health. previous studies have shown that people make better health choices when they are educated.31,32,33 education is known to be associated with improved health knowledge and better employment opportunities which create economic empowerment and lead to financial access to quality healthcare/services. in a rural setting, this can facilitate uptake of preventive and treatment services and reduce the overall disease burden in the community. as the most populous country on the african continent with a substantial number of rural dwellers, the demand for healthcare in rural nigeria is satisfied through various health service outlets.34 this study revealed that the participants (42.0%) majorly sought healthcare from patent medicine stores. this proportion is lower than that of a previous study in a rural nigerian community which reported a 62.7% utilization rate of pms.22 pms are perceived to be a more accessible and affordable source of healthcare service in many relatively poor communities in the country. this perception may account for why pms is mostly preferred among the spectrum of healthcare options in the community. besides, 42% of the respondents identified promptness of service to have the most influence on their choice of healthcare. this may further buttress the finding of a higher pms utilization rate. operators of pms are individuals who are well known to the community, and this relationship potentially helps to overcome the barriers to prompt health service delivery such as a delay due to distance from the source of care and extensive pretreatment documentation. this observation, however, raises a concern about the standard of care administered by pms practitioners in rural areas and its implication for the overall health of the community. also, it provides an opportunity for health administrators to investigate the factors accounting for poor utilization of standard medical care despite the presence of a primary healthcare center in the community. closely tied to the perceived influence of promptness of health service delivery is cost. in this study, the cost of healthcare service was the second most reported factor influencing the respondents’ choice of health care. a previous study has identified finance to play an important role in ensuring healthcare access in rural africa.35 most rural dwellers are poor and can barely afford the cost of hospital care which has been on the increase in recent times, and this may explain their choice to utilize alternative sources of healthcare such as traditional healers or faith healers. this can potentially lead to the exclusion of a large segment of the population from accessing standard health care, thus making them prone to complications of substandard treatment procedures from poorly trained local care providers. the resulting poor health will lead to low economic productivity, further deepen poverty, and increase proneness to more disease.36 90 okojie & lane june 2020. christian journal for global health 7(2) as shown in the study, there was a significant association between the length of stay in the community and health-seeking practices. it is known that time is crucial to learning, hence long-term residents are naturally expected to be more aware of the available healthcare options in a community. it is, however, unclear the extent to which such awareness due to length of stay in a community can influence health-seeking behavior. therefore, this finding of a significant association between length of stay in the community and health-seeking practices may be artifactual. this study may be limited by self-reporting bias. the fact that this study was done in one small rural community may make its findings less generalizable. besides, the non-inclusion of a qualitative component, like a focus group, may have restricted the scope of analysis of factors influencing the choice of healthcare in the community. further community-based studies should incorporate qualitative tools to explore the potential role of community gatekeepers and ward health development committees in championing positive health-seeking practices. rural-based health service research with a focus on quality management will address the community’s perception of cost and timeliness of health service delivery. besides, a follow-up study should address the nature and type of illnesses which may have influenced the health-seeking in the study participants. the authors acknowledge that this study does not provide information on the proportion of faith-related or tradition-related problems compared to modern healthcare-related problems which may have explained the patterns of health care utilization in this study. conclusion this study draws attention to the suboptimal utilization of standard health care in a rural community setting mainly due to perceived influences of cost and promptness of health care service. it revealed that rural dwellers mainly seek health care in patent medicine stores. it further showed education and duration of stay in a community as significant determinants of health care options. the health authorities should, therefore, prioritize the eradication of delays at the point of care and expand financial access to health care. these would enable rural dwellers to optimize the minimum standard of health care available within their various communities. references 1. gillam s. is the declaration of alma ata still relevant to primary health care? bmj. 2008;336(7643):536–8. http:dx.doi.org/10.1136/bmj.39469.432118.ad 2. who and wonca. working party on mental health? what is primary care mental health? ment health fam med. 2008;5:9-13. available from: https://www.ncbi.nlm.nih.gov/pubmed/22477841 3. ten years in public health 2007-2017. report by dr. margaret chan, director-general, world health organization. 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[published 2019 nov 3]. http://dx.doi.org/10.1155/2019/8739170 28. bertakis k d, azari r, helms lj, callahan ej, robbins ja. gender differences in the utilization of health care services. j fam prac. 2000 [cited 2019 dec 28];49(2):147–52. available from: https://www.ncbi.nlm.nih.gov/pubmed/10718692. 29. tenenbaum a, nordeman l, sunnerhagen ks, gunnarsson r. gender differences in care-seeking behavior and healthcare consumption immediately after whiplash trauma. plos one. 2017 [cited 2019 dec 31];12(4): e0176328. available from: https://doi.org/ 10.1371/journal.pone.0176328. 30. shankar j, ip e, khalema e, couture j, tan s, zulla rt, et al. education as a social determinant of health: issues facing indigenous and visible minority students in postsecondary education in western canada. int j environ res public health. 2013 aug 28;10(9):3908–29. http://dx.doi.org/10.3390/ijerph10093908 31. gumà j, solé-auró a, arpino, b. examining social determinants of health: the role of education, household arrangements and country groups by gender. bmc public health. 2019;699(19). https://doi.org/10.1186/s12889-019-7054-0 32. onyeonoro uu, ogah os, ukegbu au, chukwuonye ii, madukwe oo, moses ao. urban-rural differences in health-care-seeking pattern of residents of abia state, nigeria, and the implication in the control of ncds. health serv insights. 2016;9:29–36. http://dx.doi.org/10.4137/hsi.s31865. 33. hahn ra, truman bi. education improves public health and promotes health equity. int j health serv. 2015;45(4):657–78. http://dx.doi.org/10.1177/0020731415585986 34. wellay t, gebrselassie m, mesele m, gebretinsae h, ayele b, tewelde a, et al. demand for health care service and associated factors among patients in the community of tsegedie district, northern ethiopia. bmc health serv res. 2018;18(1):697. http:dx.doi.org/10.1186/s12913-018-3490-2 35. versteeg m, du toit l, couper i. building consensus on key priorities for rural health care in south africa using the delphi technique. glob health action. 2013;6:19522. http://dx.doi.org/10.3402/gha.v6i0.19522 36. murray s. poverty and health. cmaj. 2006;174(7):923. http://dx.doi.org/10.1503/cmaj.060235 peer reviewed: submitted 31 dec 2019, accepted 18 feb 2020, published 22 june 2020 competing interests: none declared. correspondence: paul west okojie, liberty university, united states of america. okwestonline@yahoo.com cite this article as: okojie pw and lane r. healthcare options and factors influencing health seeking behavior in a rural community in nigeria: a cross-sectional study. christian journal for global health. june 2020; 7(2):83-92. https://doi.org/10.15566/cjgh.v7i2.335 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.1155/2019/8739170 https://www.ncbi.nlm.nih.gov/pubmed/10718692 https://doi.org/%2010.1371/journal.pone.0176328 https://doi.org/10.1186/s12889-019-7054-0 http://dx.doi.org/10.4137/hsi.s31865 http://dx.doi.org/10.1177/0020731415585986 http://dx.doi.org/10.1186/s12913-018-3490-2 http://dx.doi.org/10.3402/gha.v6i0.19522 http://dx.doi.org/10.1503/cmaj.060235 mailto:okwestonline@yahoo.com https://doi.org/10.15566/cjgh.v7i2.335 http://creativecommons.org/licenses/by/4.0/ editorial june 2020. christian journal for global health 7(2) the changing landscape of mission hospitals: relevance, quality and sustainability for this issue, the journal’s editors called for papers dealing with the challenges facing faithbased hospitals in the light of changing social, governmental, economic, and technological landscapes in the countries where these hospitals serve. the changes have been accelerated and the challenge multiplied by covid-19’s effect on economies, health systems, and social dynamics. this has led mission hospitals to re-evaluate and adapt their role in these changing landscapes. one definition of challenge is to dare or to arouse or stimulate by the presence of difficulties. a challenge is thus an opportunity for learning, for change, for growth, and for development. the theme is introduced by bruce dahlman’s guest editorial, in which he outlines cogent reasons why capacity building can be a strategic avenue for continuing christian outreach in the majority world. this strategy is complemented by his parallel commentary on why healthcare and the broader mission of the church must go together. it is only through integration of the two that the gospel is preached and lived out in the way jesus indicated in sending out his disciples. we hope that the submissions we publish here begin to illustrate in particular ways how the opportunities before us can be met. four complimentary perspectives on the transitions occurring in mission hospitals in india are shared. father john thekkekara used a multiple, embedded, case-study method to evaluate 16 faith-based institutions in india in terms of sustainability and inclusiveness, noting that these objectives may often be in tension. various strategies and their relative successes are evaluated. kate long and her colleagues from boston university assessed the challenges to christian mission hospitals in india over a more recent time period, that from 2010 to 2017. they identified three core capacities that helped these institutions navigate these challenges. perry jansen offers a systematic literature review which identified core themes for success of faith-based hospitals in india. flint, ismavel and miriam analyze how the makunda christian leprosy and general hospital in assam over the last 25 years has modeled a sustainable approach to quality care in low resource settings despite minimal external funding. this is a peer-reviewed paper of a study which originated from scholars at the wharton school of business. all four studies can contribute significantly to maintaining resilience in the face of institutional challenges that without doubt will continue throughout the world. these systematic studies are complemented by a case study by professor bern lindtjørn who details the intriguing history of yirga alem hospital in southern ethiopia under the aegis of the norwegian lutheran mission since the middle of the last century. this hospital has sustained decades of political and economic challenges, both in ethiopia and in norway, yet the hospital continues to do its important work as an example of fruitful collaboration between a christian mission and a secular government. in the light of the difficulties that have come to impede long-term hospital-based medical mission work, short-term medical missions have become more popular in response to global disparities. yet many of these efforts do not align with international standards and best practices. to study this phenomenon using a convenience sample, susan andrews found considerable variation in the degree to which there was adherence. this assessment was of the supply side of healthcare provision, but there are greater gaps in the literature on the demand side. paul west https://journal.cjgh.org/index.php/cjgh/article/view/413 https://journal.cjgh.org/index.php/cjgh/article/view/413 https://journal.cjgh.org/index.php/cjgh/article/view/321 https://journal.cjgh.org/index.php/cjgh/article/view/337 https://journal.cjgh.org/index.php/cjgh/article/view/319 https://journal.cjgh.org/index.php/cjgh/article/view/319 https://journal.cjgh.org/index.php/cjgh/article/view/389 https://journal.cjgh.org/index.php/cjgh/article/view/351 https://journal.cjgh.org/index.php/cjgh/article/view/341 https://journal.cjgh.org/index.php/cjgh/article/view/335 2 editors june 2020. christian journal for global health 7(2) okojie and richard lane surveyed rural citizens in southern nigeria with regard to their choices for healthcare. the most popular healthcare provider was the local medicines store followed by the local hospital, but traditional healers are often consulted. promptness and cost as well as tradition were the major drivers for the choices these patients made where health insurance was not accessible. there are many factors which affect health and longevity, including faith and justice in communities. does universal health insurance with its provision of increased access to healthcare result in increased life expectancy? sabina ampon-wireko and her colleagues from jiangsu university in china used sophisticated statistical methods on data from 13 emerging countries to suggest that it did, along with increased physician ratios, heath expenditures, and education. health workers in short supply can themselves be casualties in the demands of work and learning. gretchen slover studied fourth-year, medical students at the university of zambia school of medicine and whether counselling services were either needed or desired to help them address common stress, worries, and fears. in the face of changing demand and supply amid both public and private competition, and the influence of the primary health care approach of alma atta, traditional mission hospitals have often diversified into community health and development approaches. dykstra and paltzer’s review of faith-based holistic health models identified community engagement and cultivating relationships as key motivating themes. a classic but updated resource used for community health is setting up community health and development programmes in low and middle-income settings, a book by ted lankester and nathan grills, reviewed in this issue. spirituality and health is a sustained focus of interest for the journal and to that end, matthew bersagel braley reviews why religion and spirituality matter for public health: evidence, implications and resources, edited by doug oman. the book provides a comprehensive basis for public health practitioners to understand religion and spirituality. taking us even deeper into spiritual understanding in these days of covid-19 which seem to be a never-ending affliction, lois armstrong reflects on how these circumstances can encourage us to “number our days” in the ways moses had in mind in psalm 90. which brings us back to covid-19. our special issue in may generated significant interest and was accessed by record numbers of readers. we have continued to receive submissions on that subject as our call for papers on epidemics and pandemics continues. the christian voice has distinctive content to express, and the opportunities for the church are immense in the face of a global pandemic. we will soon be publishing a special issue on a prior call for papers on the formative first years of the human life cycle. please contact us with any interest in joining the editorial team to continue to offer the world evidence of the work of god’s people empowered to face the challenges before them with courage and grace. https://journal.cjgh.org/index.php/cjgh/article/view/335 https://journal.cjgh.org/index.php/cjgh/article/view/347 https://journal.cjgh.org/index.php/cjgh/article/view/347 https://journal.cjgh.org/index.php/cjgh/article/view/325 https://journal.cjgh.org/index.php/cjgh/article/view/311 https://journal.cjgh.org/index.php/cjgh/article/view/343 https://journal.cjgh.org/index.php/cjgh/article/view/343 https://journal.cjgh.org/index.php/cjgh/article/view/399 https://journal.cjgh.org/index.php/cjgh/article/view/399 book review hoping to help: the promises and pitfalls of global health volunteering by judith lasker, ithaca: ilr press; 2016 laura m. montgomerya a phd, dean of global and experiential learning, professor of anthropology, wheaton college, united states of america keywords: short-term medical missions, humanitarian volunteerism, service learning in hoping to help: the promises and pitfalls of global health volunteering, judith lasker seeks to go beyond the simple question of whether shortterm medical volunteer opportunities do more harm than good to answer “... a larger ethical question: whether the investment of billions of dollars of resources in the short-term volunteering enterprise can be justified by the results in terms of improvement in health, reduction in health disparities, or other measures of value to the host communities (p.16).”1 she gathers information from a survey of 117 organizations that sponsor opportunities for short-term volunteer medical missions or brigades, and interviews 119 individual volunteers and staff of both sending and receiving organizations from around the globe. she also participates as a volunteer in programs to ecuador and haiti. the strength of hoping to help is that it provides the reader with an overview of the heterogeneity of organizations, stories of volunteer motivation and experience, and information on the effects on host communities of numerous efforts to provide health-care through short-term efforts to underserved populations in the global south. lasker makes clear that understanding global health volunteering requires avoidance of simplistic generalizations. her extensive use of quotes from survey data and interviews illustrate the commonalities and differences in the perspectives of program leaders, volunteers, and hosts. the organizations range from churches, educational institutions, faith and non-faith-based nongovernmental organizations, to corporations. in some cases, these opportunities spring from the initiative of a single individual who felt a need to respond personally to circumstances encountered during a sojourn in an underserved area. volunteers express many and often mixed motivations for their participation: a desire to help, self-actualization, improved educational or employment opportunities, religious convictions, or a sense of “giving back.” likewise, the perspectives of receiving organizations reflect both positive and negative assessments; the most positive often relate to longerterm projects that focus on training. lasker also draws attention to the disparities among these organizations in the selection and preparation of participants, and the quality of care provided. in the final chapters, she offers nine practices based on her research findings that, if followed, may result in efforts more likely to yield positive rather than negative outcomes. the appendix provides both recommendations and cautions to those considering participation in health-related volunteer opportunities. she concludes that long-term programming is probably a better approach especially if focused on capacity-building. in hoping to help, lasker rightly points out that the voices of host communities are often unheard in assessments of short-term, health-related volunteer efforts. she explains, “it is crucial to know what people in the host communities — the global south — think...” which is the rationale for “... 44 montgomery nov 2018. christian journal for global health 5(3):43-46. devot[ing] so much space... to recounting what they have to say (p. 15).”1 unfortunately, she commits the same omission. she relies heavily upon the perspectives of host-country staff or health-care providers to describe or evaluate the benefits to host communities. these individuals may or may not be members of or the appropriate spokespersons for the communities or populations served. with reference to the effects on host communities, lasker does reiterate a basic principle of healthcare: “first, do no harm”, and points out that “harm” is not limited to medical harm but includes the potential to undermine local practitioners and host organizations, and to consume their time and resources in addition to challenges regarding continuity of care. a more descriptive title of the section on host communities would have been “host providers or organizations.” apart from rare examples, however, we do not hear the voices of those on the receiving end of the care provided by global health volunteers: the patients. we learn little about their experiences or perspectives regarding the effects on their health status, access to health care, or implications for their daily lives. those served by volunteer groups are often from vulnerable populations such as the poor, the educationally disadvantaged, or victims of disaster. vulnerable groups often incur proportionately higher costs for transportation, lost wages, and long waiting times when seeking health care than more affluent patients. health care provided by volunteers should not add to these burdens, whether from prolonged or unclear communication due to lack of skill in the local language, affront to dignity caused from cultural ignorance, stress created by the need for assessments or tests done by untrained individuals to be rechecked, unexpected costs incurred from complications or side effects of free care or medications, or other inconveniences which affect these populations but are often invisible or incidental to others. to do otherwise is to exploit their vulnerability. more importantly, who provides compensation when a patient is harmed, permanently disabled, or dead from the care received from volunteers? certainly, careful attention must be paid to the challenge of soliciting candid responses from those who may perceive their access to health care as dependent upon positive reports of their experience. nonetheless, patients’ accounts of their own needs, perspectives, and experiences must be heard directly and weighed heavily in any analysis of the ethical or practical worthiness of global health volunteering. the book’s weakness is the paucity of data from persons served. the major contribution of hoping to help is that it compiles and organizes information gained from many organizations, volunteers, and hosts, and summarizes problems and concerns discussed in the academic literature in an accessible narrative. in this respect, it will be a helpful resource for those unfamiliar with global health volunteering or those organizations and individuals who would like to examine their own efforts within a broader context. nonetheless, the book’s general findings and principles have been long noted in the scholarly literature; the book offers little new information. 2,3,4,5 prior work has identified the lack of evaluation or recognition of its importance as a significant barrier to assessing the efficacy or appropriateness of global health volunteering.2,4 greater attention to the body of research on christian short-term missions in general would have provided the author a broader context to interpret the comments and perspectives of leaders and participants in faith-based health efforts.6,7 similarly, previous research has addressed issues that lasker claims are undocumented or understudied, such as the significance of religious motivation or affiliation, effects on charitable giving, influences on the “global perspectives” of participants, or benefits to the local community — issues common to most short-term humanitarian efforts even though additional research is warranted.6,7 the nine practices identified as keys to improve the efforts of organizations or individuals engaging in short-term medical volunteering are those that scholars have described over the last few decades for shortor long-term humanitarian or community development efforts.8,9 if these 45 montgomery nov 2018. christian journal for global health 5(3):43-46. principles were heeded, global health volunteering would be more likely than not to reduce its drawbacks and increase its benefits, but employing them properly requires high levels of expertise, deep cultural knowledge, language proficiency, and longterm knowledge of communities. organizations in long-term community development or health projects find them difficult to implement, especially when compounded by the pressures of donors or governments to produce quick results. for these reasons, lasker’s expectation that organizations or individuals with a short-term focus might incorporate these practices broadly is overly optimistic. in summary, the primary question posed by hoping to help is left unanswered. the book fails to provide the empirical evidence needed to assess whether the significant investment of money and effort is justified through measured improvements in health status, reductions in health disparities, or greater access to health service beyond mostly anecdotal accounts. even the information that leads lasker to conclude that longer-term capacity building may provide some measure of value to the host communities is not clear-cut. granted, the data required to draw a more definitive conclusion is complex and may be difficult to gather or may even prove elusive. nevertheless, clearer evidence is needed urgently given the great health needs of much of the world’s population, the staggering amount of financial and personnel resources consumed by these efforts, and the potential for great harm to vulnerable populations. we need more than a “maybe” coupled with the hope that with the right structure, motivations, and preparation the answer is more likely than not to be, “yes.” references 1. lasker j. hoping to help: the promises and pitfalls of global health volunteering. ithaca: ilr press; 2016. 2. dohn mn, dohn al. quality of care on short-term medical missions: experience with a standardized patient record and related issues. missiology: int rev. 2003;37(4):417-29. https://doi.org/10.1177%2f009182960303100403 3. landa a. short-term medical missions: a summary of experiences. j lat am theol. 2007;2(2):104-18. 4. montgomery lm. short-term medical missions: enhancing or eroding health? missiology: int rev. 1993;21(3):333-41. https://doi.org/10.1177%2f009182969302100305 5. montgomery lm. reinventing short-term medical missions to latin america. j lat am theol. 2007;2(2):84-103. 6. priest rj, guest editor. special issue: short-term missions. missiology: int rev. 2006;34(4). 7. priest rj, howell b, guest editors. special issue: anthropology and sociology of short term missions. missiology: int rev. 2013;41(2). 8. priest rj. effective engagement in short-term missions: doing it right. evangelical missiological society series #6. pasadena, ca: william carey library; 2008. 9. the literature here is almost too extensive to cite. two examples are: chambers r. rural development: putting the last first. essex, england: longman group limited; 1983. chambers, r. whose reality counts? putting the first last. london: intermediate technology publications; 1997. submitted 16 sept 2018, accepted 20 sept 2018. competing interests: none declared. correspondence: laura m. montgomery, wheaton college, united states of america. laura.montgomery@wheaton.edu https://doi.org/10.1177%2f009182960303100403 https://doi.org/10.1177%2f009182969302100305 mailto:laura.montgomery@wheaton.edu 46 montgomery nov 2018. christian journal for global health 5(3):43-46. cite this article as: montgomery l m. hoping to help: the promises and pitfalls of global health volunteering by judith lasker, ithaca: ilr press; 2016. christian journal for global health. nov 2018; 5(3):43-46. https://doi.org/10.15566/cjgh.v5i3.246 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.15566/cjgh.v5i3.246 http://creativecommons.org/licenses/by/4.0/ conference report nov 2018. christian journal for global health 5(1):59-63. the xvi international christian medical and dental associations’ world congress indira kurapati a , daniel w. o’neill b a manager, development & special projects, christian medical association of india, organising member, xvi icmda world congress. b md, ma(th), assistant clinical professor, family medicine, university of connecticut school of medicine, usa the xvi quadrennial icmda world congress was held from 21-26 august, 2018, at leonia holistic destination, hyderabad, telangana, india. the theme of the congress was “in the footsteps of the great servant healer,” the focus being to “reflect-repent-renew.” it was inspired by the verse from isaiah 42:6, “i will give you as a covenant for the people, a light for the nations.” (esv) the congress was well attended, with 847 delegates representing 86 countries. the congress was organized by the international christian medical and dental association (icmda), christian medical association of india (cmai), and evangelical medical fellowship of india (emfi). the program consisted of bible expositions, devotions, plenaries, and a wide range of workshops / sessions over the 6 days on 88 topics, with 81 facilitators who were experts in their areas of work / mission. students and junior graduates’ congress students and junior graduates met for 3 days prior to the main congress. dr. daniel ho (malaysia) gave the bible expositions, calling them to be a commissioned, committed, and compassionate people, serving as a contrast, compass, companion, comrade, and catalyst to “regularly affect the situation” amid global healing contexts while “serving people with no strings attached.” dr. helen sigua (philippines) spoke on health and wellness as well as leadership in healthcare. four pre-congress workshops for graduates were held on 22nd august: ‘saline process,’ ‘christian perspective and christian response to mental health,’ ‘kingdom of god in health care,’ and ‘whole person medicine education (prime).’ the “family time” on 22 nd august was a meeting for leaders of national organizations, organized for the first time to build capacity of and fellowship among the leaders of national movements. 60 kurapati & o’neill nov 2018. christian journal for global health 5(1):59-63. main congress dr. vinod shah, ceo, icmda, commenced the inaugural ceremony by saying a word of prayer and delivering his welcome address, and dr. bimal charles, general secretary, cmai, formally introduced the dignitaries on dais including dr. elmer thiessen, chairperson, icmda, dr. mathew george. dr. rajkumar songa from the national/local organising committees. inaugural address the lamp lighting ceremony was led by the chief guest, dr. s. venkatesh, director general of health services, ministry of health and family welfare, government of india, along with other dignitaries on the dais. dr. venkatesh spoke on the health needs of the indian population, highlighting the important role of christian health professionals taking the lead in medical education and service toward the unreached populations, especially in areas requiring malaria and disaster relief. he noted the problems of health systems constrained by the lack of love and compassion, superspecialization and reductionism, antimicrobial resistance, climate change, outbreaks, and disaster. he also pointed out how faith plays an important role in providing a safe place, social structure, partnerships, and intentional strategies for health promotion. there is a need for wholistic care and community-based researchers and healthcare delivery through public-private partnerships, emphasizing caring, team-based efforts, evidence, and informatics. he emphasized that the future doctors would be required to not only be competent clinicians but also good managers, qualified researchers, and advocates of promotive and preventive health care, that our whole lives would be testimonies to god’s honor. bible exposition each day of the congress included a scholarly bible exposition by rev. charles price (canada) in the morning who emphasized the new covenant and the internalized, fulfilled law marked by transformation into christ’s likeness (2 cor 3:17-18), and the “indwelling of the life of god in our own existence.” in the evenings, an inspirational devotion led by mr. rajkumar ramachandran (india) emphasized being a light to the nations through imitation of christ and worldaffecting personal holiness. 61 kurapati & o’neill nov 2018. christian journal for global health 5(1):59-63. plenary sessions there was one plenary session each day. dr. peter saunders (uk) spoke on ethical challenges in healthcare, noting the global burden of disease, injustice toward the unborn (42% of all global deaths), and the challenge of facing the four prominent ethical drivers of society: autonomy “we want it,” personal pleasure “we need it,” technology “we can do it,” and moral relativism “why not?” he called for following in christ’s footsteps, as “flawed masterpieces,” assuming responsibility as “delegated vice-rulers” to protect human dignity, speak truth no matter what the cost, uphold god’s design for human sexuality, bear one another’s burdens, and seek justice for the voiceless. dr. david stevens (usa) gave a call to “be bold” by maintaining the faith amidst strong secular humanist pressures by being willing to be mentored, to take risks, to learn from failures, to lead and mentor others, and to fully trust in god. dr. daleep mukarji, obe (uk) spoke on poverty (65% of the indian population, and 1.5 billion globally in severe poverty), inequity, and discrimination, and christ’s call to bring justice to the nations (isaiah 42:1-7) and hope to the impoverished – looking at root causes, advocating for the poor (prov 31:8-9), and healing through reconciled relationships. this requires christian doctors who are professionally competent, spiritually alive, socially committed, and sensitive to context and culture. parallel and breakout sessions there were a wide variety of excellent sessions (parallel workshops and breakout sessions). there were eight parallel workshops that were on servant leadership, mentoring and spiritual formation, bio-ethics, missions, governance and strategic thinking, understanding world views, care for the elderly, and palliative care. there were 18 breakout sessions that were designed around three themes: mission and engagement, building people, and program design. these included surgical health care for rohingya refugees, geriatric and palliative care capacity building, integrative mental health, transformational leadership, strategic hiv care, rethinking short-term missions, and a session on research and publishing by two of this journal’s editors. some time, during and after dinner, was set aside for networking and fellowship. there was a colorful and lively graduates international night, where the youth alive group presented a glimpse of india’s rich and colorful culture through fusion of christian music and dance. many countries came forward to represent their regions by presenting songs, dances, videos, and skits in their traditional attires, showcasing diverse cuisine, art, and crafts from various countries that delegates could enjoy. it was truly a time of beauty, friendship, and unity across cultures. 62 kurapati & o’neill nov 2018. christian journal for global health 5(1):59-63. praise and worship the two indigenous groups did a wonderful job of leading praise and worship on all the days of the congress: the shiloh worship band, a group of medical and healthcare professionals (alumni of christian medical college, vellore) who were from various backgrounds but with one heart to serve god through music. the ministry, sounds of the nation also sought to carry people on a heavenward quest through the medium of indigenous music. team uganda cmf included 6 multi-age vocalists who led african style worship, and the north east choir, a group of 50 vocalists sang for the closing session. closing session the congress concluded as rev. roger gaikwad, general secretary of the national council of churches in india, conducted the holy communion service using a meaningful contemporary order of service and spoke about reflecting the life and work of the lord jesus as bearers of justice, light to the nations, promoters of the message of freedom, reconciling servant healers, and transformational servant leaders – with a character of self-emptying, humility, and attention to mentoring new generations of christfollowers. the quadrennial icmda congress is looking forward with excitement to reconvene in 2022 in tanzania. 63 kurapati & o’neill nov 2018. christian journal for global health 5(1):59-63. competing interests: none declared. acnowledgements: international christian medical and dental associations (http://icmda.net), christian medical association of india (www.cmai.org), and evangelical medical fellowship of india (http://www.emfi.in) correspondence: indira kurapati, cmai, new delhi, india indira.k@cmai.org cite this article as: kurapati i, o’neill dw. the xvi international christian medical and dental associations world congress. christian journal for global health. nov 2018; 5(3):59-63. © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://icmda.net/ https://eur02.safelinks.protection.outlook.com/?url=http%3a%2f%2fwww.cmai.org%2f&data=02%7c01%7c%7cb70cf0c4b93a457634da08d64549c2d9%7c84df9e7fe9f640afb435aaaaaaaaaaaa%7c1%7c0%7c636772581658942688&sdata=%2bb6yymy9klecxaqsn%2b7wavbj%2fwjsxko9epi5wh50p1e%3d&reserved=0 http://www.emfi.in/ mailto:indira.k@cmai.org http://creativecommons.org/licenses/by/4.0/ original article sustainability and inclusiveness in a competitive market: a study of faith-based hospitals in india john varghese thekkekaraa a mha, mphil, phd, department of hospital administration, st. john’s medical college, bangalore, india abstract introduction: the christian healthcare network is the largest faith-based healthcare network in india, functioning, most often, in the hard-to-reach and underdeveloped areas. it is facing serious challenges such as being forced to comply with the recent changes in government regulations, policies, and globalized market situations. such changes in the social and financial environment are driving hospitals to adopt newer strategies to remain sustainable. some of the mission hospitals are compromising their mission goals for which they were founded. if financial viability becomes the goal, social responsibility to the community and the true meaning of mission gets distorted. their mission must remain the primary belief system, which legitimizes the structural arrangements and ideology of business. mission and business must go hand-in-hand. methods: an embedded case study method was used to purposively study 16 selected cases of christian faith-based hospitals (fbhs) pan india with the objective to understand the nature of services employed, the role played by fbhs in india in different contexts, their challenges in the changing business environment, and how successful they were in remaining both sustainable and inclusive at the same time. results: the study found that despite the variation in the services and infrastructure of mission hospitals across india, these facilities have had an on-going commitment and a long-standing operation with regard to population health. in their different settings, they are either the only service provider or the referral centre for the public facilities and the trusted choice of the middleand lower-middle class population. the least sustainable and inclusive among them seem to have deviated from their founding objectives due to market changes, but more than a quarter of them were successful in remaining inclusive and sustainable. in pursuit of competitive advantages, some of them remained sustainable by dropping their inclusiveness, while a few ended up in existential crisis because of their adhesiveness to inclusivism. the challenges of attracting professionals, generating funds for development, and operating within the ethical boundaries set by the church are well addressed by the models which are sustainable and inclusive. conclusion: in the context of drastic changes in both internal and external environments, some of the fbhs lost their business, some lost their mission and a few got corporatized. but a few remain successful in terms of inclusiveness and sustainability by innovative strategies. 8 thekkakara june 2020. christian journal for global health 7(2) key words: faith-based hospitals, indian mission hospitals, sustainability, inclusive healthcare, not-for-profit hospitals introduction more than three-fourth of indian healthcare facilities are owned by private providers. christian faith-based hospitals (fbhs), which were the pioneers in introducing the practice of modern medicine in india four centuries ago,1 form a major chunk of the service providers, mostly located in rural india. a study conducted in 1993 on the catholic health association of india2 (chai), the largest fbh network in india, pointed out that they were facing challenges such as getting doctors and other trained professionals, inadequate infrastructure facilities, financial constraints, nonavailability of medicines, the inability to afford even basic care for the majority of their beneficiaries living in poverty, malnutrition and communicable diseases, and the emergence of small clinics in their neighbourhood. researchers had already pointed out that changes in social and financial environments were driving hospitals to adopt newer strategies to remain sustainable.3 economic liberalization of the early 1990s opened the market for corporate for-profit multinational players to invest in indian healthcare. the government reduced tariffs on trade and provided incentives for foreign direct investment (fdi) of up to 100 percent. the proportion of healthcare provided by the private sector increased rapidly.4 unregulated imports and the installation of high-end medical technology was a strategy that the corporate healthcare industry used for market penetration.5 accreditation was another strategy used which benefitted in giving larger private hospitals a competitive advantage. reforms were also happening in the indian public sector simultaneously. by the year 1999, insurance regulatory and development authority of india (irda) also opened the healthcare insurance market for investment to foreign corporates. the introduction of national rural health mission (nrhm) in 2005 decentralized the organization of and resource allocation in indian healthcare. infrastructure modifications and manpower availability in public facilities improved. schemes offering financial protection from the central government (rsby) and state governments came to the help of the people, especially the poor. in the meantime, the union government also brought a plan to control the private sector through the introduction of clinical establishment act (2010). still 60 percent of the total health expenditure is financed through out-ofpocket expenditure and the national sample survey (71st round) shows that the private sector caters to 75 percent of out-patient and 62 percent of in-patient services in india, holding 70 percent of the total hospitals and 40 percent of the total hospital beds in india.6 internally, fbhs had already been suffering from a shortage of financial support as “funds from the sending churches have tended to diminish materially in recent years.”7 in this context, fbhs had to face a changed business environment with several new challenges. one such challenge was complying with the regulatory framework as per the clinical establishment act (2010),1 and another was the competition for the paying patient from the growth of commercial health sector consequent to government incentivizing investment in healthcare infrastructure,8 increased fdi in healthcare,4 and unregulated penetration of high-end medical technology in the indian market.5 studies on christian fbhs, their challenges and sustainability are not reported in the past decade. in the context of the recent national health policy of india (2017), which is imploring more private participation in healthcare delivery, it is momentous to study how christian mission hospitals make themselves sustainable† and inclusive††. materials and methods the objectives of the study were to understand the nature of services and the role played by fbhs in india in different contexts, their 9 thekkakara june 2020. christian journal for global health 7(2) challenges in the changing business environment, how successful they were, and the strategies they adopt for remaining both sustainable and inclusive at the same time. the multiple embedded case study method proposed by r.yin9 was used to study sixteen purposively selected fbhs across india. the case study method makes extensive use of qualitative data and limited use of quantitative data, both from primary and secondary sources including archival reports. when multiple variables of various cases are analysed for their similarities and differences, the method is called multiple embedded case study. each case setting may have its own culture, values and ways of thinking, judging, and talking about living experiences. all these contribute to make evidences in a case study research which is the basis for theorizing. according to gillham, “case study method uses both objectivity and subjectivity in its pursuit to understand the underlying reasons. it has its own dynamics.” 10 the three major fbh service providers in india, namely christian medical association of india (cmai), chai, and emmanuel hospital association (eha), all of which have a wide presence across the different states of india, were considered as population for the study. three sample hospitals each from the five regions of india, namely north east, north, central, western, and southern india with at least 40 years of existence, were purposively selected based on discussions with key informants* who assessed the performance of these hospitals as successful or struggling to survive. the sample had two catholic hospitals and one protestant hospital each from all the five regions. an outstanding case of nearly one hundred years of existence from the north east was added to the sample during the data collection period, resulting at a final sample size of sixteen hospitals. site visits and in-depth interviews with administrators, senior managers, doctors, and beneficiaries were conducted after obtaining informed consent. additionally, statistical and financial data were also collected. this study was conducted as part of a doctoral research study and not funded in any way. ethical clearance was obtained from the institutional review board of tata institute of social sciences, mumbai. however, the identities of the hospitals studied are not disclosed due to ethical reasons. detailed case study reports are ready for reference and may be made accessible on request. results services offered by fbhs three of the sixteen hospitals studied had less than 100 beds, three of them had more than 300 beds, and the rest of them had 100 to 300 beds. the percentage of “general beds” in these facilities varied between 40 to 95 percent. bed occupancy level showed a range of 40 to 90 percent; the majority of them had more than 60 percent occupancy. three of the hospitals provided primary care; eight of them also provided secondary care; and only five of them provided both secondary and tertiary care. the range of out-patient services utilized was 40 to 1200 patients daily, but six had more than 100 outpatient department (opd) visits per day, and another six had more than 400 opd visits per day. emergency visits ranged from 20 to 120 per day with the median being 25. the number of surgeries varied between one and 30 per day, with a median of 8.1. five of them had more than five surgeries a day, another three had more than 10 surgeries a day, and one had more than 30 surgeries a day. the number of deliveries ranged from 80 to 5000 per year. ten of these hospitals had their own licensed blood-bank, and one used an outsourced facility. five of them had their own ambulance, but three of them depended on a public ambulance (dial 108 system). in one sub-district (taluka), there was no ambulance; only autorickshaws were available for moving patients. all the hospitals studied had ecg and ultrasonography six of them had ct scanners, four had mri scanners, four had cath-labs, and one had a cobalt unit. only one of them had an integrated it system. five of them had limited it 10 thekkakara june 2020. christian journal for global health 7(2) applications, mostly for registration and billing. others had no it applications. challenges for fbhs today a comparison of the challenges observed in this study with those found in the 1994 study using the delphi method,11 would be interesting. the top ten items are taken for comparison (table 1). table 1. comparison of challenges identified among chai hospitals in 1994 and 2018 findings of the delphi study in 1994 findings of this study in 2018 1.lack of infrastructure and facilities 1.doctors, their availability and retention 2.difficulty in getting professionals such as doctors and nurses 2.government regulations including cea and pollution control 3. financial constraints 3.financial constraints – inability to raise funds 4. social issues like poverty, illiteracy, etc. 4.turnover of nurses 5.expectations of free care and medicine 5.demands from customers for high-end technology and facilities 6. non-availability of drugs 6.mushrooming of hospitals and competition raised by corporates 7.follow-up of cases due to lack of education among patients 7.infrastructure limitations 8. large number of communicable diseases 8.accreditation as a need 9. mushrooming of private clinics 9. poverty among the beneficiaries 10. lack of referral facilities 10.violence against hospitals a few items among the top ten challenges reported in 1994 are not among the top ten now. (1) non-availability of drugs. this shows that drugs and medicines are available everywhere in the country now, even in very remote locations. none of the cases studied faced this problem. in fact, the north east hospitals reported that introduction of the goods and services tax (gst) made the movement of medicines and supplies faster than before. (2) challenge of follow-up. better education and awareness among patients seem to have changed the situation. (3) communicable diseases are still present. the management of them might not be as big an issue now as it used to be. (4) referral facilities are available now in most of the locations. most of the mission hospitals themselves have grown into referral centres. there is difficulty in accessing referral centres reported in the cases studied. but this challenge seems to be a relatively small threat now. a few challenges which were not among the top ten items formerly have now found a place there. (1) government regulations including cea and pollution control. this is not only a new entrant but has also received the second highest place among the major challenges. this is an indication that the recently introduced policy changes and regulations, especially those by the cea, have raised a serious challenge for fbhs in india. (2) turnover of nurses is an issue now. in 1994, they faced difficulties in getting professionals; now retention of nurses is a challenge. this points to the fact that nurses trained at fbhs are also not staying with them; rather they are moving away for better prospects. fbhs are becoming training centres from which other institutions are benefitting. this seems to be a serious threat when associated with the statement from some patients that they are not happy with the services of fbhs because they mostly have inexperienced junior nurses. (3) accreditation as a need: some of the cases studied inform us that accreditation is an essential requirement for sustainability, but they do not have the trained 11 thekkakara june 2020. christian journal for global health 7(2) personnel or resources for it. (4) among the top ten challenges, there is a surprising new entrant— violence against hospitals. this indicates that the response of the people towards healthcare providers, even those who are mission hospitals, is changing, and this could be due to increased expectations and awareness. one can also see that “infrastructure limitations” has moved from the leading constraint faced in 1994 to a much lower position by 2018. there are infrastructure modifications happening in fbhs, but other challenges have become a greater priority. in the earlier study, the demand was for free care and medicines, but now the patients are demanding better technology and amenities. for instance, an administrator in jharkhand said: “they (patients) have become aware about the machines and technology in hospitals in the city. they have started demanding for such high-end technology which we cannot afford.” another one in jharkhand said: “people have become very demanding, aggressive, and violent irrespective of their socioeconomic class. they live with better facilities now. in hospitals, also, they like to see better facilities and technology.” only clinics were reported to be mushrooming in their immediate business environment in 1994, but now more hospitals have come up, and corporate players are raising challenges for fbhs. the result of these changes is that the affordable class of beneficiaries are moving away from fbhs, and with it, not only does sustainability come under threat, but also inclusiveness since the financial surplus needed for cross-subsidy is much less available. providers who were interviewed also perceived a change in perception of what good healthcare is among the new generation. this is not surprising since the new market situation, experienced in all realms of life, modifies the perception in healthcare also. this has been perceived as behaviour changes in health seeking in the mission hospitals studied. on the contrary, providers perceive the older generation as still looking for ethical and value-driven healthcare, irrespective of the nature and location. for example, a doctor in karnataka said in the interview: now the patients are dictating the plan of treatment and they even propose diagnostic tests to be done. still, the older generation show much respect and trust. the young generation comes with demands and they look for magical remedies. they have some knowledge, but no comprehensive knowledge. one of the administrators in assam said: the older generation still has trust and confidence in this hospital and its treatment. but the young generation turns demanding and violent very soon. they feel that because they are paying, they should get guarantee of recovery. to a large extent, this is an urban trend, but as markets penetrate rural areas and similar perceptions emerge, it could result in decreased sustainability of many mission hospitals which would, in turn, result in a vacuum of healthcare provisioning in many rural regions. the corporate hospitals that have already signalled their interest in rural healthcare would exploit this situation, leaving the poor rural indians further impoverished. strategic choices under the pressure of changing external and internal factors affecting the business environment, fbhs were forced to make a strategic choice and adapt themselves in the changed situation. the three major choices available to them were: (1) to be like their corporate counterparts in the market and be “successful” according to the market logic, which is equivalent to being financially sustainable, (2) to offer selective services and ensure that either sustainability or inclusiveness is maintained, and (3) to stick to inclusiveness, which is the raison d’etre of mission hospitals,12 and adopt innovative means with utmost professionalism to ensure sustainability. a fourth and the worst choice is to exit the market and be non-existent. the outcome of their choices would 12 thekkakara june 2020. christian journal for global health 7(2) be reflected in four decisive indicators: (1) the ability to generate funds to subsidize the care for the poor; (2) the capacity to invest in high-end technology and infrastructure to attract specialists as well as paying middle-class patients who would otherwise seek affordable private sector options; (3) “witnessing” the christian mission by serving the poor.13,14 according to christian teachings, an act of serving the poor with utmost humility is the act of serving christ and, thus, an end in itself; and (4) fidelity to the original objectives of the organization and the ethical norms of the church.12 certainly, the underlying consideration, which is the pivotal point of their choice, is the sustainability-inclusiveness spectrum and reaching an equilibrium balancing the two. sustainability versus inclusiveness sustainability sustainability,† in this study, is theorized as being associated with four variables: (1) the ability to generate running costs and a surplus over that, (2) the potential of charging higher fees from at least a section of the customers being served,15 (3) the capacity to provide comprehensive services, and (4) lower dependency on high-end medical technologies, since studies have indicated that this could render them more vulnerable to a debt burden16 and push them into excessive use of technologies compromising affordability and value for money.17 regaining running cost and surplus generation capacity are evaluated based on the financial data and the track record of repayment of loans without external funding. the customers are the source of income for any cross-subsidy model which can function without external funding. hence, the customers’ ability to pay higher user charges has a bearing on cross-subsidy. being selective about services delivered was also considered a potential threat for sustainability; since, in our case studies, the selected essential services are not the most remunerative (in contrast to the experience of corporate hospitals which focus on high cost services like in-vitro fertilization [ivf] or cancers), but the most that the poor needed, like care in delivery, common infections, and injuries. a scoring pattern of zero to ten (0 to 10) was set for all these four variables. the highest surplus generation capacity was rated as “10” and the lowest as “0.” customers who belonged to the middle-class, lower middle-class, and below were rated as ten, five, and zero, respectively. the comprehensive nature of services offered was scored “10,” moderate services was scored “5,” and selective services was scored ”0.” lowest dependency on technology was given a “10” and higher levels of dependency was scored lower with a “0” for the most highly dependent (table 2). table 2. details of scoring method used to assess “sustainability” score characteristic indicators 10 lowest dependency on high-end medical technology high ability to generate surplus comprehensive nature of services customers can be charged higher fees absence of ct scanners, mri scanners, cath labs, fully automated labs, etc. break-even achieved and loans repaid all basic specialties available majority of customers belonging to middle-class or above 5 moderate dependency on high-end medical technology moderate ability to generate surplus focus on selective services customers can be charged moderately higher fees presence of one or more of ct scanners, mri scanners, cath labs, fully automated labs, etc. moderate dependency on external funding higher utilization of selected specialties majority of customers belonging to lower middle-class 13 thekkakara june 2020. christian journal for global health 7(2) 0 highest dependency on high-end medical technology least ability to generate surplus selective services only customers cannot be charged any higher fees presence of ct scanners, mri scanners, cath labs, and fully automated labs running at a loss and dependence on external funding only selective/outsourced services high proportion of the poor among the total beneficiaries inclusiveness inclusiveness†† was evaluated based on the associations made by our analysis of the case studies. it was reflected by three indicators: (1) the percentage of annual turnover spent as free or subsidized care, (2) the percentage of beds available in the general category, and (3) the nature of community and outreach services offered. scores were assigned with the highest having a “10” and the lowest a “0.” considering 80 percent as the required score, it was found that seven of our case studies rated high in inclusiveness, and the rest were low in inclusiveness. categorization of cases according to the sustainability-inclusiveness spectrum based on these indicator readings, we categorised our sixteen case studies and built an analytics framework that gives us a better understanding of what happens to the mission hospitals operating in widely different contexts across the country where forces linked to economic globalization have been changing the nature of healthcare practices. we have categorized the case studies into four groups: (1) category a: least inclusive and least sustainable, (2) category b: more sustainable and less inclusive, (3) category c: more inclusive and less sustainable, and (4) category d: highly sustainable and highly inclusive. the results showed that hospitals w and h had high inclusiveness but were low in sustainability (category c). five hospitals, n, s, f, j, and me, had high sustainability scores but were low in inclusiveness (category b). five hospitals, bc, b, d, c, and st, were high in both sustainability and inclusiveness (category d). the weakest status of having low sustainability and low inclusiveness (category a) was found in four case studies, namely sc, r, p, and l. features of category a: least inclusive and least sustainable cases these hospitals were located in urban assam, goa, urban gujarat, and semi-urban karnataka. certain common features are found in their external environments. all these hospitals were situated in locations with well-developed road and transportation infrastructures. they had a common feature of being situated in the midst of healthcare markets with a large number of private nursing homes and corporate hospitals as their competitors in the same geographical area. most of such competitors had adopted high-end technologies and set a culture of practice. none of these four case studies had any external funding. insurance schemes were not providing resources nor bringing in customers for them, though the reasons for this varied. the political climate in their locality was not conducive for them, and government support and collaboration are minimal or non-existent. the internal factors affecting them also showed commonalities. these providers did not articulate “inclusiveness” as one of their main objectives, although they initially had it in their original objectives, as noted in their documents. there was no sign of management techniques with focus on quality found in any of these four case studies. they did not have active links with the community being served, nor do they engage with the government in any form of healthcare for the people. the public healthcare facilities in these locations functioned better, and therefore, even the poor had an option. they have lost competitiveness in the market as they did not seem 14 thekkakara june 2020. christian journal for global health 7(2) to understand the changing needs of the middleclass customers who were able to pay, but who would seek affordable care. the push to maximize insurance as a source of funds was not found in these case studies. and these models, like many others, have difficulty in attracting specialists. these cases were not able to invest in technology or infrastructure that attracts doctors, and they were not able to raise funds to subsidize the poor. for example, the administrator of one of them said: “we are not in a position to offer free service. mission in terms of serving the poor remains nominal.” there was poor internalization of objectives related to inclusiveness and poor readiness to take on the extra burden of effort that would be required to adapt to changing times. features of category b: more sustainable and less inclusive urban settings with higher competition were the locations for these hospitals, for example, punjab and kerala. the external factors influencing the business of the hospitals in this category were not different from that of category a. but the internal factors showed significant differences. a majority of the beneficiaries of these hospitals were the middle-class population. political polarization and legal regulations manifest highly in the settings of these cases. all these hospitals function as referral centres for primary and secondary care in their settings. they have adopted high-end technology to gain competitive advantage in the market as well as to attract specialists. most of them are accredited hospitals under national accreditation board for hospitals (nabh), a mark of their stature with regard to their business and marketing skills. inclusiveness is not a part of their articulated or emphasized objectives. for instance, an administrator of one of them said: “the poor do not know that they can avail free service here. mostly, the middle class are the beneficiaries of the services of this hospital.” their management focus is on carefully ensuring that all the services provided by them break-even and do not run into loss. these case studies showed the ability of hospitals to generate funds for capital investment and growth. but subsidizing for the poor was not a consideration or objective they set for themselves in their present scope of business. the christian “witnessing” to individuals was not apparent in the interviews, and, organizationally, their values were more linked to portraying a professional stature and being seen as one among other private “market leaders” in their area. the social teachings of the church and their parent body were relatively low, and what had been characterized as a “culture of globalization” (pope john paul ii,1993) had a significant influence in their decision-making. features of category c: less sustainable and more inclusive there are two case studies among the sixteen samples studied that were in this category. both these hospitals were situated in poverty-affected locations, one in maharashtra and the other in chhattisgarh. political polarization in their settings was very evident. state control through the enforcement of legal regulations was also strictly practiced in these contexts. they were not in a position to charge higher fees for services from their beneficiaries. their dependency on government schemes for financial protection was very high. nearly 20 to 40 percent of the total income of these two hospitals come from this source. their survival currently rests on this funding mechanism. they also offer some of the loss-making services for the benefit of the poor in their locality. to quote an administrator: we are here for the poor people of this tribal belt. we know that. we give a lot of charity. this rsby is a loss in many of the cases. there are times when (what) we spend for treatment is much higher than what the insurance company repays. but we cannot deny the patient treatment even if the government denies the claim. 15 thekkakara june 2020. christian journal for global health 7(2) inclusiveness is found to be of high priority, but sustainability is a challenge. these two hospitals were pooling all their funds to give free or subsidized care to the poor. the hospitals were unable to generate funds for investment in technological or capital developments. building renovation and infrastructural development were planned only when they felt they could raise external funding support, and without this, they were unable to do the renovations. providers in these hospitals emphasise motivations consistent with the concept of “witnessing,” and hospital management emphasizes their goals of missionary service and gospel values as reflected in the founding objectives. category d: highly inclusive and highly sustainable the fourth category of hospitals had demonstrated a higher level of sustainability and inclusiveness. these hospitals were in rural locations with underdeveloped roads, poor accessibility, and insufficient power supply. the public healthcare facilities in their regions are weak and functionally lower than that of the other fbhs. there were hardly any competitors in their contexts. all other facilities, including that of the government’s, depended on these hospitals for referral support and technical expertise. they had not invested in high-end medical technology, nor are they following accreditation as a means for gaining competitive advantage. political polarization is not manifested in their settings. these hospitals had regular and organized community health activities by which they reached out to the poor and needy. they were constantly engaged with the public system, identified more with it, and tried to empower it. in most cases, they were functioning as an extended arm of the government and as resource centres for the public health system. these hospitals showed higher utilization of their services, but not higher human resource availability. they were offering comprehensive care and were not focused on any selective care. both the poor and the elite benefitted from the services that they were able to provide under the cross-subsidy model. they followed differential pricing, and the poor were not left unserved because of their inability to pay. absence of these hospitals would leave a huge vacuum in the health system of these locations. these hospitals were able to generate a nominal surplus they can invest for future developments, but they too would seek external funding from local sponsors and churches for expansions and renovations. good hr practices were also followed that helped in attracting and retaining their workforce. the most important of this is a positive practice environment which places high value on excellence in service and dedication for the poor. here too, interviews of providers emphasise service to the poor and sick as central to their faith and an organizational commitment to its founding objectives, as reflected in their documents and work processes. the medical administrator of one such hospital said: we will continue to focus on the poorest and those who are still not able to reach the healthcare facilities. we try to keep the balance by reaching out to the poorest through our cdhp activities. the rich have increasing demands for high quality care. we are not after them. our focus is on the poorest who are denied even the primary care. discussion the strategic choices made by our case study hospitals may have been deliberately planned. they may also have been the result of unplanned but gradual adaptation to situational changes. but we tried to understand what could have been the driving force that led to the outcomes to which they arrived, whether desirable or undesirable. in the absence of external funding, the ability to raise funds became a challenge for the mission hospitals. some of them raised their tariff rates, but this was not grounded on strategic pricing policies or a deeper understanding of the profile of beneficiaries. the lion’s share of their beneficiaries, poor and of lower middle-class, 16 thekkakara june 2020. christian journal for global health 7(2) opted to use the public facilities which were by that time providing facilities and services as good as that of the mission hospitals. they were unable to attract the rich due to their limited facilities and technology. the fear of reduced working capital prevented them from empanelment in government health financing schemes and entering into contracts with insurers. sustainability and inclusiveness were diminishing in these cases. some of their counterparts instead went for loans and invested in infrastructure renovation and high-end medical technology. they could either maintain market leadership or be at par with the top players in the market. doctors and patients with financial means were attracted to such facilities. in their struggle to mitigate financial liabilities, they were pressured into focussing on revenues and repayment rather than subsidized care. the culture of globalization seems to have influenced their choice of service delivery, as reflected in a greater proportion of earnings coming from high-end diagnostics and procedures and market-driven healthcare patterns. empanelment in government health schemes, with the maximisation of insurance as an earning opportunity, helped them in resource mobilization. the third group, which were traditionally known for giving free and subsidized care, continued as before because they could not drop the poor whom they consider as the target of their services. professionalism, for these hospitals, seemed to be their missionary objective, and they do not value success in the market as a critical measure. sustainability of the mission seemed to surpass financial sustainability in these hospitals. the fourth category, which is both sustainable and inclusive, made careful choices with regard to appropriate technology required in their context and retained their clientele, both the rich and the poor, by their excellence and empathy in service. they leveraged “cross-subsidy” to serve the poor. a careful balance of sustainability and inclusiveness was maintained by these hospitals by choosing to serve the “mass” and not the “class.” they served a nominal percentage of the class in order to cross-subsidize for the poor. attracting specialists was another crucial issue for the fbhs in the changing contexts. those who could not attract them by offering money or assuring the presence of high-end technology, switched over from employing doctors to “attaching” doctors, leaving them to use the facility of the fbhs to run their own clinic at their disposal. this method seemed to have relieved the hospitals from the financial liability of paying salaries; but it also showed a loss of control of operations and assurance of doctors’ presence and quality and resulted in dissatisfaction of the beneficiaries. on the contrary, the second category of fbhs attracted specialists by installing high-end medical technology for accurate diagnosis and effective therapies. the third category of hospitals retained full-time doctors with more monetary benefits. the fourth category pulled doctors to them by their service excellence, dedicated work, team spirit, and their personal example of living a humble life. they adopted different hr techniques such as a careful selection of doctors in line with their missionary objectives, participative management, and transparency in administration. laxity and compromise seemed to have crept into the minds of the missionaries helpless to serve the poor in the changing contexts. providing options for the poor was the inspiration, on the other hand, for some of their co-players to continue the mission, even in resource-constrained situations. community health services were the strategy for many of them to reach out to the poor and the underserved. good service quality and becoming referral centres for other facilities in the location brought the poor and the rich to the hospitals with high sustainability and inclusiveness. those who left the poor were left by the poor also; those who stood for the poor were demonstrating the love of god for the poor, the value that the church wants to uphold by healthcare. conclusion while there remained a variation in the services and infrastructure of mission hospitals across india, these facilities had long-standing 17 thekkakara june 2020. christian journal for global health 7(2) operation and ongoing commitment to population health that could and would make meaningful contributions to the indian health system. they are offering a wide range of services from primary to tertiary care and home-based to critical care. their presence was the only provision of healthcare in certain remote and hard-to-reach locations in india. they were leading providers of rural healthcare, while they continued engaging with the community and the public system for the good of the people at large. the challenges faced by these hospitals have changed over the last 25 years from predominantly patient care issues to market-related issues in the present context. the economic changes, market trends, and the culture of globalization coerce fbhs to retreat from the mission of being inclusive and to shift to a strategic choice of profit-based, technology dependent, market responsive sustainability. a few hospitals have, however, been able to resist this coercion, and to do so, they have had to make strategic choices that balanced an adoption of the right technology, an active engagement with government programs and public health systems, building mechanisms of continued engagement with the community and professionalizing management. they had to do all of this without losing the core values that defined their mission—where it is the spirit of service and not market leadership or professional pride that is the main motivation of both management and individual providers. * the key informants were the leaders of the associations of the faith-based hospitals at state and national levels who were very familiar with the functioning of the hospitals. leaders of other ngos also were consulted. † our notion of ‘sustainability’ is limited to market sustainability which denotes the ability to continue in the given market context. other aspects of sustainability of the mission, organizational values, etc., are not in the scope of this term. †† inclusiveness indicates the ability of the hospital to serve all sections of the community, including the poor and the marginalized, which is core to the existence of the mission hospitals. references 1. cherian a, mathew a, tomy t, priya j, mercy.t, santosh m, et al. potential of non-state players for universal health coverage, in india infrastructure report. 2013/14, idfc foundation, orient long swan. available from: http://www.idfc.com/pdf/report/2013-14/iir2013-14.pdf 2. narayan t, johney j, tomy p. a golden harvest: a dream come true. 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accepted 15 nov 2019, published 22 june 2020 competing interests: none declared. acknowledgements: the guidance received from dr t. sundararaman, dr thelma narayan and prof bino paul is acknowledged with a deep sense of gratitude. correspondence: fr john varghese thekkekara, st.john's medical college, bangalore, india. frthekkekara@yahoo.com cite this article as: thekkekara jv. sustainability and inclusiveness in a competitive market: a study of faith-based hospitals in india. christ j global health. june 2020; 7(2):7-18. https://doi.org/10.15566/cjgh.v7i2.321 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v7i2.321 about:blank case study dec 2019. christian journal for global health 6(2) church-led partnerships with interfaith religious leaders and government for raising awareness on leprosy in sri lanka james samuel pendera, cletus praveen gomezb, ranasinghe arachchige tuder mahesh pererac, john anthony williamsd, ravindran roshane a programmes and advocacy officer – asia, the leprosy mission england and wales, united kingdom b alliance development trust, sri lanka c alliance development trust, sri lanka d alliance development trust, sri lanka e alliance development trust, sri lanka abstract sri lanka is a leprosy endemic country with one of the highest incidences of the disease globally. low levels of leprosy awareness were identified as one of the reasons for high prevalence. in order to address this low awareness, inter-faith communities were mobilized by trained church leaders to work together to increase leprosy awareness, reduce stigma, and support people affected by leprosy, building strong relationships across inter-religious divides in the process. the efforts were highly successful with over 30,000 people involved in leprosy awareness events. this indicates that faith communities can be an important partner for development agencies and governments; churches can make an impact in improving health outcomes, even where the members are a persecuted minority, as well as contribute to inter-communal peacebuilding efforts. key words: leprosy, health, church, inter-faith, sri lanka introduction there is an increasing number of new leprosy cases being detected in sri lanka despite the greater economic prosperity in the region. this is unusual, as higher leprosy prevalence is usually associated with lower-income developing countries. in 2017, 1,877 new cases1 with 195 child cases were identified in sri lanka.2 these statistics indicate high rates of transmission and, although the longrunning conflict in the country may have contributed to this, one of the leading causes is low levels of awareness,3 and misconceptions and prejudices still exist even among public healthcare workers,4 which have contributed to insufficient leprosy detection. therefore, alliance development trust (adt), an arm of the national evangelical alliance of sri lanka (nceasl), with support from the leprosy mission england and wales (tlmew) started to look at how it could raise awareness of leprosy, reduce stigma, and contribute to increased detection. the project’s major resource was the 27 pender, gomez, perera, et al dec 2019. christian journal for global health 6(2) island-wide network of churches with which it was associated and its previous experience of working on a project to reduce hiv/aids stigma. adt offered support to those affected by leprosy through churches and a partnership with district interfaith committees. when adt began working with interfaith leaders, it mobilized district interfaith committees under the inter religious peace foundation. the foundation had originally been set up in 1993 by religious clerics trying to bring about peace between the different religious and ethnic communities that were polarized along religious and ethnic lines during the conflict in sri lanka.5 many of these committees had been largely inactive for years, and some had not previously existed in some districts, so they needed to be formed for the first time. they were brought together with the objective of leaving their differences aside to fight a common enemy— leprosy. materials and methods a core team was formed involving one church pastor representing each district of the country, thereby making it a 25-member core team. members of the teams were nominated by the district pastors’ fellowship teams. they were given leprosy training by the government anti-leprosy campaign (alc) who recognized them as “trained community leaders for community awareness programmes on leprosy.” each core team member was then tasked with the responsibility of mobilizing church leaders in their respective districts. the core team selected churches and pastors known to them and who were part of their respective district pastor’s fellowship teams. the core team met every quarter to plan and report progress of their respective district interventions. the district church teams were firstly trained by their district public health inspectors about leprosy and then raised awareness within their respective churches by conducting leprosy awareness sunday services. church pastors were also taken through training on integral mission so that they understood the need to love their neighbor while they loved god. next, each district team was linked up with a district interfaith team. the interfaith leaders were all members of the inter religious peace foundation with which adt had an agreement. each interfaith committee consisted of a representative of each major faith community in the locality, including buddhists, hindus, muslims, and christians (evangelical, anglican, and catholic) (figure 1). the representatives were mostly clerics but also included elders from their congregations. other interested community and religious leaders sometimes attended the training meetings. after training, individual representatives organized outreach events within their religious community or jointly with other interfaith committee members. the core team pastors then became district facilitators for the interfaith committees, organizing meetings supported by adt that together coordinated leprosy awareness activities in each district. these district committees worked alongside the government alc’s district public health inspector-leprosy who attended meetings as a trainer and resource person and utilized the committee members to spread awareness through their networks, including places of worship, schools, women’s groups, and youth groups. 28 pender, gomez, perera, et al dec 2019. christian journal for global health 6(2) figure 1. district interfaith leaders results table 1. statistics from “leprosy sunday” programs conducted through churches categories leprosy sunday 2016 leprosy sunday 2017 number of leprosy sundays 349 349 number of people at church 20,640 19,639 people affected by leprosy identified 45 13 29 pender, gomez, perera, et al dec 2019. christian journal for global health 6(2) table 2. statistics on outreach activities conducted through the interfaith committees target group 2017 2018 total number of activities participants count total number of activities participants count faith leaders 7 501 8 181 members of faith communities 5 1,764 8 345 government officials 2 190 4 181 village community 14 1,291 18 3,590 widows 1 70 prisoners 1 320 women 1 32 students 1 40 6 985 ayurvedic doctors and staff 1 40 parents and teachers 1 100 total 32 4,208 46 5,422 as a result of this intervention, 25 pastors were trained as core team members, who in turn trained 785 church leaders at the district level and reached 20,640 church members through 349 leprosy awareness sunday services in the first year (table 1). through 78 interfaith awareness events in 2017 and 2018, 9,630 individuals heard about leprosy (table 2). this led to the diagnosis of 58 new cases of leprosy. twenty people affected by leprosy received asset transfers to enable them to improve their livelihoods with new income generating activities and better relations between different communities. it is suspected that there may have been further new cases diagnosed due to an increased number of leprosy cases self-presenting after awareness activities, but this could not be verified as once a suspected person visits the government hospital for diagnosis, there is no record maintained to know whether or not an affected person suspected leprosy as a result of an interfaith awareness program. in addition, it is notable that the intervention appears to have had a positive impact on the government alc because in leprosy detection, it is important to trace the close contacts (family members, neighbors, close friends) of leprosy index cases that have been newly diagnosed as there is a higher probability of them contracting leprosy. so, it was encouraging that the preliminary data suggested that contact tracing improved in districts that ran successful interfaith awareness programs; the contact tracing percentage of the districts with inter-faith activities was high and averaged at 82% compared with districts that had not implemented them, which averaged at 77%. furthermore, the districts with interfaith activities had a higher percentage (7.4%) of new cases detected via contacts compared with districts without the interfaith 30 pender, gomez, perera, et al dec 2019. christian journal for global health 6(2) activities (3.5%). the results were statistically significant (p < 0.05). 6 discussion the approach of working through pastors and churches proved effective in raising awareness of leprosy, but this was mostly limited to the christian community, and as leprosy is a health condition which comes within the remit of the government alc, churches were not able to work on it independently outside their congregations. however, when the director of the government alc trained the core team on leprosy, the core team members were recognised as trained community leaders for community awareness programs on leprosy. the director recommended that public health inspectors-leprosy (phi-l), who coordinate leprosy control in each district, utilize their services. this opened up the opportunity for close partnership with the alc, but religious sensitivities also meant that christians were viewed with suspicion, and the alc were wary of only using pastors to raise awareness. by expanding the program to all religions, the programme became acceptable to the authorities. in addition, evangelical christians are a small minority, and it also made sense to include other faith leaders who could expand the reach and impact of the awareness on leprosy into communities the church pastors would struggle to access. it was also an opportunity for the trained church leaders at district and local levels to show that they did not just care about “saving people from sins” but also saving them from their present sufferings and showing the positive contribution they could bring to wider society. this initiative is also of wider benefit as it contributed to peace-building and inter-religious harmony. inter-religious and inter-ethnic mistrust or misunderstanding exists as a result of the recent conflict as well as rising nationalistic sentiment. in some parts of sri lanka, mosques and churches have been burnt down, and religious minorities report persecution.7 however, members of the inter-faith committees working in this program improved community relationships and improved relations with counterparts of other religious backgrounds, and they believed that these relationships could function to defuse communal tensions in the future. what began as a church-based initiative has now become a successful interfaith initiative that is “owned” as part of the sri lankan government’s intervention to reduce leprosy prevalence across the country. 31 pender, gomez, perera, et al dec 2019. christian journal for global health 6(2) figure 2. interfaith collaboration to address leprosy conclusion there are several lessons to be drawn from this project. firstly, it demonstrates that projects involving churches in their communities are possible even in countries where christians are a small minority and suffer persecution. it also shows that other faith communities are willing to work alongside christians to make a difference in their communities (figure 2). the project also arguably contributed just as much towards peacebuilding and increased understanding in a fragile context as to health outcomes. secondly, by working in a professional and strategic manner, the church (in this case through its development wing adt) can become a valued strategic partner of the government. the government, in turn, recognizes the importance of involving faith communities in achieving improved community health outcomes. thirdly, it led to a change in outlook among participating churches. they went beyond preaching to their communities to understanding the value of being “salt and light” in their communities. they then reaped the benefits of improved relations with their neighbors. the churches, as a result, were more highly regarded, as the gospel is being demonstrated as well as talked about. it is also important that churches learn how to engage with other faiths in positive ways and become more open to those of other faiths without compromising their message. engagement around a neutral topic, such as reducing leprosy, of which everyone could agree, was a helpful way to start. 32 pender, gomez, perera, et al dec 2019. christian journal for global health 6(2) references 1. weekly epidemiological record, 31 august 2018, vol. 93, 35 [p. 444–56] [internet]. [cited 2019 mar 28]. https://doi.org/10.1080/03068374.2018.1467660 2. anti-leprosy campaign. anti-leprosy campaign annual report 2017. colombo, sri lanka. antileprosy campaign, ministry of health; 2018. 3. anti-leprosy campaign. national strategy of reducing the disease burden due to leprosy and enhancing quality of leprosy services, 2011-2015. colombo, sri lanka.: anti-leprosy campaign, ministry of health; 2012. 4. wijeratne m., østbye t. knowledge, attitudes and practices relating to leprosy among public health care providers in colombo, sri lanka [internet]. leprosy review. 2017;88:75. available from: https://www.researchgate.net/publication/316090053_ knowledge_attitudes_and_practices_relating_to_lep rosy_among_public_health_care_providers_in_colo mbo_sri_lanka 5. bilodeau a. the inter-religious peace foundation: christians, muslims, buddhists and hindus — addressing the conflict in sri lanka [internet]. cambridge, ma: cda collaborative learning projects; 2000 [cited 2019 mar 26]. available from: https://www.cdacollaborative.org/publication/theinter-religious-peace-foundation-christians-muslimsbuddhists-and-hindus-addressing-the-conflict-in-srilanka/ 6. gomez cp, wijesinghe msd, de silva m, perera m, williams ja, ravindran r. 2019. interfaith teams for leprosy control: reaching the unreached. 20th international leprosy congress. manilla 2019. [abstract number: ilc2. p-350] 7. devotta n. religious intolerance in post-civil war sri lanka. asian affairs. 2018;49(2): 278-300. https://doi.org/10.1080/03068374.2018.1467660 peer reviewed: submitted 27 mar 2019, accepted 12 oct 2019, published 23 dec 2019 competing interests: none declared. correspondence: james samuel pender, programmes & advocacy officer-asia, the leprosy mission england and wales, united kingdom. jamesp@tlmew.org.uk cite this article as: pender js, gomez cp, perera ratm, williams ja, roshan r. church-led partnerships with interfaith religious leaders and government for raising awareness on leprosy in sri lanka. christian journal for global health. december 2019; 6(2):26-32. https://doi.org/10.15566/cjgh.v6i2.317 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1080/03068374.2018.1467660 https://www.researchgate.net/publication/316090053_knowledge_attitudes_and_practices_relating_to_leprosy_among_public_health_care_providers_in_colombo_sri_lanka https://www.researchgate.net/publication/316090053_knowledge_attitudes_and_practices_relating_to_leprosy_among_public_health_care_providers_in_colombo_sri_lanka https://www.researchgate.net/publication/316090053_knowledge_attitudes_and_practices_relating_to_leprosy_among_public_health_care_providers_in_colombo_sri_lanka https://www.researchgate.net/publication/316090053_knowledge_attitudes_and_practices_relating_to_leprosy_among_public_health_care_providers_in_colombo_sri_lanka https://www.cdacollaborative.org/publication/the-inter-religious-peace-foundation-christians-muslims-buddhists-and-hindus-addressing-the-conflict-in-sri-lanka/ https://www.cdacollaborative.org/publication/the-inter-religious-peace-foundation-christians-muslims-buddhists-and-hindus-addressing-the-conflict-in-sri-lanka/ https://www.cdacollaborative.org/publication/the-inter-religious-peace-foundation-christians-muslims-buddhists-and-hindus-addressing-the-conflict-in-sri-lanka/ https://www.cdacollaborative.org/publication/the-inter-religious-peace-foundation-christians-muslims-buddhists-and-hindus-addressing-the-conflict-in-sri-lanka/ https://doi.org/10.1080/03068374.2018.1467660 mailto:jamesp@tlmew.org.uk https://doi.org/10.15566/cjgh.v6i2.317 http://creativecommons.org/licenses/by/4.0/ introduction materials and methods results discussion conclusion references editorial may 2019. christian journal for global health 6(1) reflecting on human rights in global health contexts mathew santhosh thomasa a mbbs, md, international christian medical and dental association, former executive director, emmanuel hospital association, india though human right to health is not widely discussed in theological literature, general human rights from biblical perspectives are a wellresearched and reflected issue, and there is no dearth of knowledge on the topic. a few, with some from the majority world, are worth mentioning. yogarajah and shirrmacher, in their very comprehensive four articles, review the christian faith and practice, the biblical roots and basis for international human rights, and reflect on the various christian arguments for religious freedom. these articles came out of a global consultation in 2015, in albania, and covers the above topics in detail.1 owoeye, from obafemi awolowo university in nigeria, looks at the operation of fundamental human rights in the deeper life bible church, of which he is part, and reflects on the nigerian constitution, church practices, and the biblical understanding of human rights as derived from the inherent dignity of the human person.2 in a review on human rights issues of dalits in india, the author monica jyotsna melanchthon notes that christian theory and practice have also been woven into the fabric of dalit, adivasi, and the indian woman’s faith, courage, and healing in the face of the violation of their rights. she raises the question whether the christian faith and theology can become a more certain foundation and steadfast resource for justice and human rights for this community, and goes on to review the biblical basis for human rights based on an individual’s integrity, worth, and dignity. “an individual is entitled to at least three kinds of personal freedom: freedom of conscience, freedom from unjust exploitation or oppression, and freedom to live a properly human life.”3 in his article, robert mccorquodale recognizes that international legal protection of human rights offers both obligations on governments to which individuals or groups can appeal, and international standards by which governments can be judged. he identifies that one consequence of these developments is that the language of human rights is now used in many contexts: from national and international conflicts to personal relationships. he explores the extent to which this use of human rights is consistent with christian understandings, noting the biblical emphasis of responsibility toward the oppressed (rather than rights of the oppressed) and the responsibility of individuals rather than only governments’ (as expressed in the international rights system). the prophets do not address the oppressed, encouraging them to claim their rights, but rather address the powerful, noting their social responsibility toward orphans, widows, the poor, and foreigners. human rights is a concept that includes responsibilities to others and to the community. 4 all humans created equal and in imago dei (genesis1:27) is the underlying foundation of the christian stand on human rights. the uniqueness of humanity, as carriers of imago dei, though a marred masterpiece that needs to be restored back into its original form, is what drives our compassionate responses. advocating for systems and structures that treat all of humanity as equal has been the foundation of many human rights and rights-based movements. prophets of old testament times reprimanded and highlighted the 4 thomas may 2019. christian journal for global health 6(1) injustice of leaders and the systems they had set up, especially regarding their failure to treat the widow, the orphans, the poor, and aliens as equal to others. the bible has much to say on this and about caring for people in the margins of society at that time. (exodus 22:21-12; leviticus 19:34, 25:35; deuteronomy 10:18, 14:28-29, 15:7-11, 24:17-18; isaiah 1:17; jeremiah 7:6-7, 49:11) jesus role-modeled by reaching out to those who were at the receiving end of such unjust systems and openly reprimanded the leadership who had set up systems that discriminated against the poor. (matthew 23:14) at the same time, pauline writings clearly show that rights and freedom must be seen considering the overall kingdom lifestyle and kingdom character. (galatians 5:1, 13-15) freedom and rights must exist in order to live to the full potential of god’s purpose for one’s life. the hope of the “new heaven and new earth,” where there will be the no infant mortality or premature deaths and an enhanced life expectancy (isaiah 65:17), and where there will be justice and righteousness flowing like a river, is what gives us hope (amos 5:24). as we live in this broken world, the perspective of the “here but not yet” kingdom gives us the ability to persevere. the bible also records stories of people who gave up their rights for the sake of a greater purpose. abraham gave up his right to choose the land for the sake of a relationship (genesis 13: 8 11); david gave up his right to fight for his kingdom and position, leaving it to god to work out his plans at the right time (2 samuel 15:25, 26); paul gave up his rights for the sake of the gospel (1 corinthians 9: 1 -12) and used his rights as a roman citizen, sparingly as and when required. jesus gave up his rights as son of god and became son of man to redeem the world (phil 2:5-11). balancing individual rights along with the rights of the community and being aware that fighting for our rights could be stumbling blocks for others challenges us to look at our own rights from a broader perspective. knowledge of these is good for those of us coming from a monotheistic and judeo-christian world view to undergird our life and work. the challenge one faces is the question of how to live this out in the context of a majority community whose world views differ or right to health is influenced by various socio-cultural and religious factors. last week, a father brought premature twins into our emergency department and clearly and bluntly told the treating doctor, “i do not have resources to care for both the children, take care of the boy. let the girl twin die.” when a girl is a “lesser human,” where current and future economic constraints (a girl child needs more resources to get her married) affect decisions, how should one respond? what happens to the rights of this “lesser human being?” when the majority world view does not consider women as equal, how long and what would it take to change these views and, thus, change the lives of many women who live as second-class citizens? would education and awareness alone affect change when these beliefs are part of deeper social, cultural, and religious beliefs? or when the caste system, a disabling myth which disfigures and disables a nation, influences every decision, what is the way forward? where ingrained inequality has led to tacit acceptance of the caste system5 due to its undergirding religious and cultural roots, and has led to, among other challenges, a preventable epidemic of mortality among women and children, what does one do? when inequality is ingrained into the sociocultural and religious moorings of a society, when systemic structures perpetuate this inequality since religion and culture at times even supersedes law, how does one live and engage? in this issue, armstrong writes, “rights, in general, are about individuals and fairness and are often connected with laws or legal systems, and so these sit very comfortably within a guiltinnocence culture. however, rights do not fit so easily within a fear-power culture or a shamehonor culture.”6 when more than 75% of the world’s population live in a fear-power or a shame-honor culture, how does one engage with 5 thomas may 2019. christian journal for global health 6(1) such communities? how can health care professionals who have a biblical understanding of rights that is undergirded by a guilt-innocence culture engage effectively and sensitively? or when the rights of the unborn are considered as secondary to the rights of the woman, even by law, how does one respond? when law forces you to destroy the life of a disabled fetus since it is an economic burden to the nation, how does one respond?7 armstrong was part of a team working for more than a decade with a community at risk for hiv that was marginalized and unable to access health care due to their high-risk behavior. an end of project evaluation revealed that communities were empowered to access health care services as their right, but the evaluation also revealed that some sections of the community were much more vocal and open about their high-risk behavior, at times, fighting for their rights to continue in such behaviors. the question arises — when rights of the marginalized become rights to continue engaging in a behavior that further mars the imago dei, how does one respond? when empowering communities that are stigmatized and marginalized due to harmful behaviors to stand for their right to health care access, how does one respond when the communities fight for the right to continue in these harmful behaviors? in such challenging contexts, will a responsibility frame work suffice instead of a rightbased one? as crouch in this issue writes, an apparent conflict exists between the principles of individual human responsibility and certain aspects of health as a human right. a legitimate question arises when the determinants of health are partially or wholly within the decisionmaking powers of the citizen(s) themselves.8 in such communities, where decision making is not within the power of the individual, how can either the right or responsibility-based framework be lived out? crouch, in the concluding section, writes, “an appreciation of fundamental rights can go only as deep as the fundamental world-views of those involved.” 8 it is important to recognize the complexity of cultural context and issues that affect or influence rights of the individual, along with a biblical understanding of human rights. we need to move from the knowledge of “theology of rights” to “reflective practice of rights.” we need to encourage reflections that consider the complexity of the issues, the context and the dominant world views that prevail in each context. we need to use such reflections to build the capacity of christian health care professionals, and take responsibility for those who have no power to access their rights. we need to motivate each other to engage with knowledge, compassion, wisdom, and discernment, based on the learnings from such reflections. references 1. yogarajah g, schirrmacher t. the biblical basis for human rights and religious freedom [internet]. tirana, albania: global consultation on discrimination, persecution, martyrdom: following christ together; 2015 nov 1-5. available from: https://www.worldea.org/pdf/the%20biblical%20b asis%20for%20human%20rights%20and%20relig ious%20freedom%20(gy,%20ts).pdf 2. owoeye sa. the deeper life bible church and the issues of human rights [internet]. ile-ife, nigeria: iosr j human social science (iosr-jhss); 2013 jul – aug;13(5):33-40. available from: http://www.iosrjournals.org/iosr-jhss/papers/vol13issue5/g01353340.pdf 3. melanchthon mj. the biblical bases for human rights [internet].chennai, india: department of old testament at gurukul lutheran theological college: n.d. available from: https://docplayer.net/53655811-the-biblical-basesfor-human-rights.html 4. mccorquodale r. human rights and responsibilities: a christian perspective. in: human rights, faith and culture. australia: association for baha'i studies australia; 2001. p. 101-14. available from: https://bahailibrary.com/pdf/m/mccorquodale_human_rights.pdf 5. the lancet. the health of india: a future that must be devoid of caste. london: lancet; 2014. nov https://www.worldea.org/pdf/the%20biblical%20basis%20for%20human%20rights%20and%20religious%20freedom%20(gy,%20ts).pdf https://www.worldea.org/pdf/the%20biblical%20basis%20for%20human%20rights%20and%20religious%20freedom%20(gy,%20ts).pdf https://www.worldea.org/pdf/the%20biblical%20basis%20for%20human%20rights%20and%20religious%20freedom%20(gy,%20ts).pdf http://www.iosrjournals.org/iosr-jhss/papers/vol13-issue5/g01353340.pdf http://www.iosrjournals.org/iosr-jhss/papers/vol13-issue5/g01353340.pdf https://docplayer.net/53655811-the-biblical-bases-for-human-rights.html https://docplayer.net/53655811-the-biblical-bases-for-human-rights.html https://bahai-library.com/pdf/m/mccorquodale_human_rights.pdf https://bahai-library.com/pdf/m/mccorquodale_human_rights.pdf 6 thomas may 2019. christian journal for global health 6(1) 29;384:1901. https://doi.org/10.1016/s01406736(14)62261-3 6. armstrong lj. rights, health, and culture – reflections from a cross cultural worker. chr j glob hlth. may 2019; 6(1):64-69. https://doi.org/10.15566/cjgh.v6i1.269 7. taylor p. non-invasive prenatal testing [internet], cmf christian medical fellowship files. 2017;63. available from: https://www.cmf.org.uk/resources/publications/cont ent/?context=article&id=26653 8. crouch m. working order: health, human responsibility, and rights in an age of limited agency. chr j glob hlth. may 2019; 6(1):59-63. https://doi.org/10.15566/cjgh.v6i1.261 peer reviewed: submitted 23 nov 2018, accepted 9 jan 2019, published 31 may 2019 competing interests: none declared. correspondence: mathew santhosh thomas, international christian medical and dental association, former executive director, emmanuel hospital association, india. santoshmathee@live.com cite this article as: thomas ms. reflecting on human rights in global health contexts. christian journal for global health. may 2019; 6(1):3-6. https://doi.org/10.15566/cjgh.v6i1.267 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1016/s0140-6736(14)62261-3 https://doi.org/10.1016/s0140-6736(14)62261-3 https://doi.org/10.15566/cjgh.v6i1.269 https://www.cmf.org.uk/resources/publications/content/?context=article&id=26653 https://www.cmf.org.uk/resources/publications/content/?context=article&id=26653 https://doi.org/10.15566/cjgh.v6i1.261 mailto:santoshmathee@live.com https://doi.org/10.15566/cjgh.v6i1.267 http://creativecommons.org/licenses/by/4.0/ historical review health paradigm shifts in the 20th century jose miguel deanguloa and luz stella losadab a md, mph, regional director for latin america, map international, bolivia b mhpe, community health specialist, map international, bolivia abstract the application of systems theory and the study of complexity to medicine and human health allows for a more comprehensive understanding and a more holistic view of what it means to be human. such application overcomes the limitations of the traditional, fragmented understanding of phenomena and problems based on the mechanistic or newtonian worldview. it recognizes that phenomena are interrelated, and that individual parts cannot be understood by only focusing on the analysis of their individual qualities. rather, the individual parts can only be understood in relation to the whole and by being analyzed in the context of their interaction with the whole. the door is opened to previously unimagined models of thinking. in the 20th century there have been shifts in the paradigms that have governed medicine and human health in the modern western world. there has been a shift from the focus on specific biological analysis and pathological diagnostics to complex human interactions with the environment and with sociopolitical and economic processes.  there are complex models of systems in immunology, in neuroscience, and in genetics, as well as complex ways of understanding interactions as in epidemic modeling, in social media technologies, socioeconomic factors, and artificial intelligence.  in this paper we describe three paradigms of the health-disease process that in some degree correspond to the historical development of modern medicine and healthcare over the previous century.  the oldest paradigm focused on specific disease mechanisms and treatment.  this gave way to paradigms that historically were broader and more inclusive, such as “international health”.  the international health paradigm focused primarily on the control of epidemics across national borders and considered government as the only health actor.  however, this perspective has come to be seen as excessively reductionist and excluded many critical components essential to a robust understanding. the old “international health” has in turn been replaced by the paradigm of “global health” that exercises more comprehensive claims, and paved the way for emerging paradigms of complexity in the 21st century.   introduction we are witnessing the emergence of new paradigms that allow for a more comprehensive understanding of the world in general and various phenomena specifically.  these emerging paradigms overcome the limitations of the traditional, fragmented understanding of phenomena and problems based on the mechanistic or newtonian worldview.  systems theory and the study of complexity allow for a more holistic view of what it means to be human.1,2  these new approaches recognize that phenomena are interrelated, and that individual parts cannot be understood by only focusing on the analysis of their individual qualities. rather, the individual parts can only be understood in relation to the whole and by being analyzed in the context of their interaction with the whole.  complex systems open the door to previously unimagined models of thinking.3   paradigmatic shifts have affected medicine and an understanding of human health in the modern western world.  there has been a shift from focus on specific biological analysis and pathological diagnostics to complex human interactions with the environment and with sociopolitical and economic processes.  there are complex models of systems in immunology, neuroscience, and genetics, as well as complex ways of understanding interactions as in epidemic modeling, social media technologies, socioeconomic factors, and artificial intelligence.  paradigms that historically were broader and more inclusive, such as “international health” excluded many critical components essential to a robust understanding.  the previous “international health” paradigm has been replaced by the paradigm of “global health” that exercises more comprehensive claims.4  the international health paradigm focused primarily on the control of epidemics across national borders and considered government as the only health actor; this has come to be seen as excessively reductionist. in the following paper, we initially discuss two paradigms that share a focus on pathologies and the organism of the individual.  then, we will describe a paradigm shift toward an understanding that the health-disease process is not merely a biological and organic phenomenon in individuals, but represents an attempt to overcome a fragmented focus and attempts to handle reality in a more comprehensive manner.  these paradigm shifts in some degree correspond to the historical development of modern medicine and healthcare over the previous century. hospital-based pathogenic biomedical paradigm this paradigm uses the concept of “pathogenic” because it is based on a search for and discovery of the origin of a disease.  health is viewed as the absence of disease, with disease being defined as a deviation from the normal biological functioning of the body.  the paradigm is called “biomedical” because it requires highly qualified scientific personnel, with the doctor playing the main role supported by a team of other professionals such as laboratory technicians, pharmacologists, biochemists, nutritionists, nurses, etc.  the human body is viewed as a complex biological machine, requiring the services of “biological engineers” who understand its complex chemical reactions as well as the possible modifications in its cells and organs.  the model is called “hospital-based” because health care is delivered primarily in this setting.  biomedicine emphasizes the scientific treatment of the individual.  such services require sophisticated and expensive instruments and high technology equipment.  hospitals, by keeping patients together, can more efficiently utilize both human and technological resources. this paradigm has many strengths, such as more effective methods for diagnosing and treating life-threatening and disabling diseases. it has saved many lives, alleviated pain, and facilitated the recuperation of patients.  it also has several limitations such as high costs for qualified human resources, advanced technology, and extensive infrastructure.  it has low geographical, financial, and cultural accessibility.  its high cost affects healthcare everywhere.  low cultural accessibility occurs because of language and worldview differences between patients and service providers affecting how signs, symptoms, and feelings are framed.  misuse of pharmaceuticals constitutes an additional problem.  furthermore, many doctors and hospitals fail to treat the poor as well as they would treat the wealthy, so that a large sector of the population avoids doctors and hospitals due to the fear of inferior care. an important limitation of this paradigm has been in the management of disease processes that require intervention in social groups rather than individuals.  even in developed countries, health officials now recognize that a high percentage of pathologies depend on lifestyles that lead to chronic and degenerative diseases.  adoption of a lifestyle has a major social dimension.  linear causality, a feature of the pathogenic aspect of the paradigm, may be insufficient to explain diseases whose cause and evolution is multifactorial.  an example of this is the failure to deal with mental illness.  a reductionist approach to health care is blamed for making medical practice impersonal and seeing patients as isolated “problems.”  in the developing world, this limitation of the paradigm may be amplified since the prevalent diseases need to be viewed in the context of complex social, economic, sanitary, environmental, and political conditions. infant diarrhea illustrates this.  the paradigm says that diarrhea is the result of a virus or parasite being transported by a vector, which in this case is contaminated food or water, to a host, the child.  the “colonization” of these germs in the child produces the disease.  if the many other factors associated with this illness such as lack of potable water, poor sanitary conditions in which the child lives, or lack of time for the mother to care for him due to her excessive work responsibilities are dismissed, this solution begins to be simplistic.  the same mother returns a month later with the same child with the same symptoms.  the same diagnosis is given as before, and she leaves with the same recommended treatment.  this mother will return several weeks later with the same problem.  because of this, hospitals, clinics, and health centers have been called disease palaces or patient recycling centers.  this critique has been made by helfdan mahler, director general of the world health organization and ivan illich.  mahler has deplored the tendency to devote increasingly large sums of money to maintaining “disease palaces.”5 perhaps the best summary critique of this paradigm is that of john germov: while the biomedical model represented a significant advance in understanding disease and resulted in beneficial treatments, it has come under significant criticism from both within medicine and from a range of social and behavioral disciplines such as sociology and psychology. the major criticism is that the biomedical model underestimates the complexity of health and illness, particularly by neglecting social and psychological factors 6 community-based bio-sanitary pathogenic paradigm in the 1970s, a second paradigm appeared that made efforts go beyond the dominant role of institutions and physicians in managing healthcare. the international conference of alma ata defined primary health care (phc), as: . . . essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community. it is through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.7 although this second paradigm, which we have called the “community-based bio-sanitary pathogenic paradigm”, shares many principles with the first one, it has produced advancements in how government and communities get involved with health care. despite the fact that populations, in general, frequently prefer the services provided by the first paradigm, governments and international organizations began promoting primary health care.  instead of concentrating on the human body and disease, the community-based bio-sanitary pathogenic paradigm takes more account of the role of vectors and the environment in disease.  its emphasis is not on curing diseases as much as in preventing them.  this paradigm also shares its predecessor’s limitation of proposing that disease originates in biological causes, even though it places more emphasis on the roles played by vectors and microorganisms.  for this reason, this paradigm is also given the descriptor “pathogenic”.  while the disease process is still understood on the basis of the “origin of disease”,  this paradigm considers that health can be achieved insofar as the community learns to take certain measures to prevent disease and, if disease occurs, learns how to cure it.  the paradigm is called “biological” rather than “biomedical” because the physician’s role is secondary.  interventions are carried out by personnel with limited training, such as nurses' aides or health promoters.  due to the short training period, the cost of preparing personnel is much lower than for the biomedical paradigm, resulting in more adequate coverage of the population.8 a good example of the impact of this paradigm shift was seen in the work done by the nongovernmental organization map international.  in the 1950s, map’s work focused on the provision of medicines to hospitals in the developing world.  later in the 70s, 80s and 90s, map employed a new strategy that increased involvement with local communities and explored causes of diseases and what could be done to prevent them.  the international shift to this new paradigm was published by map in new agenda for medical missions, edited by d. merrill ewert.9  the book contains a variety of reflections about the contribution to international health provided by the thinking and experiences of medical missionaries working in developing countries.  this second health paradigm opened the door for lay people to play a key role in the health of their communities, even those with minimal formal education. even though the alma ata movement offered greater coverage of health services, several groups and governmental authorities began to call the movement unrealistic and unattainable.  to respond to this criticism, selective primary health care (sphc) was launched.  this offered low-cost interventions to address the most prevalent diseases:  oral rehydration for diarrheal diseases, breastfeeding and monitoring to fight malnutrition, malaria treatment, and immunizations.  there were efforts to produce a set of technical, linear, and fragmented interventions and programs that could be easily implemented and measured.  however, pressure to develop greater reliance on private-sector healthcare provision and the influence of the world bank to reduce existing inefficient and ineffective health systems led to a reduction of public involvement in broader public health actions. the new paradigm called for collaboration between health sectors, equity, affordability, and a multidimensional approach to health and socioeconomic development.  it emphasized the use of “appropriate technology”, and encouraged active community participation in health care and health prevention.  this meant that health strategies and activities were carried out in the communities themselves, a contrast with the first paradigm, which was hospital based.  since the community-based bio-sanitary pathogenic paradigm considers health a right of the entire population, it requires the active participation of the entire society in identifying and solving its health problems.  also, it requires access to health services for a population at sites where people live and work.  primary health care came to embody the entire collection of health intervention strategies featured by this paradigm. in 1982/83, the united nations children’s fund (unicef) established a revolution for the children. this featured growth monitoring, breastfeeding, immunizations, management of diarrhea, and family planning. the main argument for this strategy has been that it only costs a few dollars per child. the success of the world health organization’s (who) intensified smallpox eradication program appeared to justify other such targeted programs. there was an expectation that future vaccines against diseases such as malaria, rotavirus, leprosy, and aids, among others, would lead to the success of “health for all by the year 2000.” more recently, social marketing has been used to encourage people towards specific behaviors in the targeted conditions. this paradigm is less reductionist than the first and provides broader coverage for targeted health services.  people are not assumed to be passive; there are responsibilities that people need to assume in order to be healthy.  accordingly this paradigm puts considerable responsibility on the shoulders of individuals, particularly women. responsibilities that are rightly those of the government, the community, and the couple in charge of each family have been allocated uniquely to the mother.  such a heavy load may have the effect described by ashton and seymour in the new public health movement and illustrated by a well-known parable.  the parable describes a health worker diagnosing the same diseases in the same children without looking at the context in which these children live.  this is likened to a lifesaver on the bank of a river: every so often a drowning person is swept alongside. the lifesaver dives in to the rescue, retrieves the ‘patient’ and resuscitates them. just as they have finished another casualty appears alongside. so busy and involved are the lifesavers in all of this rescue work that they have no time to walk upstream and see why it is that so many people are falling into the river. 10 these two previous paradigms were challenged because of their organicist approach.  the health of the society was more than just biological interaction of the human organism with other organisms. community-based health development should not be managed as isolated biological or sanitary conditions, but should focus on comprehensiveness and the processes generated by the interactions of multiple actors.  even though science has been able to identify the specific biological causes of many diseases and the specific medical actions that need to be taken to cure those diseases, the multiple social, cultural, political, religious, and economic factors that underlie disease processes cannot be managed in isolation.11  the traditional western development approach is a problem-driven process.  the approach is an expression of newtonian science that views the world like a gigantic clock with reality made up of discrete parts, each with its individual structure and function.  it breaks systems and units into their constituent sub-units and analyzes their distinct elements.  a problem-solving approach focuses on “rational dimensions” and, frequently, loses its connection with people’s lives and runs the risk of being unnatural and ineffective. a problem-driven development approach reproduces the old model in which the focus is the problem itself instead of the capacity of people to build healthy and sustainable environments, to maintain healthy behaviors, and to promote policies that foster those environments and behaviors.  problem-driven development takes the effort away from building people’s capacity for self-agency in their lives. the newtonian worldview is inadequate to account for the intricacies and interconnections of complex living and social systems.  problems manifest the failures of social systems to provide self-regulating capabilities that foster the fullness of life.  the exploration of more comprehensive approaches to development that deal with a holistic model of reality is urgent.  understanding community reality implies recognizing local people’s capacity to be aware of the interconnections, mutual influences, and dynamic relationships that flow among the elements of their community and history.  when a learning and development approach is embedded in the day-to-day context of the people, its impact is more natural, effective, and sustainable.  models of intervention need to be self-organizing, dynamic, and complex enough to deal with the wholeness of reality. health-genic systemic ecological paradigm of comprehensive health the effort to construct a more comprehensive understanding of health produced the emergence of what we call the “health-genic systemic ecological paradigm.”  we employ the descriptor “health genic“ to indicate that it is not pathogenic.  in other words, the health-disease process is not understood on the basis of the origin of disease, but on the origin of health, the way to achieve a full and abundant life.  it recognizes and defends, at personal, family, community, and societal levels, the role of the different elements of the bio-psycho-social life of the human being.  each element represents an ecosystem in which life is experienced.  the paradigm requires individuals, families, and communities to live in a mutually binding and integrated way, making choices for life instead of choices which promote death.  the choice for life is people committing themselves to transform the world in ways that establish a society marked by justice, liberty, and harmony. the role states and societies need to play in health determinants has been a force for the emergence of this third paradigm.  the international conference on health promotion held in ottawa in 1986 presented the charter for action to achieve health for all by the year 2000 and beyond.12  in the 1990s, the world health organization published social determinants of health: the solid facts.13  this stated that actions for health need to be geared towards addressing the social determinants of health in order to attack the causes of ill health before they can lead to problems.  it showed the strength of the scientific evidence on social determinants and presented them in a clear and understandable form.  a broad classification to deal with social factors was presented in a newer version of this document showing a remarkable sensitivity of health to the social environment.  a list of ten critical topics that need to be addressed for healthy societies included the following: the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport.14 this list went beyond the biomedical and bio-sanitary paradigms and put social systems in the center of the analysis. complex thinking helps us to deal more effectively with complex realities.16  in the effort of constructing a more comprehensive understanding of reality, edgar morin invites us to go beyond simplicity and to engage complexity.15  this may allow us to develop a way of thinking, being, and acting that in its wholeness is without fragmentation or mutilation of life.  this is in contrast to adherence to only one perspective provided by only one discipline and controlled by the hyper-specialization continually promoted in the academic world.  complex thinking may facilitate people to become richer in feeling and intuition and to live more fully with ourselves and with others by being more sensible of and appreciative of the complexities, paradoxes, tragedies, joys, failures, fears, dreams, and successes that occur every day.  complex thinking helps people become trans-disciplinary in their thinking, more creative, more strategic, and more oriented toward the search for new possibilities.  even though this approach to health is hampered by the privatization of health-care services and the division of “purchaser” and “provider” functions, it is critical that all sectors of society be organized to maintain a comprehensive approach.  those who consider themselves as jesus’s followers and have opportunity to understand the concepts of shalom (peace, completeness, wholeness, welfare), sozo (to save, keep safe and sound, to rescue from danger or destruction) and zoteria (salvation deliverance) cannot turn their back to the core message of jesus.  fragmented attention to particular aspects of health easily diverts attention from the determinants of health and discourages cooperation between different sectors of society.  as robert beaglehole and ruth bonita state, a public health approach that incorporates a multidisciplinary and intersectorial approach to the health determinants is the way forward in order for society to achieve wellbeing for all: a broad focus easily leads to accusations of “woolly breadth”, but this breadth is exactly what public health should be about. the challenge for public-health practitioners is to justify and promote global concerns and at the same time proceed with evidence-based, public-health inequalities.16 the human rights movement in the second part of the twentieth century showed a link between the exercise of human rights and people’s health and wellbeing.  this linkage indicated the need for a spectrum of strategies and activities that went beyond traditional primary health care services.  public health practitioners and organizations committed to the health for all movement began to explore the best avenues to build healthy societies.  the ottawa charter for health promotion sets out the following framework: build public policies which support health. create supportive environments. strengthen community action. develop personal skills. re-orient health services.13 paradigms that see and describe the world using words like organic, holistic, and ecological have been promoted by new developments in physics and related sciences.  the universe is no longer seen as a machine, made up of separate objects, but as one indivisible, dynamic whole whose parts are interrelated.  the mechanistic, hierarchical cause-effect understanding of the universe has been replaced by a world of multiple and complex processes and interactions.  parts interact and influence each other, acting as partners; compartmentalizing or fragmenting this integrated reality risks harming the whole.  as the health of one individual cannot be understood as the sum of the health of each part or organ, neither can the individual be considered apart from his/her relationships and interactions with the community and the environment.  new ways of understanding these interactions are required to be able to care for and embrace the whole person.  instead of focusing on diseases and biological processes, a broader scientific approach is needed to identify health determinants and how governments and civil society need to learn how to monitor, and care for those health determinants. even though this third paradigm became consolidated in the last decade of the 20th century, the initial foundation was laid down many years before, even during the 19th century; rudolf virchow, then, and salvador allende, more recently, were clear examples, acknowledging the social origins of illness; showing how workplace and environment cause infection, disease and disability; and promoting a new view of social etiology and multi-factorial causation.  social epidemiology identified social patterns of health and illness — such as the different health status between women and men, between the poor and the wealthy, or between the indigenous and non-indigenous populations.  this helped reveal social rather than the traditional biological explanations.  new voices began to affirm that the primary determinants of disease are mainly economic and social; therefore, its remedies must also be economic and social. 17 a number of epidemiological studies show the role income, shelter, education, access to nutritious food, services, community norms and cohesion, and social justice play in the health of communities and individuals.  social determinants affect the factors and resources essential to the health of communities and individuals as well as the resources available to support their health and to deal effectively with illness and disease.  social determinants cluster around three basic areas: income inequality, social connectedness, and sense of personal or collective control over one’s life or self-efficacy.  this understanding has led to a movement to develop policies and strategies to promote social equity in health.18 health needs to be understood by merging key ideas from ecology, medicine, genetics, immunology, and epidemiology.19, 20, 21 there is an acknowledgment of the role a stable ecosystem plays in the health of society. clean air, clean water, and protection of the natural environment are critical components of achieving health.  this includes sustainable resources such as water, farmland, minerals, industrial resources, plants, animals, and renewable sources of power such as sun, wind, water, and biomass, etc.22  an ecological view of health allows what we call a “health-genic” understanding about the health and disease process.  in this health-genic model, comprehensive health is understood as a social process which enables individuals and societies to adapt dynamically to their environment.  it also enables individuals and societies to avoid progressive conflict or disease and conditions whose presence poses a high risk of damaging their state of health.  comprehensive health is the capacity for full self-actualization according to the will of god in its various bio-psycho-social aspects in a self-sustaining manner that does not jeopardize the conditions which would allow successive generations to experience this fullness.  this is why it is necessary to be sensitive to the interactions and processes between the different actors or social groups and the systems that regulate how they live and interact.  the processes, themselves, modify human systems that in turn generate social forces for change and transformation. comprehensive health must seek to promote a new way of appreciating human beings and life through modifications of the interaction between different social systems or subsystems.  now large sectors of population cannot remain passive, waiting for governments to do something to remove a disease or a group of health problems.  multiple organized groups see that systems need to be effective if they want to overcome these problems; they want to put pressure on government to become more effective.  as the article reinventing public health: a new perspective on the health of canadians and its international impact states: in the 1970s all the english-speaking developed nations were facing deficits as curative costs rose. adopting health promotion policies permitted them to shift responsibility back to local governments and individuals while limiting their expenditures. health and community activists, however, used this concept to broaden their focus to include the social, economic and political determinants of health and thus reinvented public health discourse and practice for the 21st century.23 social systems modify historical processes in different areas of human life including health. if we seek long-term changes, it is useful to observe, evaluate, and analyze the processes generated by these systems. the environment, both natural and modified, and individual and collective behaviors are the largest determinants of health conditions in a community. acquiring information and skills is not sufficient to generate changes with regard to health; it also requires developing personal and community power to implement changes. total health example an example of how to use a systems and health-genic approach is the effort that map international expressed in the strategy for total health summarized in an unpublished internal document elaborated by the president michael nyenhuis in 2007.24  he offered a definition of total health not as describing the state of someone’s health, as if he or she is free from illness, disease or other conditions. rather, total health describes the ways that individuals, families, and communities can take responsible action to improve their well-being.  it is the integration of two important ideas: self-empowerment transformation and sustainable change happen when individuals, families, and communities discover and begin to exercise the god-given power they have over their own lives.  they are responsible to “create their own momentum, gain their own skills, and advocate for their own change,” as the world health organization wrote in a paper, “what is the evidence on effectiveness of empowerment to improve health?”25  approaches grounded in total health must help communities discover their power and build their own capacity to improve their wellbeing.  research increasingly shows that health outcomes are dependent on self-empowered citizens actively participating in their own change.  if outside experts always plan and implement health interventions — even comprehensive ones — communities will be disempowered and without incentive to solve their own future problems. holism a holistic or comprehensive view of health recognizes the inter-connected spiritual, physical, emotional, social, and other factors that influence wellbeing.  map’s broad understanding of health comes from scripture, from the hebrew word shalom.  sometimes translated “health,” shalom actually implies a much broader conception of wholeness, wellbeing, and peace in every area of life.  truly effective, transformational projects must work toward this ideal.  this is why, for instance, we resist simple interventions so common in development work.  a typical “child survival” project might have as its goal adding vitamin a and zinc to the diets of children.  while important, these simple interventions do not address the integrated factors that influence the health and wellbeing of children. our desire is to address — as well as we can and in partnership with others — the whole, rather than individual parts. with that in mind, total health is defined as communities taking ongoing, comprehensive action to improve their health and wellbeing. map bolivia’s work done through chilimarca programs is a good model of transformational work in the area of total health, showing how individuals, organizations, families, and communities can experience an “inside-out” process, a self-empowerment journey to heal brokenness in their lives and progressively gain control over health determinants.  individuals, families, communities, and organizations have progressively developed a better understanding of how to pursue the fullness of physical, spiritual, relational, and mental well-being of god’s shalom.  this model has shown how efforts toward total health communities or nations require far more than the work of medical professionals.  gaining control over the personal and social determinants of health requires family and community programs that engage people in the process of transforming their lives and learning to live in harmony with each other, with god, and with nature.  these elements all provide resources for healthy living and what will allow them to experience abundant and meaningful life in a sustainable way without jeopardizing the life of coming generations.  large changes have been experienced by map staff in bolivia, their families, the organization, and the communities with which they have been working.  political advocacy efforts on violence against children and on human rights violations increase the holistic perspective.  they indicate the large impact map can have in other countries in latin america and the world. 26, 27 the engagement of christian organizations with communities to go beyond the traditional approach of treating and preventing diseases, lowering exposure to germs, and to seek the transformation of social health determinants has helped to show that god really cares for the suffering and injustice experienced by large sectors of society.  if the announcement of “a god disconnected from the world” led to a society that attempted to live in “a world without god,” committed jesus-followers engaged in the transformation of society will allow people to see that god comes to their midst seeing the signs of the abundant life jesus has offered.  if the primary determinants of many diseases are mainly economic and social, a true engagement with the health of a society must also include economic and social engagement.  in the same way that medicine, politics, and social transformation should not be kept apart28, the spirituality and faith of jesus’ followers must be clearly integrated in their faith and practices as health professionals contributing to the transformation of the world. foundations for the future the end of the 20th century left us with an open horizon to address the root causes of many health problems and also the health determinants fostering familial, communal, and societal wellbeing.  at the turn of the century, neuroscience research provided the material for developing a new understanding of how people think, learn, and behave.  though this research was not then considered critical for addressing global health, it has provided the foundations for a new health paradigm.  this would focus on the critical period of life during which human beings establish their brain architecture and lay the foundations of the key determinants for mental and physical health.  the last verse of the old testament’s last book calls fathers to turn their hearts to the children. behold, i will send you elijah the prophet before the coming of the great and dreadful day of the lord: and he shall turn the hearts of the fathers to the children, and the hearts of the children to their fathers, lest i come and smite the earth with a curse. (malachi 4:5.6) a new 21st century paradigm would call all of humanity to turn their hearts toward the children, to go to the children to understand critical aspects about how we can become a healthier society.  it is as if god were using science to announce — as the prophet elijah and john the baptist did in former times — that the time has arrived for the turning of our hearts toward the children. and he shall go before him in the spirit and power of elijah, to turn the hearts of the fathers to the children, and the disobedient to the wisdom of the just; to make ready a people prepared for the lord. (luke 1:17) jesus invites us to a precious encounter with him by turning our hearts toward and receiving children into our lives: “whoever receives one little child like this in my name receives me.” (mat 18:5) references morin e. from the concept of system to the paradigm of complexity. j soc evol syst. 1992;15(4):371-85. http://dx.doi.org/10.1016/1061-7361(92)90024-8 morin e. on complexity (advances in systems theory, complexity, and the human sciences). cresskill, nj: hampton press; 2008. samet rh. exploring the future with complexity science: the emerging models. fut evol psych. 2011;43(8):831-9. http://dx.doi.org/10.1016/j.futures.2011.05.025 brown tm, cueto m, fee, e. the world health organization and the transition from “international” to “global” public health. am j public health. 2006 jan;96(1):62-72. http://dx.doi.org/10.2105/ajph.2004.050831 last jm, wallace rb, editors. maxcy-rosenau-last public health and preventive medicine 11th ed. norwalk, connecticut: appleton & lange; 1980. [p. 1709] germov j. second opinion: an introduction to health sociology. melbourne, australia: oxford university press; 2009. [p.12] world health organization. declaration of alma-ata. adopted at the international conference on primary health care; 1978 sept 12; alma-ata, ussr. perry hb, zulliger r, rogers mm. community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. annu rev publ health. 2014 mar;35:399-421. http://dx.doi.org/10.1146/annurev-publhealth-032013-182354 ewert dm, editor. new agenda for medical missions. brunswick, ga: map international; 1990. ashton j, seymour h. the new public health: the liverpool experience. open university press; 1988. [p. vii] joseph a, abraham s, muliyil jp, george k, prasad j, minz s, et al. evaluation of suicide rates in rural india using verbal autopsies, 1994-9. bmj. 2003;326:121-2. world health organization. the ottawa charter for health promotion. adopted at the international conference on health promotion; 1986 november 21; ottowa, canada: who. available from: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ world health organization. social determinants of health: the solid facts. copenhagen, denmark: who; 1998. available from: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf world health organization. social determinants of health: the solid facts. 2nd ed. marmot m, wilkinson r, editors; copenhagen, denmark: who; 2003. available from: http://www.euro.who.int/en/publications/abstracts/social-determinants-of-health.-the-solid-facts morin e. from the concept of system to the paradigm of complexity. j soc evol syst. 1992;15(4):371-85. http://dx.doi.org/10.1016/1061-7361(92)90024-8 beaglehole r., bonita r. public health at the crossroads: which way forward?. lancet. 1998;351:590-2. [p. 591] http://dx.doi.org/10.1016/s0140-6736(97)09494-4 waitzkin h, rosen g. the evolution of social medicine. in: freeman he, levine s, reeder lg, editors. handbook of medical sociology. englewood cliffs nj: prentice hall; 1972. p.30-60. dahlgren g, whitehead m. policies and strategies to promote social equity in health. stockholm, sweden: institute of futures studies; 1991. gesler wm., bird st, oljeski sa. disease ecology and a reformist alternative: the case of infant mortality. soc sci med. 1997;44(5): 657-71. http://dx.doi.org/10.1016/s0277-9536(96)00219-5 real la. sustainability and the ecology of infectious disease: diseases and their pathogenic agents must be viewed as important parts of any ecosystem management strategy. bioscience. 1996;46(2),88-97. http://dx.doi.org/10.2307/1312811 collinge sk, ray c. disease ecology: community structure and pathogen dynamics. cary, north carolina: oxford university press; 2006. ku work group for community health and development. the community tool box, section 3. healthy cities/healthy communities. [internet] lawrence, ks: university of kansas; 2010. available from: http://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/healthy-cities-healthy-communities/main macdougall h. reinventing public health: a new perspective on the health of canadians and its international impact. j epidemiol commun h. 2007;61:955-9. http://dx.doi.org/10.1136/jech.2006.046912 nyenhuis m. strategic planning for unpublished internal document. map international. 2007. world health organization [internet]. what is the evidence on effectiveness of empowerment to improve health?. geneva: who;2006. available from: http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/publications/pre2009/what-is-the-evidence-on-effectiveness-of-empowerment-to-improve-health kinman e. whose clinic is it anyway? a case study of health care access in bolivia. in scholarship for teaching: case studies in latin american geography. 2004. miranda mg. advocacy, defensa de causas justas y autoempoderamiento. systematization of map’s work in bolivia. 2008. rose ga. the strategy of preventive medicine. oxford: oxford university press; 1992. peer reviewed. competing interests: none declared. correspondence: jose miguel deangulo, map international, bolivia,â  mapbol@verizon.net cite this article as: deangulo jm, losada ls. health paradigm shifts in the 20th century.â  christian journal for global health (may 2014), 2(1): 49-58. ©deangulo jm, losada ls. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ commentary may 2019. christian journal for global health 6(1) working order: health, personal responsibility, and rights in an age of limited agency mark croucha a md, public health officer, staff physician, kudjip nazarene hospital, in his image international, papua new guinea abstract a seeming contradiction exists between the approach to health as a fundamental human right or as the natural consequence of human responsibility. this paper investigates a christian approach to health attempting to reconcile these disparate views. the biblical basis of human responsibility for health is considered as well as the greater forces affecting the health choices of individuals and communities. ultimately, a combined approach or "working order" toward the fundamental right to health based on human responsibility is attempted. key words: personal agency, human rights, health, responsibility nothing is more easily thrown out of working order than the balance between different spheres of thought. henry drummond1 a young woman presents to a faith-based organization’s (fbo) maternal health clinic in a lowmiddle income nation for family planning services. the fbo does not provide hormonal-based methods of contraception but instead instructs its patients to use fertility awareness methods. in her society, this young woman’s ability to dictate when she participates in sexual intercourse (and perhaps even with whom) is almost entirely out of her control. three months later she presents to the same clinic, the only one accessible to her, because she is 7 weeks pregnant. the clinic initiates antenatal care for her. two weeks later she returns extremely ill with an infected and perforated uterus after a failed attempt at a “bush” abortion and subsequently dies. introduction an apparent conflict exists between the principles of individual human responsibility and certain aspects of health as a human right. health is defined by the world health organization (who) not just as the absence of disease but a more robust condition of “complete physical, emotional, and social well-being”2. in fact, the expansive definition of health and the inclusion of “the highest attainable standard of health” as a fundamental right in the constitution of the who is a powerful force motivating current efforts in safeguarding the health of individuals in a globalized world. according to the who fact sheet on human rights and health, states are obligated to secure access to health care and to provide reasonable conditions affecting the determinants of health for their citizenry.3 a conflict arises when the determinants of health are partially or wholly within the decision-making powers of the citizen(s) themselves, i.e., in our example, the choice to engage in unsafe sexual practices or to access inappropriate health services. one could argue that personal responsibility in making unhealthy choices negates the need to provide for a right to health, since a person has taken action to jeopardize their own health. biblical principles of stewardship of the body might be used to support this stance.4 looking into the united nations universal declaration of human rights, one might argue against providing health as a human right because safeguarding one person’s right to “medical care and 60 crouch may 2019. christian journal for global health 6(1) necessary social services” (article 25) might infringe another’s not to be “deprived of his property” (article 17).5 perhaps because of this conflict, the who fact sheet suggests that states focus on access to health care and the conditions that are (supposedly) within government control, like gender equality and reasonable infrastructure, rather than on guaranteeing health as a human right.3 yet could this right to health care access foster an entitlement mentality and a shirking of individual behaviors, leading to the health system or tax-payers cleaning up after the unhealthy choices of the sick? for the christian, is there a conflict between a biblical approach to responsible stewardship of the body and the right to health? these different spheres of thought interact frequently in global health, where fbos provide a substantial amount of services in many low-middle income countries and where many cultures appreciate the influence of faith on health. if the balance of biblical stewardship of the body and health as a human right is not elucidated, christians may find themselves struggling to provide care that is both christ-like and socially just. to strike this balance appropriately, the christian global health worker should recognize the danger in attributing principles like personal responsibility to biblical virtues. they must also acknowledge the complex array of forces shaping individuals’ behaviors. while personal health choices ought to be considered when crafting policy based on health as a human right, the limited agency available to many of the world’s destitute and sick should temper arguments that entitlement will naturally follow provision of health as a human right. christians have a unique role to play in addressing the spiritual and cultural factors that influence the complex forces which shape an individual’s health. the danger of personal responsibility for the christian, social and political forces often intersect with biblical principles. most pertinent to the discussion of health as a human right would be a political view that social ills like poverty or ill health represent a failing of personal responsibility. is this a biblical principle? as pointed out, some would argue that the scriptural mandate to steward the body in a way that honors god’s instructions is evidence that responsibility dictates personal health. for behaviors with clearly elucidated links to poor health, this makes sense. those who drink to excess or use tobacco products and subsequently develop liver disease or emphysema may, rightly, blame their own behaviors. however, taking this concept of personal responsibility further, a state may conclude that the health of its citizenry is not something that can or should be guaranteed as a right. people should exercise temperance, moderation, and civility in order to safeguard their own health. governments might provide access to care or work to improve conditions affecting health but may emphasize conditions felt to be beyond an individual’s choices. christian authors have suggested that this represents a union of “moral discipline and civil government” and creates a system in which the “focus shifts from rights to responsibilities.”6 such a shift to responsibility suggests that when considering how to provide health services and to whom, the christian worker should ask, “who is to blame for this malady?” looking into scripture, though, when christ is asked by his disciples regarding a man being born blind, he ignores the issue of blame. indeed, he says that assigning it only distracts from the true issue— “that the works of god should be revealed.”7 it seems that jesus considers demonstrating god’s heart to restore an individual as more important than considering how their brokenness occurred. perhaps the better question to ask is not if personal responsibility absolves the christian from promoting health as a human right but, instead, what role the christian plays in bringing the tangible expression of god’s healing into the lives of those they encounter. the principle of personal responsibility may not be the primary virtue evident in biblical scripture. complex forces human responsibility is not exercised in a vacuum. the choices that individuals make occur within a complex system of competing forces. these forces often drive individuals or entire communities into unhealthy living. as bryant myers explains in discussing the underlying issues creating poverty, these include the physical, social, mental, and spiritual spheres. such issues applied to poverty involve entire “disempowering systems.”8 yet such systems not only influence choices that individuals make regarding their social or economic situation, but their health as well. the various forces that affect a person’s 61 crouch may 2019. christian journal for global health 6(1) responsibility may make healthy choices impossible. the christian who attributes all ill health to individual human responsibility must ignore, or at least seriously underestimate, the effects of a world groaning for redemption.9 as medical anthropologist simon cohn points out, if one fails to recognize the complex forces acting upon an unhealthy person’s choices, “the social, affective, material, and interrelational features of human activity are effectively eliminated, as behaviour becomes viewed as an outcome of the individual.”10 if behaviors are solely an outcome of personal responsibility, then health as a human right is a violation of natural consequences. such an argument lends itself to those who endorse policies directed at improving health behaviors, like health education activities, but abandon the greater battle against larger social structures at play. this might be expedient for stretched governance bodies, often balancing thin budgets, who can level accusations at individual or community choices and wash their hands of responsibilities to provide health care. however, the christian should exercise caution in following suit. when assessing whether a person’s choices are a genuine reflection of their level of responsibility, one ought to consider broader factors that could limit that person’s agency. limited agency in the opening narrative, a young woman succumbs to the catastrophic consequences of a tragic personal decision to pursue an unsafe abortion. if human responsibility is to blame for her ill health and subsequent death, whose responsibility has fallen short? the young woman who did not “control” her sexual activity or chose to pursue a dangerous medical procedure? the society around her that allows men to enforce their sexual appetites with little concern for their partners? the fbo for not providing a more effective method of contraception in that environment? if the young woman’s claims to health depend on human responsibility rather than as a basic right, should her death be viewed as a just end to poor choices? there is nothing wrong with underlining personal agency, but there is something unfair about using personal responsibility as a basis for assigning blame while simultaneously denying those who are being blamed the opportunity to exert agency in their lives.11 paul farmer the christian health worker must recognize a litany of areas in which individual human responsibility yields to the greater and complex forces around it. even the capacity for exercising individual choice may yield to beliefs that affect “levels of perceived control.”8 for example, an illiterate woman whose husband tells her that their holy book prescribes sex on demand would foster a deep belief that forces her to give up any attempt at personal agency in such interactions—like suggesting the use of a condom. while limited agency does not grant an individual limitless excuse, it should powerfully color the dialogue of health as a human right, especially for christians working in such environments. the tragedy would be amplified if the individual operating under limited agency shoulders blame for their conditions, which then excludes them from receiving appropriate health services. for example, a mission hospital refuses care for complications to those who have undergone illegal abortions. in this sense, the health of the individual is best safe-guarded by viewing it as a right. for those who instead choose to emphasize personal responsibility, perhaps the greater responsibility is not on the sick individual but on the christian to reach out to the afflicted, without blame, and ameliorate their suffering as in the biblical story of the good samaritan.12 “rights and responsibilities... are two sides of the same coin. if you are sick, because i see in you the image of god it is my duty to care for you.”13 the reconciliation of human responsibility with limited agency enables the christian to find a working balance that sees health as a human right which, like all others in a fallen world, can only be realized to a limited extent. the working order these two disparate spheres of thought, health as a human right and the reality of human responsibility, must find a “working order” in the christian who would provide care to the destitute and sick of the world. individuals powerfully shape their health within the forces around them. yet a health worker attempting to bring christ-like care to the suffering may, like nouwen, ask, “why do i spend so many hours talking about the individual pains of people, while i leave the society that creates these pains unchanged?”14 to acknowledge external forces affecting health behaviors enables a physician to not 62 crouch may 2019. christian journal for global health 6(1) only treat the suffering of the patient they encounter, but to examine the structures around that person. critically, this allows the christian to separate “responsibility” from “blame.” this must happen if the spheres are to be reconciled. individuals and entire communities bear responsibility for adverse health. however, blame does not inseparably follow responsibility because of greater realities that influence health. an active enemy, social disempowerment, and spiritual vacuity, they all bear varying levels of blame for much of the misery that threatens to overwhelm our world.15 when human choices are understood in light of the complex forces that shape them, the christian is free to emphasize health as a fundamental right that requires an environment promoting personal agency. if willing to address fundamental rights issues, christians can guide a discussion of fostering favorable environments to a greater degree than strictly secular actors can. too much emphasis on “structural violence” or other powers disrupting personal agency ignores an arena that much of the world considers important, namely the spiritual or religious.11 an appreciation of fundamental rights can go only as deep as the fundamental world-views of those involved. the christian shares a basic belief structure in the supernatural with much of the world. from there, deeper forces that constrain personal agency can be investigated in light of the gospel—a gospel which offers the redemption of entire societies.16 such changed societies can expect to see the fundamental right of health realized in communities that value persons, and their ability to make choices, in the image of god. references 1. baillie j. a diary of readings. new york: charles scribner's sons; 1955. day 183 2. who [internet]. constitution of the world health organization. geneva / new york. available from: https://www.who.int/governance/eb/who_constitution_e n.pdf. accessed 20th feb, 2019. 3. who [internet]. fact sheet: human rights and health. 29 december, 2017. geneva. available from: http://www.who.int/news-room/factsheets/detail/human-rights-and-health. accessed 8th november 2018. 4. 1 corinthians 6:19-20 (all scripture references are based on new king james translation) 5. united nations [internet]. universal declaration of human rights. 10 december, 1948. available from: http://www.un.org/en/universal-declaration-humanrights/. accessed 8th november 2018. 6. miller dl. discipling nations: the power of truth to transform cultures. seattle: ywam publishing; 1998. 7. john 9:3 8. myers bl. walking with the poor: principles and practices of transformational development. new york: orbis books; 1999. 9. romans 8:22 10. cohn s. from health behaviours to health practices: an introduction. sociology of health & illness. 2014;36(2):157-162. https://doi.org/10.1111/14679566.12140 11. farmer p. infections and inequalities: the modern plagues. los angeles: university of california press; 1999. 12. luke 10:25-37 13. christian aid [internet]. theology and international development. april, 2010. available from: https://www.christianaid.org.uk/sites/default/files/201708/theology-international-development-april-2010.pdf. accessed 11th november 2018. 14. nouwen hjm. creative ministry. new york: image book / doubleday; 1971. 15. 1 peter 5:8 16. romans 1:16 peer reviewed: submitted 11 nov 2018, accepted 20 feb 2019, published 31 may 2019 competing interests: none declared. correspondence: mark crouch, public health officer, staff physician, kudjip nazarene hospital, in his image international, papua new guinea. crouchm@gmail.com https://www.who.int/governance/eb/who_constitution_en.pdf https://www.who.int/governance/eb/who_constitution_en.pdf http://www.who.int/news-room/fact-sheets/detail/human-rights-and-health http://www.who.int/news-room/fact-sheets/detail/human-rights-and-health http://www.un.org/en/universal-declaration-human-rights/ http://www.un.org/en/universal-declaration-human-rights/ https://doi.org/10.1111/1467-9566.12140 https://doi.org/10.1111/1467-9566.12140 https://www.christianaid.org.uk/sites/default/files/2017-08/theology-international-development-april-2010.pdf https://www.christianaid.org.uk/sites/default/files/2017-08/theology-international-development-april-2010.pdf https://www.christianaid.org.uk/sites/default/files/2017-08/theology-international-development-april-2010.pdf 63 crouch may 2019. christian journal for global health 6(1) cite this article as: crouch m. working order: health, personal responsibility, and rights in an age of limited agency. christian journal for global health. april 2019; 6(1):59-63. https://doi.org/10.15566/cjgh.v6i1.261 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ original article dec 2019. christian journal for global health 6(2) barriers and enablers provided by hindu beliefs and practices for people with disabilities in india andrew wilsona a bs, md, university of melbourne, intern at southwest healthcare, melbourne, australia abstract background: faith beliefs, and associated cultural beliefs, play an important role in affecting responses to disability. there is no systematic review of how hindu beliefs affect approaches to people with disabilities. the majority of the world’s hindus live in india, as do a large number of people with disabilities. therefore, this article seeks to explore the positive and negative ways that hindu beliefs affect people with disabilities in india. methods: we undertook a scoping review of the available literature aiming to explore the barriers and enablers for people with disabilities provided by hindu beliefs and practices. the databases pubmed, scopus, and psycinfo were systematically searched and several additional articles from other sources were included from searching the grey literature. results: historically, the literature indicates that indian, hindu, karmic beliefs have advanced the view that people with disabilities are deserving of their condition. this literature suggests that this view continues into the present and can lead to stigmatisation of both people with disabilities and their families. in turn, this karmic understanding of disability can discourage people with disabilities from accessing medical treatment. additionally, certain hindu tribal remedies for disability may cause bodily harm and prevent the person with disability from receiving allopathic treatment. it was also documented that the attitude of indian doctors toward people with disabilities are negatively affected by hindu beliefs. one research study suggested that karmic beliefs can benefit families of people with disabilities by providing them with a context for suffering. conclusion: the study shows that hindu religious belief effects, mostly negatively, the response to disability. this is important to consider when undertaking disability and inclusive development activities in india. introduction the indian cultural landscape is dominated by religion, which significantly impacts the social perception of people with disabilities.1 according to the model of disability proposed by wolfensberger, the services offered to people with disabilities in a community is dependent upon the underlying beliefs held by that community.2 this understanding is based upon the “social model” of disability. shakespeare notes that the social model of disability was originally outlined by the union of the physically impaired against segregation (upias).3 in their foundational position statement, the upias argued strongly that disability was caused by societal exclusion of people with 13 wilson dec 2019. christian journal for global health 6(2) impairments.4 in its purist form, this understanding means that disability is eliminated when society adapts to accommodate peoples’ impairments.4 this social model has been lauded by many academics as the catalyst for much beneficial change for people with disabilities throughout the world.3 therefore, it is vital to understand the prevalent philosophies and attitudes toward people with a disability within the indian society in order to understand their experiences and develop more effective strategies to benefit them. this review will investigate how hindu beliefs and practices affect people with disabilities in india. although other religions are practiced within the indian subcontinent, there are several reasons for focussing upon hinduism. firstly, hinduism is the most influential religion in india. it is practiced by just under 80% of indian nationals as identified in the 2011 indian census.5 the historical traditions of hinduism still exert considerable influence on the societal structure and culture of india today.6 for instance, the hindubased caste system has persisted in india despite being outlawed by the government, and hindu notions of karma remain prevalent in modern indian thought.7,8 secondly, this literature review looks at hinduism because the vast majority of existing work on the topic of faith and disability in india has focussed upon it, rather than other religions. the situation of people with a disability in india has long been an issue of concern. in the 2011 census, 2.1% of indians identified as having a disability, which anees thinks to be a conservative estimate.9 people with disabilities in india are often illiterate and unemployed.5,9,10 furthermore, they face frequent stigma and discrimination in many forms, often linked to prevalent community beliefs surrounding disability, as reported by anees and balasundaram.9,11 stigma has been shown to negatively affect health outcomes by several processes, including social isolation and negative psychological responses from stigmatised individuals.12 significant gaps in knowledge exist around understanding how hindu beliefs and practices affect people with disabilities in india. a variety of studies have examined this topic in different localities, but they have not been synthesised and thematically analysed. hence, this review aims to provide a broader understanding of the day-to-day effects of hinduism in the lives of people with disabilities from across the nation of india. this study investigates the causal explanations, benefits, barriers, and effects on treatment provided by hindu beliefs and practices for people with disabilities in india. beginning with some historical perspectives, it transitions into the current experience of people with disabilities. finally, it considers how hindu beliefs and practices map onto the established models of disability. materials and methods this piece is written as a scoping review. this was the most appropriate review form available for the topic, since most relevant articles were either observational studies or commentary pieces, which did not draw clear distinctions between culture and religion. consequently, it was not possible to establish the rigid inclusion and exclusion criteria required for a systematic review. therefore, this article is written as a scoping review which nevertheless utilises systematic methodology, where appropriate, to maximise its rigour. the online databases pubmed, scopus, and psycinfo were searched in february 2018 using keywords. the same keywords were used to search all databases. they were as follows: (disable* or disabilit* or handicap* or retard*) and (faith* or religio* or belief* or superstit* or spirit* or hindu* or jaini* or buddhi* or christian* or sikh* or moslem* or muslim* or islam* or attitudes* or karma*) and (india* or hindu* or hindi*). scopus and pubmed were used because these databases provide especially broad coverage of the medical literature. pyschinfo was additionally utilised because it focusses on sociological pieces that may not be available in more classic medical databases. given the relative paucity of papers available on the subject, the search terms were kept intentionally broad, aiming to find any papers related to people with disabilities and the hindu faith. 14 wilson dec 2019. christian journal for global health 6(2) for inclusion, papers were required to be written in english. included papers discussed the impact of hindu beliefs and practices on physical, intellectual, or sensory disability. justification for the latter criterion is that some papers identified by the search strategy mentioned religion as a factor affecting disability, yet neglected to explain it in any depth, thereby providing insufficient material for discussion in this review. hinduism was chosen as the religion of focus owing to its strong influence on modern indian society and widespread coverage in the disability literature, as previously described. with reference to who classifications of impairment, only studies focussed upon individuals with primary intellectual, aural, ocular, language, skeletal, visceral, generalised, or disfiguring impairments were included in this review.13 articles that discussed participants with a combination of these impairments were also included. one key exception to this was articles that described people with memory impairment, which were excluded despite falling under the who category of intellectual impairment.13 a distinction was made between primary and secondary impairment on the basis that individuals with these impairments are viewed differently within the community. that is, a person with an acquired disability may have accrued significant social respect prior to the occurrence of their disability, as suggested by anees.9 conversely, a person with a congenital disability “may experience less hope and chance of attaining substantial education and opportunities for success due to the family, community and/or societal perceptions of disability.”9 thus, persons with primary impairments were chosen as the topic of this study. studies discussing persons with psychological impairment were excluded from this review. regarding conditions of the mind, the justification for differentiating “mental health” from intellectual disability is explained by the intellectual disability rights service.14 additionally, dental studies were excluded. two studies in which the researcher could not access the full text were also excluded. several other search strategies were employed in addition to database searches. reference lists of articles identified via the database search were scanned for relevant articles missed in the search, yielding one resource. additionally, a thesis was included in the literature review on the suggestion of one of the researcher’s supervisors. results during the database searching process, 1481 articles were identified. additionally, 2 articles were identified by the researcher’s supervisors. these records were screened by title and abstract and 46 articles were identified as relevant. when the full texts of these articles were analysed, 36 were deemed not to meet the inclusion criteria, leaving 10 articles for inclusion in the study. this process is detailed below in figure 1 15 wilson dec 2019. christian journal for global health 6(2) figure 1. prisma diagram showing process of identifying records for literature review.15 of the studies included, six were commentary pieces, three were case studies, and one was a thesis. all included journal articles were peerreviewed. qualitative results are demonstrated below. the difficulty of defining hindu beliefs and disability religion is a difficult entity to define within the indian context, yet it profoundly shapes the interpersonal relationships of indian people, as rao points out.1 he reports that hinduism consists of innumerable writings compiled over thousands of years without a singular doctrinal focus. despite this, there are consistent themes that shape hindu thought, such as the concept of karma. anees finds that the teaching of karma has important implications for people with disabilities.9 as alluded to, it is very difficult to pin down a concise definition of hinduism, which has significant historical variation in its codification according to rao.1 to further complicate matters, there are multiple sources from which the teachings of hinduism have been drawn. for example, some strands of hindu thought are pluralistic and incorporate teachings from other religions, while orthodox hinduism only accepts teachings from the vedic tradition. furthermore, local hindu teachings may be intermingled with superstitious beliefs, as described by rao.1 thus, it is almost impossible to form a concise definition of hinduism. defining disability in india is also challenging, although not to the same extent as defining hinduism. in western thought, disability has traditionally been defined according to a medical model, whereby certain physical and/or mental impairments were deemed to render a person “disabled.” however, more recent understandings have focussed upon a “social model” of disability, which reframes disability as being a situation caused by social conditions.4 records identified through database searching (n = 1481) sc re e n in g in cl u d e d e li g ib il it y id e n ti fi ca ti o additional records identified through other sources (n = 2) records screened (n = 1483) records excluded (n =1423) full-text articles assessed for eligibility (n =46) full-text articles excluded (n = 36) studies included in qualitative synthesis (n = 10) records after duplicates removed (n = 46) 16 wilson dec 2019. christian journal for global health 6(2) according to the upias, disability may be addressed purely by reforming society to accommodate people with impairments. yet, neither models necessarily explain local perceptions of disability in india. for instance, mehrota found that persons required to depend upon others were considered to have a disability in a rural haryana community.16 for example, study participants questioned whether people with a hearing impairment had a disability since they could still carry out manual labour and were selfsufficient. this example is worth bearing in mind because it demonstrates that indian people may have different understandings of disability to those adopted by scholars in the field. historical hindu perspectives portray disability negatively historically, the teachings of hinduism have profoundly affected the treatment of people with disabilities in india, often in unhelpful ways. the concept of disability was frequently explained in hinduism as being “sent by deity, fate [or] karma; often associated with parental or personal sin.”18 (p.57) anees writes that people with disabilities are considered scheming and evil in hindu writings.9 in one instance, the laws of manu state that people with disabilities are suffering punishment for crimes which they allegedly committed in previous lives.18 it further states that they are “despised by the virtuous.”18 (p.57) elsewhere, miles found that the laws of manu prohibited people with various impairments from attending a sacred festival as they were thought to spoil it.19 he also notes that the laws of manu advised that people with disabilities should be avoided by other participants at the festival, to maintain ritual purity. another example of negative sentiment towards disability is found in the hindu epic the mahabharata. anees recounts that in one story, king dhritarashtra is made blind by the gods because in a previous life he had maliciously blinded a swan.9 women with disabilities appear to have an even worse treatment than men in the hindu scriptures, as anees explains. manthara, for example, is an ugly, evil, manipulative servant with a hunchback, described in the ramayana. like king dhritarashtra, she had a disability, but unlike him she was not in a position of power. similarly, anees reports that the sister of the goddess lakshmi was told by the god vishnu that people with disabilities are not welcome in heaven. she was also made to marry a tree, which is clearly a humiliating experience.9 according to rao, the hindu concept of “maya” can be applied to mean that all disability is an illusion of human perception.1 in essence, maya teaches that the human cognition does not actually perceive reality, but rather an illusion. furthermore, rao writes that the real self is beyond human sensual perception in some streams of hindu thought. drawing upon these ideas, rao contends that hindus could conceive disability to be an illusory human perception. for a hindu, rao believes that maya could highlight “the real person behind the mere physical person receiving care.”1(p.132) hence, he believes that hindu carers of people with disabilities can take comfort that the actual self of someone with an impairment is not defined by their bodily limitations. yet this proposal seems overly optimistic. the documented real-world experience of hindu carers of people with disabilities does not reflect or make mention of an illusory dimension to disability. hindu carers in existing studies invariably acknowledge the reality of disability and then respond to it. an example of this is khima, the hindu mother of a child with a disability who sought help from numerous sources for her child’s condition.11 therefore, rao’s argument does not appear to have a solid basis in praxis. on a more positive note, there is evidence that hindu society occasionally made concessions for people with disabilities. miles notes that efforts were made to include children with visual and speech defects during the upanayana ceremony at the beginning of their education.19 this demonstrates some flexibility within the historical hindu laws for people with disabilities, although their prospects for further education in this instance were “in most cases doubtful.”19 (p.256) 17 wilson dec 2019. christian journal for global health 6(2) certain laws were also made to prevent discrimination against people with disabilities, according to miles.18 the hindu ruler, kautilya, and the aforementioned laws of manu contained a provision for the heads of families to care for relatives with a disability. thus, it can be seen that hindu teachings provide some benefit to people with disabilities. the influence of judeo-christian ethics upon hinduism during the colonial era aided certain marginalised hindu societal groups, as recorded by rao.1 he notes that the christian imperative to love one’s neighbour profoundly influenced the teaching of the hindu, keshub sen. in turn, rao writes that sen’s advocacy greatly improved the status of widows in indian society. although not directly applicable to the disability sphere, rao argues that this humanist attitude, inspired by the teachings of christ, may have contributed to the current focus upon providing service to people with disabilities in india. expanding upon his argument, it is worth considering the potential of judeo-christian ethics to improve the status of people with disabilities in india today. an example of hindu beliefs being utilised to uplift the marginalised is possibly found in the teachings of gandhi. yet rao notes that gandhi himself was significantly influenced by christian teachings. he reports that gandhi saw a calling to love all people in both the hindu bhagavadgita and the biblical sermon on the mount.1 to gandhi, discrimination was not acceptable, according to rao.1 for example, gandhi strongly advocated for the rights of the “untouchable” hindu caste because he believed that their worth was equal to that of all other humans.1 drawing upon this, rao proposes that gandhi would have treated people with disabilities with love and respect. he makes this argument as an extension of gandhi’s humanitarian principles, noting that gandhi did not explicitly mention people with disabilities in his teachings.1 since gandhi has been described as the “spiritual and practical leader of modern india,” it may be helpful for discussions on the rights of people with disabilities in india to make mention of his love for all humanity.1(p.187) yet, despite the humanistic ideals of sen and gandhi, rao notes that no major hindu leader has directly addressed the issue of disability in india.1 hindu explanations for the cause of disability are negative hindus frequently utilise karma as an explanatory means for the cause of disability, as noted by anees.9 as mehrota points out, karma states that “if one has committed misdeeds in [a past life], one has to inevitably bear the consequences.”16(p.37) according to anees, disability is often seen as a punishment for previous sins. she mentions that these sins could have occurred in a previous life, according to hindu teaching.9 thus, people with a disability can be looked down upon by the general community for an unverified offence which cannot be proven. anees notes that an alternate hindu explanation for disability is that a family member of the person with a disability had committed a sin. needless to say, this creates significant stigma for both the person with a disability and their family, as found by edwardraj.8 it is, of course, very difficult to defend oneself against the accusation of a sin committed in a previous life. gupta argues that the law of karma can bring hope to people with disabilities and their families. he states that karma may provide encouragement for people with disabilities to better their futures by doing good deeds.10 therefore, by doing good deeds in the present, people with disabilities may have the hope of improving their social standing in their next incarnation, according to gupta. yet, although the idea of hope being provided through karma sounds good, it is not evidenced in empirical studies. karma provided no hope for the women in balanadunsaram’s report of a multi-faith self-help group and was cited as a ground for social stigma by families of children with an intellectual disability in a study performed by edrawrdraj.8,11 interestingly, john found that a subset of parents denied that their child’s disability was a punishment for past sins and yet still held karma as 18 wilson dec 2019. christian journal for global health 6(2) a possible explanation for disability.20 this seeming contradiction may reflect the tension felt by hindus with personal experience of disability about how to integrate their beliefs with their personal experience. a related explanation for disability in hindu thought is fatalism. there is some confusion over the nature of fate in the literature. gupta defines fate as being ascribed to god’s actions, as opposed to karma which is a natural law that nonetheless may be modified by a deity.10 on the other hand, mehrota found that indians in rural haryana viewed fate as an overarching, supreme reality that was determined in multiple ways, including via karma and through divine intervention.16 owing to this confusion, it is difficult to ascribe the role of fate in the causation of disability in hindu writings, except to say that it is generally considered a separate entity from karma and unable to be modified by an individual. fate and karma aside, several more peripheral explanations for disability emerged from literature. mehrota found that various maternal behaviours were sometimes blamed for a child’s disability.16 for instance, her study reports that hindus in rural haryana sometimes viewed conception during a solar or lunar eclipse as a cause for limb deformity.16 historically, miles found that maternal behaviour was believed to cause disability in the writings of caraka.19 a more sinister explanation for disability in haryana was that wandering spirits caused limb deformities at the command of the local witchdoctor, as found by mehrota.16 these peripheral beliefs are not derived from the hindu texts, but they are nonetheless beliefs held by hindus and illustrate what rao labels as the pluralist viewpoint of many hindu people.1 hindu beliefs can enable people with disabilities in a study investigating parental explanatory models for intellectual disability, john found that the majority of participants utilised religion as a coping resource.20 these parents viewed their child as a blessing from god. additionally, they also believed that god would give them the strength to cope with any challenges arising from their child’s disability, as reported in the study.20 by doing this, the parents “[drew] strength from their faith,” thereby transforming the culturally unfavourable event of their child’s disability into a meaningful experience through which god gave them strength.20(p.301) in another instance, balasundaram found that religion benefitted parents of children with an intellectual disability who formed a self-help group.11 the group was organised by a christian but consisted of women of multiple faiths, including hinduism. in this group, the parents found comfort and solace together by articulating their spiritual quest for meaning in the context of their child’s disability. for these mothers, organised religion had provided scant comfort, yet spirituality had given meaning to their suffering, as reported by balasundaram.11 for example, the hindu mother, khima, found support in the self-help group, but not in her hindu beliefs, according to balasundaram.11 previously, khima’s fervent prayers to hindu gods and attempts to seek answers from hindu religious leaders had been unsuccessful in either explaining or resolving her child’s disability. this led khima to the conclusion that a god was punishing her for a sin, as balasundaram notes. yet throughout the course of attending the faith-based, self-help group and the meaningful connections she made there, khima ultimately concluded that god had given her the strength to cope with her child’s disability. therefore, according to balasundaram, faith became a source of comfort for khima, but not the practice of the hindu religion. reflecting upon this story, it is reasonable to conclude that the interpersonal and spiritual connections made in the self-help group were the turning point in khima’s faith journey. at this point, faith became an enabler in her life, whereas it had formerly been a barrier. this example, while only one person, demonstrates that the barriers resulting from hindu beliefs and practices toward people with a disability can be overcome by the love and support of a faith community. yet, balasundaram does not make it clear in which faith 19 wilson dec 2019. christian journal for global health 6(2) khima found comfort. it may have been christianity, hinduism, or a mixture of both. hindu beliefs can be a barrier for people with disabilities there are also numerous instances in which hindu beliefs and practices provide barriers for people with disabilities in india. some of these barriers concern community and familial attitudes toward people with disabilities. other barriers afforded by hindu practices relate to the treatment options sought by the families of people with a disability. entire families frequently bear shame because of a family member’s disability within hindu communities, as previously mentioned. edwardraj reports that shame is frequently attached to the families of children with a disability in hindu culture.8 he found that this is especially directed toward the mother of the family, who may be blamed for her child’s condition by her extended family. according to gupta, such stigma may bring dishonour on the entire family within the wider community.10 these barriers are exemplified in a study by john of parental explanations for disability.20 in his study, a minority of participants believed that their child’s disability was due to karma or the wrath of god. john commented that these parents believed that “god had saddled them with a burdensome responsibility” in giving them a child with a disability. 20(p.304) when such an attitude is propagated from within the family, it is easy to imagine it also being propagated from outside sources who may have no personal experience of disability to inform their worldview. spiritual beliefs leading to inadequate treatment for disability people with disabilities may also be blamed for their impairments within the indian medical community. staples found that medical practitioners in hyderabad generally thought that people with a disability had contributed to their own condition by being slow to seek medical treatment.17 medical professionals studied explained the slow response of people with disabilities to seek treatment as being due to inadequate education and superstitious beliefs. for example, staples describes a neurosurgeon’s belief that indian people with disabilities often place faith in sacrifices to gods and goddesses to cure them, instead of seeking medical treatment. in the neurosurgeon’s opinion, people with disabilities frequently sought these sacrifices in order to atone for past sins and appease the gods, as found by staples.17 likewise, lay people studied frequently described people with disabilities as “careless,” according to staples.17 thus, in a similar manner to health professionals, lay people unwittingly framed disability as a problem which must be fixed. they “deflect[ed] culpability for disabling conditions away from social institutions,” thereby removing the pressure from society to accommodate people with a disability.17(p.571) furthermore, staples found that poorer members of the indian disability community in hyderabad frequently held simultaneous religious and medical explanations for disability. he points out that faith-based, causative beliefs for disability were sometimes held by poorer families, but not to the exclusion of western medical explanations. in particular, he reports that the poorer people studied were more likely to take medical advice from a doctor than their wealthy counterparts.17 this was contrary to the opinion of the doctors in the study, who believed that people of low educational background held religious explanations for disability which prevented them from seeking medical treatment.17 yet, as staples17 notes, treatment is often inaccessible for the poor because they lack the funds for its implementation. drawing upon these findings, staples believes that existing public health education in india is largely ineffective. that is, he reports an inverse relationship between level of education and reliance upon doctors to manage disability amongst study participants, who were primarily hindu.17 when the poor did seek medical attention, they often lacked the financial resources for it to be effective. hence, according to staples, more public health education will not significantly alter the 20 wilson dec 2019. christian journal for global health 6(2) health-seeking behaviour of carers for families with disabilities in india. yet despite the evidence for staple’s argument, it seems that public health initiatives could improve the lives of hindus with disability. he appears to diagnose a flaw in the delivery of the public health message but fails to suggest ways in which it could be altered. for instance, education aimed at addressing the karmic explanations adopted by many hindus could significantly reduce the stigma encountered by people with disabilities. by utilising culturally sensitive means to frame disability as a challenge that can be overcome, more families might view disability in the terms of the “religious resilience” category described by john.20(p.300) furthermore, it is important to note that staples’ study was conducted in a predominantly hindu city, but one in which there was also a significant portion of muslims. as the study did not describe the religion of each participant, it cannot be assumed that all participants were of the hindu religion, although the author indicates that the majority were. of course, such a localised study does not represent every region of india or even a “typical” hindu response pattern to disability and healthcare seeking practices. thus, further work is needed in the field to develop the most effective strategies for utilising medicine to improve the lives of people with disabilities within the hindu community. there is a suggestion in the literature that hindus are predisposed to avoid parental support groups. specifically, gupta states that hindu people generally hide their suffering relative to disability.10 he argues that parents of children with disabilities may be less inclined to join parental support groups as this would make their personal needs known and may bring them shame from community members.10 however, this is a generalisation which the author does not back up with any empirical data. hence, further research is required to validate this suggestion. drawing upon balasundaram’s study, it is apparent that parental support groups are of great benefit to hindu parents when they do join them.11 in light of this finding, parental health support groups could be a useful public health intervention to accommodate the practical and spiritual needs of hindu parents of children with disabilities in india. on another note, some interpretations of fatalism may prevent indian families from seeking medical attention for their family members with disabilities. mehrota writes that fate is viewed as an all-encompassing reality in hindu thought, which is pre-determined for an individual but actuated by a number of different mechanisms. 16 expanding upon this proposition, there may be a tendency amongst hindus not to seek medical attention for people with a disability because their fate is considered sealed until they are reincarnated. in some instances, indian people with disabilities are brought to doctors when their condition has deteriorated beyond the reach of medical treatments, as found by mehrota.16 furthermore, she also reports that various treatments of unknown efficacy are utilised by traditional faith healers in india, which sometimes make an individual worse or can even cause disability via nerve damage.16 in some cases, this is due to hindu beliefs that specific gods are responsible for certain ailments.16 these hindus believe that it is necessary to appease the relevant god with offerings to cure the sickness, while giving traditional treatments to the patient.16 mehrota notes that this may delay people with disabilities from being brought to the attention of allopathic practitioners until it is too late for treatment to be effective. based upon this, a public health message which promotes early medical intervention in disability may be beneficial in certain rural indian contexts. discussion it has been estimated that a large proportion of india’s population has a disability.9 thus, both policy makers and healthcare workers need to understand how this large sector of the population is treated within indian society. unfortunately, culturally driven stigma and negative connotations associated with people with disabilities are prevalent norms in india today, as anees, mehrota, and staples point out. 9,16,17 21 wilson dec 2019. christian journal for global health 6(2) since religion is “intertwined and immersed in the fabric of indian society,” it is necessary to review the barriers and enablers that hindu beliefs provide for people with disabilities in india. 9(p.32) it is hoped that a greater understanding of this situation will inform meaningful policy toward disability in india going forward. mapping hindu beliefs onto our models of disability indian hindu beliefs generally appear to favour a medical model of disability. hindu society tends to view people with disabilities as having a problem which needs to be fixed, whether by means of medical treatment, traditional healers, or appeasement of the gods, as found by mehrota, anees, edwardraj, and miles. 16,9,8,18 this most closely resembles the medical model of disability, although local definitions of disability may differ from those established within western medicine, as described by mehrota.16 hindu teaching also contains aspects of the charitable model of disability. the law of dharma stipulates the duty of the able-bodied to care for those with a disability, albeit for the purpose of accruing good karma for themselves, as found by anees.9 yet the fear and stigma that karmic beliefs attach to disability can somewhat negate this dharmic duty. this creates what mehrota helpfully labels an “avoid-help” dilemma in hindu society, in which hindus are torn between their dharmic duty to help those less fortunate and an attitude that those with a disability are receiving a deserved punishment. 16(p.37) it is, thereby, possible that some aspect of hindu beliefs assist disability work, whereas others are barriers. limitations of this review and directions for further research this review is limited by the small number of studies published on the topic. this is probably because the topic is sensitive within the current political framework of india. more research is required into the barriers and enablers provided by hindu beliefs and practices for people with disabilities in india. to date, research has been performed with small sample sizes at scattered locations throughout the nation, thereby limiting the generalisability of the findings. while the emergence of common themes in the literature suggests that there are similarities in the perception of disability throughout indian hindu communities, there are also specific local differences. furthermore, perceptions and health seeking behaviour can vary between hindus of different caste and educational background. this also limits the scope of any conclusions drawn from this review. it is necessary to conduct more empirical studies in local hindu communities throughout india to better understand how hindu beliefs affect the response to disability. finally, the overwhelming diversity and fluidity of hindu beliefs, which are not defined by a single doctrine or creed, makes their application to disability difficult. yet it is important to gain a deeper understanding of this area to improve the standing of people with disabilities in india today. conclusion in conclusion, this review has found some common themes concerning hindu beliefs about disability in india. the most prominent and consistent themes include karmic beliefs for the cause of disability and the resultant stigma this attaches to people with disabilities in hindu communities. the information in this study is beneficial in numerous ways. investigating the ways in which hindu beliefs affect people with disabilities provides future direction for initiatives to promote their acceptance and societal integration. additionally, it helps indian healthcare workers to understand the experiences of their patients with a disability and to evaluate their own subconscious religious assumptions about disability. policy makers should seek to better understand how a hindu worldview affects the disability response in order to meaningfully implement the standards set in the rights of the persons with disabilities act (2016).21 future empirical research on the beliefs and attitudes toward people with disabilities is required for other indian religions, such as christianity, 22 wilson dec 2019. christian journal for global health 6(2) islam, buddhism, and sikhism. in particular, research at a community level needs to be performed to better understand the issues pertinent to specific areas of india. this work is worth pursuing further. challenging hindu religious attitudes toward people with a disability will help indian society to take meaningful steps forward toward their full inclusion. references 1. rao a. soteriologies of india and their role in the perception of disability. münster: lit verlag; 2004. 2. wolfensberger w. the origin and nature of our institutional models. president's committee on mental retardation, washington, d.c. [internet]. 1969 [cited 2018 april 12]. available from: available from: http://www.disabilitymuseum.org/dhm/lib/detail.html?i d=1909&page=all 3. shakespere t. the social model of disability. in: davis lj, editor. the disability studies reader [internet]. 5th ed. routledge; 2017 [cited 2018 march 13]:195-203. 4. fundamental principles of disability [internet]; 1975 february 22 [cited 2018 march 13]. available from: http://www.disability.co.uk/fundamental-principlesdisability 5. office of the registrar general and census commissioner, india. census data, india, 2011 [internet]. 2011 [cited 2018 march 1]. available from: http://censusindia.gov.in/2011common/censusdata2011.html 6. singh, rpb and aktor, m. hinduism and globalization. in: brunn sd, gilbreath da, editors. the changing world religion map: sacred places, identities, practices and politics [internet]. cham: springer international publishing ag; 2017 [cited 2018 march 13]. https://doi.org/10.1007/978-94-017-9376-6_100 7. hoff k. caste system. world bank group [internet]. 2016 [cited 2018 march 13]:2,8. available from: http://documents.worldbank.org/curated/en/452461482 847661084/caste-system 8. edwardraj s, mumtaj k, prasad jh, kuruvilla a, jacob ks. perceptions about intellectual disability: a qualitative study from vellore, south india. j intellect disabil res [internet]. 2010 [cited 2-19 february 13];54(8):736-748. https://doi.org/10.1111/j.13652788.2010.01301.x 9. anees s. disability in india: the role of gender, family and religion. j appl rehabil counsel [internet]. 2014 [cited 2018 february 22];45(2):32-38. available from: psycinfo 10. gupta vb. how hindus cope with disability. j disabil relig health [internet]. 2011 [cited 2018 february 13];15(1):72-78. https://doi.org/10.1080/15228967.2011.540897 11. balasundaram p. love is not a feeling: faith and disability in the context of poverty. j disabil relig health [internet]. 2007 [cited 2018 february 19];11(2):15-22. https://doi.org/10.1300/j095v11n02_03 12. hatzenbuehler ml, phelan jc, link bg. stigma as a fundamental cause of population health inequalities. am j public health [internet]. 2013 [cited 2018 april 14];103(5):813-821. https://doi.org/10.2105/ajph.2012.301069 13. international classification of impairment, disabilities and handicaps [internet]. geneva: world health organisation; 1980 [cited 2018 march 17]. available from: http://whqlibdoc.who.int/publications/1980/924154126 1_eng.pdf 14. intellectual disability rights service. a step-by-step guide to section 32 applications. redfern, nsw (australia): intellectual disability rights service [cited 2018 march 17]. available from: http://www.idrs.org.au/s32/_guide/p040_4_2_idandmi .php#.wthflohubix 15. moher d, liberati a, tetzlaff j, altman dg. preferred reporting items for systematic reviews and metaanalyses: the prisma statement. plos medicine [internet]. 2009 [cited 2018 feb 9]; 6(7): e1000097 [5p.]. https://doi.org/10.1371/journal.pmed.1000097 16. mehrotra n. understanding cultural conceptions of disability in rural india: a case from haryana. j indian anthropol soc. 2004;39(1):33-45. 17. staples j. culture and carelessness: constituting disability in south india. med anthropol q [internet]. 2012 [cited 2018 march 14];26(4):557-574. https://doi.org/10.1111/maq.12007 18. miles m. disability in an eastern religious context: historical perspectives. disabil soc [internet]. 2010 [cited 2018 april 14];10(1):49-70. https://doi.org/10.1080/09687599550023723 19. miles, m. social and educational responses to mental retardation in pakistan, india and bangladesh: historical and modern reflections. psychol dev soc j [internet]. 2011 [cited 2018 february 22];23(2):247275. https://doi.org/10.1177/097133361102300205 http://www.disabilitymuseum.org/dhm/lib/detail.html?id=1909&page=all http://www.disabilitymuseum.org/dhm/lib/detail.html?id=1909&page=all http://www.disability.co.uk/fundamental-principles-disability http://www.disability.co.uk/fundamental-principles-disability http://censusindia.gov.in/2011-common/censusdata2011.html http://censusindia.gov.in/2011-common/censusdata2011.html https://doi.org/10.1007/978-94-017-9376-6_100 http://documents.worldbank.org/curated/en/452461482847661084/caste-system http://documents.worldbank.org/curated/en/452461482847661084/caste-system https://doi.org/10.1111/j.1365-2788.2010.01301.x https://doi.org/10.1111/j.1365-2788.2010.01301.x https://doi.org/10.1080/15228967.2011.540897 https://doi.org/10.1300/j095v11n02_03 https://doi.org/10.2105/ajph.2012.301069 http://whqlibdoc.who.int/publications/1980/9241541261_eng.pdf http://whqlibdoc.who.int/publications/1980/9241541261_eng.pdf http://www.idrs.org.au/s32/_guide/p040_4_2_idandmi.php#.wthflohubix http://www.idrs.org.au/s32/_guide/p040_4_2_idandmi.php#.wthflohubix https://doi.org/10.1371/journal.pmed.1000097 https://doi.org/10.1111/maq.12007 https://doi.org/10.1080/09687599550023723 https://doi.org/10.1177/097133361102300205 23 wilson dec 2019. christian journal for global health 6(2) 20. john a, montgomery d. parental explanatory models of child’s intellectual disability: a q methodology study. intl j disabil dev educ [internet]. 2016;63(3):293-308. https://doi.org/10.1080/1034912x.2015.1085001 21. disability discrimination act of 2016, india [statute on the internet]. 2016 [cited 2018 april 4]. available from: http://www.disabilityaffairs.gov.in/upload/uploadfiles/fi les/rpwd%20act%202016.pdf peer reviewed: submitted 1 oct 2018, accepted 2 dec 2019, published 23 dec 2019 competing interests: none declared. correspondence: andrew wilson, university of melbourne, australia. agwilson@hotmail.com.au cite this article as: wilson a. barriers and enablers provided by hindu beliefs and practices for people with disabilities in india. christian journal for global health. december 2019; 6(2):12-23. https://doi.org/10.15566/cjgh.v6i2.250 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1080/1034912x.2015.1085001 http://www.disabilityaffairs.gov.in/upload/uploadfiles/files/rpwd%20act%202016.pdf http://www.disabilityaffairs.gov.in/upload/uploadfiles/files/rpwd%20act%202016.pdf mailto:agwilson@hotmail.com.au https://doi.org/10.15566/cjgh.v6i2.250 http://creativecommons.org/licenses/by/4.0/ a bs, md, university of melbourne, intern at southwest healthcare, melbourne, australia abstract introduction materials and methods results screening included eligibility identification discussion conclusion references commentary april 2020. christian journal for global health 7(1) covid-19 and containment: a dual burden for india nathan john grillsa a mbbs, mph, dphil, associate professor, nossal institute for global health, university of melbourne; senior research advisor, australia india institute abstract could ongoing covid-19 ‘lockdowns’ in india risk more harm than the pandemic itself given a population already facing major poverty and health challenges? key words: india, covid-19, mitigation, containment, lockdown, poverty, economy, public health. was india’s strategy of imposing a sudden total lockdown in response to covid-19 really needed? and, could an ongoing lockdown actually threaten more lives than the coronavirus itself? late last month, prime minister narendra modi announced a 21-day complete lockdown of the country’s 1.3 billion people.1 but, is this too much too soon? given the relatively small number of cases in the country at the time of the sudden announcement — less than a 1000 — there was certainly scope to delay the timing to allow people to prepare. for example, a week’s warning could have given time for the millions of migrant labourers to return home.2 we also need to consider what the lockdown is supposed to achieve and whether it is achievable. realistically, trying to suppress or eliminate covid19 in india would appear to be a pipe dream given the mass overcrowding, porous borders, and large-scale migratory labour patterns. and even if suppression could be achieved until a vaccine is developed, it’s difficult to imagine a timely vaccine roll out across a nation of the scale and complexity of india. so, the purpose of the lockdown should almost certainly be mitigation, and if that is the case, then at this early stage a more moderate approach would appear to have been justifiable. any decision on what strategy to adopt firstly needs to be informed by an assessment of the risk covid-19 poses in india. india has a median age of 28 years old, which will be protective, to some degree, given the low case fatality rate (cfr) at young ages. we know that the average age of death in italy from covid-19 has been around 79, whereas india’s average life expectancy is just 68 years of age.3 most covid-19 deaths have been in the elderly, and the risk of death when aged below 50 is smaller and nearly unheard of below 18 years old. these age factors will help protect india, but given its huge population, the total number of deaths could still be massive. in assessing the risk, we can start by mapping the case fatality rate (cfr) rates from china onto the age demographics in india. we may actually expect lower cfrs given that india has had time to adapt, and we now know how best to approach management and prevention. in the early days of the epidemic in wuhan, not much was known about covid-19, which probably resulted in higher cfrs than might be expected in india.4 if we assumed that at least around 50 to 60 per cent of indians would be infected before herd immunity could control the outbreak, and if we assume the same aged adjusted cfrs as china, then we are talking about a toll of 2.37 million deaths in india. of these, 2.22 million (or 94%) would be over 50 years of age. the young age of india’s population will provide some protection from covid-19 but the sheer size of the population means massive numbers will still be at serious risk. this is obviously a humanitarian catastrophe and represents a death rate, mostly made up of the elderly, of 0.17 per cent of the population. that is about the same number that die in india each year from tobacco and air pollution combined.5 25 grills april 2020. christian journal for global health 7(1) clearly then, serious action needs to be taken; but, there are many unknowns in imposing complete and long-term lockdowns. for example, if the pandemic is inevitable in india, we don’t really know what proportion of these potential deaths can be prevented by a strict and long-running lockdown. presumably, many deaths can be avoided by decreasing the stress on the health system. however, in india, the public health system is chronically overloaded and has little reserve, which means even a flattened curve to the infection rate will overwhelm the system and lead to many deaths.6 on the other side of the equation, the important question is how many indians might die due in a strategy of long-term containment, lockdowns, and resultant economic collapse? multidimensional poverty already affects 374 million indians, and even without the social or economic impacts of an ongoing lockdown, 38 per cent of children under five are already stunted, 59 per cent are anaemic, and 21 per cent are wasted (thin for their height).7,8 a lockdown makes these groups even more vulnerable and will increase mortality rates. already, the severe effects of the lockdown are being documented across india with many millions of informal sector workers and daily wage labourers — not covered by contracts and protections — facing destitution and hunger.9,10 these labourers are already food insecure and rely on daily wages for sustenance, to afford basic healthcare, and educate their children. containment will have a very real cost in terms of lives. at the same time, the lockdown has meant that basic services and many health facilities have either closed or their services have been drastically reduced.11 i work in community health and disability in rural north india, and our program staff have reported villagers ringing up desperate to get their basic medicines. however, supply lines are cut, their local health facility is closed, and our staff are prevented from travel. again, this will cost lives. to gain a relative understanding of the magnitude of the impact of covid-19, we can look at the impact on disability adjusted life years (daly).12 child and maternal malnutrition, and its resultant myriad of short and long term health problems, is by far the leading cause of lost dalys in india at 83 million annually, and we can assume this will be exacerbated significantly by the hardships imposed by a lockdown strategy.13 in comparison, covid-19 may cause the loss of 17 million dalys if we assume that every person who dies loses an average of 7.5 dalys, given that deaths tend to occur in the elderly and those with underlying illnesses. what we do know is that in india and in the us, more children will die from suppression, mitigation, lockdowns, and the economic downturn than from covid-19 virus. primary health facilities have either closed, or their services have been drastically reduced. this raises an ethical question as to the “rightness” of employing draconian interventions that likely increase childhood mortality in order to decrease mortality largely in the elderly. to undertake any legitimate cost/benefit analysis, we would need much better data standardised for age on both the numbers of deaths from covid-19 and deaths caused by lockdowns and the economic downturn. the current policy mantra in india is seemingly to stop covid-19 at all costs. but an “at all costs” approach is reckless. following this 21-day lockdown, and prior to further lockdowns, serious consideration of the cost-benefit of different levels of mitigation strategies is required. there needs to be a dispassionate discussion about how much cost we are prepared to pay and for what gain? references 1. vaidyanathan r. coronavirus: india enters ‘total lockdown’ after spike in cases [internet]. bbc. 2020 mar 25. available from: https://www.bbc.com/news/world-asia-india52024239 2. frayer l, pathak s. coronavirus lockdown sends migrant workers on a long and risky trip home [internet]. npr. 2020 mar 31. available from: https://www.npr.org/sections/goatsandsoda/2020/03/3 1/822642382/coronavirus-lockdown-sends-migrantworkers-on-a-long-and-risky-trip-home 3. onder g, rezza g. case-fatality rate and characteristics of patients dying in relation to cov19 in italy. jama network. 2020 mar 23. http://dx.doi.org/10.1001/jama.2020.4683 4. mcdonell s. coronavirus: china says disease ‘curbed’ in wuhan and hubei [internet]. bbc. 2020 mar 10. available from: https://www.bbc.com/news/world-asia-china51813876 5. singh k. air pollution is a bigger killer than tobacco use in india [internet]. quartz india. 2020 apr 2. available from: https://www.bbc.com/news/world-asia-india-52024239 https://www.bbc.com/news/world-asia-india-52024239 https://www.npr.org/sections/goatsandsoda/2020/03/31/822642382/coronavirus-lockdown-sends-migrant-workers-on-a-long-and-risky-trip-home https://www.npr.org/sections/goatsandsoda/2020/03/31/822642382/coronavirus-lockdown-sends-migrant-workers-on-a-long-and-risky-trip-home https://www.npr.org/sections/goatsandsoda/2020/03/31/822642382/coronavirus-lockdown-sends-migrant-workers-on-a-long-and-risky-trip-home http://dx.doi.org/10.1001/jama.2020.4683 https://www.bbc.com/news/world-asia-china-51813876 https://www.bbc.com/news/world-asia-china-51813876 26 grills april 2020. christian journal for global health 7(1) https://qz.com/india/1585690/air-pollution-is-abigger-killer-than-tobacco-use-in-india/ 6. sharma s. india’s public health system in crisis: too many patients, not enough doctors [internet]. hindustantimes. 2017 aug 29. available from: https://www.hindustantimes.com/india-news/publichealth-system-in-crisis-too-many-patients-notenough-doctors/story39xatfswgfo0e4qrkcd8fo.html 7. multidimensional poverty index, 2019, table 1 [internet]. available from: http://hdr.undp.org/sites/default/files/mpi_2019_pub lication.pdf 8. india national family health survey. 2017 dec. government of india ministry of health and family welfare. p 291, 293. 9. abi-habib m, yasir s. for india’s laborers, coronavirus lockdown is an order to starve [internet]. the new york times. 2020 mar 30. available from: https://www.nytimes.com/2020/03/30/world/asia/cor onavirus-india-lockdown.html 10. jeffrey c, de geest f, dyson j. ‘how will we eat’? india’s coronavirus lockdown threatens millions with severe hardship [internet]. the conversation. 2020 mar 30. available from: https://theconversation.com/how-will-we-eat-indiascoronavirus-lockdown-threatens-millions-withsevere-hardship-135193 11. goli s. coronavirus: the lockdown and its consequences [internet]. deccan herald. 2020 apr 20. available from: https://www.deccanherald.com/opinion/coronavirusthe-lockdown-and-its-consequences-820261.html 12. world health organization. metrics: disabilityadjusted life year (daly) [internet]. n.d. available from: https://www.who.int/healthinfo/global_burden_disea se/metrics_daly/en/ 13. nie p, rammohan a, gwozdz w, sousa-poza a. changes in child nutrition in india: a decomposition approach. 2019. int j environ res public health. 16:1815. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc657 2133/ competing interests: none declared. acknowledgements: first published with health & well-being 6 april 2020, and co-published with the australia india institute. https://pursuit.unimelb.edu.au/articles/covid-19-andcontainment-a-dual-burden-for-india correspondence: nathan grills, melbourne, australia. ngrills@unimelb.edu.au cite this article as: grills nj. covid-19 and containment: a dual burden for india. christian journal for global health. april 2020; 7(1):24-26. https://doi.org/10.15566/cjgh.v7i1.377 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://qz.com/india/1585690/air-pollution-is-a-bigger-killer-than-tobacco-use-in-india/ https://qz.com/india/1585690/air-pollution-is-a-bigger-killer-than-tobacco-use-in-india/ https://www.hindustantimes.com/india-news/public-health-system-in-crisis-too-many-patients-not-enough-doctors/story-39xatfswgfo0e4qrkcd8fo.html https://www.hindustantimes.com/india-news/public-health-system-in-crisis-too-many-patients-not-enough-doctors/story-39xatfswgfo0e4qrkcd8fo.html https://www.hindustantimes.com/india-news/public-health-system-in-crisis-too-many-patients-not-enough-doctors/story-39xatfswgfo0e4qrkcd8fo.html https://www.hindustantimes.com/india-news/public-health-system-in-crisis-too-many-patients-not-enough-doctors/story-39xatfswgfo0e4qrkcd8fo.html http://hdr.undp.org/sites/default/files/mpi_2019_publication.pdf http://hdr.undp.org/sites/default/files/mpi_2019_publication.pdf https://www.nytimes.com/2020/03/30/world/asia/coronavirus-india-lockdown.html https://www.nytimes.com/2020/03/30/world/asia/coronavirus-india-lockdown.html https://theconversation.com/how-will-we-eat-indias-coronavirus-lockdown-threatens-millions-with-severe-hardship-135193 https://theconversation.com/how-will-we-eat-indias-coronavirus-lockdown-threatens-millions-with-severe-hardship-135193 https://theconversation.com/how-will-we-eat-indias-coronavirus-lockdown-threatens-millions-with-severe-hardship-135193 https://www.deccanherald.com/opinion/coronavirus-the-lockdown-and-its-consequences-820261.html https://www.deccanherald.com/opinion/coronavirus-the-lockdown-and-its-consequences-820261.html https://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/ https://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6572133/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6572133/ https://pursuit.unimelb.edu.au/articles/covid-19-and-containment-a-dual-burden-for-india https://pursuit.unimelb.edu.au/articles/covid-19-and-containment-a-dual-burden-for-india mailto:ngrills@unimelb.edu.au https://doi.org/10.15566/cjgh.v7i1.377 http://creativecommons.org/licenses/by/4.0/ references opinion piece may 2019. christian journal for global health 6(1) public health, systems change, justice and the work of the kingdom robert e aronsona a drph, mph, professor, public health program, taylor university, upland, in, usa abstract disparities in population health statuses are tied to inequities in society, and not just differences in personal decision-making and behavior. christians should (and must) play a role in confronting these inequities, based upon three biblical themes: 1) the instructions in the book of leviticus regarding the sabbath year and the year of jubilee as a way to protect the economic system from producing insurmountable inequities and degrading the environment; 2) the eschatological image of the new jerusalem in the book of isaiah, with its focus on shalom in contrast to a religion focused on personal piety in the face of oppression and social injustice; and 3) jesus’ teachings about the kingdom, which include its imminence and the counter-cultural nature of its ethic. the notion of the kingdom can be applied in the lives of christians, particularly those involved in public health, through individual acts, corporate acts in the context of the church, and state-led actions to bring about social change to achieve social justice. social change can be described as an act of reconciliation in which systems of society are redeemed by the power of kingdom principles. key words: social change, kingdom of god, public health, systems thinking, justice. introduction in american evangelicalism, and the society more generally, the approach often taken to explain disease (as well as any kind of misfortune) reflects the broad cultural value attached to personal responsibility and the promise of the american dream. individual success is built upon individual effort, and failure indicates individual deficiencies of effort, skills, or ambition. while individuals must make responsible choices, and their behaviors are important to their health, health and disease are not solely explained by the behaviors of those afflicted, and not all behaviors are a matter of choice. in the gospel of john the disciples asked a question about a particular man born blind. “rabbi, who sinned, this man or his parents, that he was born blind?” (john 9:2 [niv translation used throughout]) the question reveals an assumption about disease causation that was common in that day. even in our day, when looking upon an individual with a chronic condition, we are likely to ask the same question. instead of “sin”, we may substitute the word 8 aronson may 2019. christian journal for global health 6(1) “behavior”. because public health looks at populations rather than individuals, the questions we ask are different. we may be more focused on recognizing patterns of exposure and disease across communities and populations. different questions lead to very different conclusions. for instance, if we ask the question, “why did this infant die?” our response might be related to the infant’s gestational age and weight, congenital malformations, or issues related to health or behaviors of the mother during pregnancy. an alternative question might be, “why do we see rates of infant mortality among african american infants that are twice the rates among white non-hispanic infants?” when asked this way, we must examine patterns of exposure that may help to explain differences in rates of disease between population groups. the field of public health has throughout its history recognized the important role that characteristics of the physical and social environment contribute to the health status of individuals by exposing people to hazardous or stressful conditions, and by shaping or constraining people’s behaviors. by recognizing these patterns, we can identify features of the environment that can be changed to produce better population health, including changes in the physical environment, changes in policies and systems, and changes in social norms and culture. in this article, i will provide a biblical foundation for christian engagement in social action to correct the injustices and inequities of societies that contribute to public health problems. this will require, first of all, an understanding of how disparities in population health statuses are tied to inequities in society and not just differences in personal decision-making and behavior. then i will describe the role that christians should (and must) play in confronting these inequities based upon three biblical themes: 1) the instructions in the book of leviticus regarding the sabbath year and the year of jubilee as a way to protect the economic system from producing insurmountable inequities and degrading the environment; 2) the eschato-logical image of the new jerusalem in the book of isaiah, with its focus on shalom in contrast to a religion focused on personal piety in the face of oppression and social injustice; and 3) jesus’ teachings about the kingdom, which include its imminence and the countercultural nature of its ethic. finally, i will describe how the notion of the kingdom can be applied in the lives of christians, particularly those involved in public health, through individual acts, corporate acts in the context of the church, and state-led actions to bring about social change to achieve social justice. social change can be described as an act of reconciliation in which systems of the society are redeemed by the power of kingdom principles. the role of systems change in public health public health as a profession began to take shape in the mid to late 19th century, but did not appear out of thin air. populations have lived with issues surrounding birth, illness, disability, and death throughout history and found ways to explain them that reflected worldviews, culture, and societal values.1 this is as true today as it was during the time john snow was investigating the great cholera outbreaks of 1848 and 1854 in london.2,3 some believed it was punishment for sin, others felt that it was due to bad smells (miasma), but no one knew about the tiny bacteria that caused it. even without knowing the cause of cholera, snow was able to determine that it was being spread by something in the water. exhaustive histories of public health describe the developing profession and the competing theories of disease causation (and prevention) from pre-modern societies to present post-industrialized societies,2,3 including the unmistakable influence of the socio-political thought of the times with explanations of disease.1 sylvia tesh describes the 9 aronson may 2019. christian journal for global health 6(1) major views of disease causation during the 19th century to include contagion theory, supernatural theory, personal behavior theory, and miasma theory (sometimes referred to as the “bad smell theory”). moving into the 20th century, these evolved into germ theory, lifestyle theory, and environmental theory, with little room for supernatural theory.1 while germ theory dominated the thinking and funding priorities in public health through much of the 20th century, it was environmental theory rising out of the earlier miasma theory that led to many of the changes that resulted in the reduction of infectious disease mortality. thomas mckeown’s analysis of mortality data from the 18th and 19th centuries show that most of the reductions in mortality due to infectious disease can be attributed to improved standards of living and living conditions, rather than advances due to bacteriology and the development of vaccines and antibiotics that took place much later. in fact, looking at the decline of infectious disease through the 20th century, we see that most of the reductions took place prior to the introduction of most vaccines and antibiotics.4 with the reduction in mortality due to infectious disease, life expectancy increased. the aging of the population made possible the epidemiologic transition that occurred when chronic diseases (or degenerative and man-made diseases) became the major contributors to mortality.5 with a changed mortality profile, germ theory lost its dominance, giving way to what would eventually become complex multi-causal theories and a greater emphasis on issues related to the life course, the context of people’s lives, and the interaction of physical, social, economic, and cultural factors that increase risk as well as influence behaviors that increase risk.6 this gets us back to the point about the man born blind. the disciples wanted to blame the problem on sin. we like to blame problems on people and their behaviors, such as smoking, eating poorly, and being sedentary. despite the desire for simple explanations and quick fixes, the problems we face are complex and need responses that will interrupt the cycles and systems that produce the problems. my oft-quoted motto cautions students about jumping to solutions when we do not fully understand the problem or the people experiencing the problem. “don’t solve problems you don’t understand for people you know nothing about.” starting in the mid-1970s and extending throughout the 1980s, both the usa and canada engaged in a process of re-examining public health approaches to address the health problems we were experiencing. in 1974, the canadian minister of national health and welfare, dr. marc lalonde, issued a report titled a new perspective on the health of canadians.7 the report included a framework called “the health field concept” that included four categories of factors that came to be referred to as “the determinants of health.” these included human biology, health care systems, environment, and lifestyle. this report, which had come to be known as the lalonde report, determined that issues related to “lifestyle” were more important to explaining premature death or illness than biology/genetics, access to quality health care, or the conditions of the physical environment. with the focus now turned to issues of lifestyle, the result was a shift from a physician-centered approach to one that increased the role of the individual in improving his/her own health by not smoking, eating wisely, and engaging in sufficient physical activity.8 this marked the beginning of the “health promotion movement.”9 in the decade that followed the lalonde report, challenges related to encouraging voluntary behavior change to improve health and prevent disease became more apparent. health promotion practitioners began to realize that an excessive emphasis on asking individuals to voluntarily change their behaviors could result in a “blame the victim mentality.”9 in addition, they recognized that the category “lifestyle” from the lalonde report was in many ways inseparable from the other categories of 10 aronson may 2019. christian journal for global health 6(1) determinants. what was needed was greater crosssector collaboration to create conditions in which healthier behaviors were encouraged and supported through health education, public policy, new legislation, the enforcement of existing laws, and eliminating barriers to healthy behavior and healthy living.9 a broader notion of “health promotion” emerged during an international conference on health promotion sponsored by the world health organization in 1986. this conference took place in ottawa, canada, and resulted in a report called the ottawa charter for health promotion.10 this report became highly influential and still remains so. the document clearly pushes public health in the direction of addressing the fundamental causes of population health problems. it is here where evangelical objections (and societal objections more generally) to public health efforts begin to become more apparent. with public health’s embrace of a perspective that understands that population health is a result of a broad set of health determinants, including social determinants, solutions to public health problems extend far beyond education and persuasion for voluntary behavior change or technical and medical interventions to halt the spread of disease. furthermore, the public health field recognizes the limits to personal autonomy and recommends responses that advocate for the common good and to correct the systems of society that produce inequities. in contrast, views among evangelicals are strongly influenced by individualistic ideals, which results in a “toolkit” of responses that do not lead to social justice efforts focused on structural or systems change.11 in the past 30 years, there has been an abundance of literature in public health that describes the work of public health as the work of social justice.12-17 this focus on social justice stands in sharp contrast with an ethic based on market justice and individual responsibility that so permeates our churches and our society.12 in their highly regarded study of attitudes and practices regarding race among evangelicals, divided by faith, emerson and smith note the important role that individualist ideology plays in shaping attitudes among white evangelicals.18 tranby and hartman summarize the perspective of emerson and smith regarding the important role of this ideology: what makes white evangelicals unique, according to emerson and smith, is not that they are more racist or supremacist, but rather that they adhere stringently and consistently to individualist, anti-structural ideals and discourse.19 there is evidence that evangelicals may understand the structural or systems factors that may produce inequities or social injustices (including systemic racism), but that this understanding may not lead to engagement in systems change. in effect, social injustices are recognized, but there may be differences among evangelicals in their willingness to take action to change structures.11 in their grounded theory analysis of interviews with 15 selfidentified christians in a midwestern state, todd and rufa identify differences in meaning of the term “social justice” among respondents, including social justice as: meeting basic needs, changing social structures to address inequities, promoting human rights and dignity, and as a religious responsibility .11 interestingly, even among christians that recognize the systems factors that produce inequities, internalized religious views may be in conflict with this understanding, producing responses that focus solely on meeting basic needs.11 these may include an emphasis on accountability for personal behaviors or even fear of losing the balance between evangelism and social action.20,21 furthermore, the public health system in the usa is largely (but not exclusively) a function of the government, particularly government at the local level (county health departments). certainly, private non-profit organizations, community associations, 11 aronson may 2019. christian journal for global health 6(1) local congregations, and community members are also engaged in working to enhance the health and well-being of populations. nevertheless, the significant role of the government in public health is unmistakable. services provided by government agencies at either the local, state, or national level require funding from somewhere, usually taxes. in addition, some of the tools of the government to create conditions where people can be healthy include policy/legislation and regulation. some of these impose restrictions on individual and corporate freedoms. in recent decades, evangelicals have been disproportionately represented among conservative republican voters, whose platform emphasizes small government, low taxes, and individual liberty.22 at times, these values appear to be syncretized into conservative christian teaching and beliefs. a biblical foundation for christian engagement in social change: teachings from the law, the prophets, and jesus while there are many approaches to laying out a biblical foundation for christian engagement in social change, i will focus my attention on just a few. from the old testament, i will focus on levitical instructions regarding the sabbath year and the year of jubilee, isaiah’s rebuke of personal piety in the face of injustice and oppression, and isaiah’s eschatological view of the new jerusalem and shalom. from the new testament, i will pull these ideas together using jesus’ teaching on the kingdom of god as a central organizing framework. a sabbath for the people, the land, and the economic system in leviticus 25, prior to crossing over to the promised land, the lord god revealed his instructions for the people of israel regarding the sabbath year and the year of jubilee. this passage provides instructions for living that will protect the health and vitality of individuals, of the land, and of the society. god had already displayed his desire for a rhythm of living that set aside a day of rest every seven days through his example set in the creation narrative. he commands us to follow this example, and jesus reminds us that this sabbath day was made for our benefit (mark 2:27). the instructions on the sabbath year require every seventh year to be a year in which the fields are given a rest from the normal agricultural practices, and allowed to remain fallow. for six years sow your fields, and for six years prune your vineyards and gather their crops. but in the seventh year the land is to have a year of sabbath rest, a sabbath to the lord. do not sow your fields or prune your vineyards. (lev 25:3-4) it has been argued that such a sabbatical year for the land represents good practice in sustainable agriculture, as the absence of this practice requires regular application of chemical fertilizers to maintain productivity.23 increased crop yields after fallow periods have also been widely documented.24 leviticus then goes on to provide instructions on a year that follows a period of seven sabbath years, or 49 years. this 50th year is known as a year of jubilee. the passage goes on to instruct the people on practices related to the land, possessions, and economic relations during the year of jubilee. “in this year of jubilee everyone is to return to their own property.” (lev 25: 13) the passage clarifies what is meant by property. first, the passage states that the land belongs to the lord, “the land must not be sold permanently, because the land is mine and you reside in my land as foreigners and strangers.” (lev 25:23) god recognizes that over time, people will be buying and selling, succeeding and failing, and thriving and suffering. this passage makes provisions for his people to prevent the permanent creation of an underclass. over time it is likely that 12 aronson may 2019. christian journal for global health 6(1) land and other possessions will naturally (within the economic system of the times) be redistributed within the population, creating disparities in wealth and earning potential. the year of jubilee instructs people to return to their lands, even when poverty or misfortune led to the loss of those lands. so the year of jubilee made it possible for people to redeem any land that was theirs at the beginning of the 50-year cycle, and anyone who was sold into slavery would be freed at that time. god’s provision of the sabbath indicates that he feels that individuals have a need for rest and restoration. the same can be said about the land and the need for a sabbath year. from the instructions regarding the year of jubilee, it seems clear that god is concerned about the growing inequities among his people and that these inequities will occur naturally through differential rates of crop loss, sickness, or misfortune. to prevent permanent inequities among his people (multi-generational poverty), god provided the year of jubilee. in summary, god provided a sabbath for the people, for the land, and for the economy. isaiah’s rebuke of personal piety in the face of injustice and oppression the book of isaiah provides rich insight into god’s heart for his people and his plans for his kingdom. in multiple places, isaiah provides a strong rebuke of a faith that focuses on personal piety while ignoring oppression and injustice, and a faith that fails to look out for the oppressed, the defenseless, and those who cannot provide for themselves. in the face of these injustices, god declares that he hates their religious practices, that he is hiding his eyes from them, and that he does not hear their prayers. when you spread out your hands in prayer, i hide my eyes from you; even when you offer many prayers, i am not listening. your hands are full of blood! wash and make yourselves clean. take your evil deeds out of my sight; stop doing wrong. learn to do right; seek justice. defend the oppressed. take up the cause of the fatherless; plead the case of the widow. (isaiah 1:15-17) and again, in chapter 58, isaiah once again sharply rebukes god’s people for failing to address the needs of the oppressed, the hungry, the poor, and the naked. is not this the kind of fasting i have chosen: to loose the chains of injustice and untie the cords of the yoke, to set the oppressed free and break every yoke? 7is it not to share your food with the hungry and to provide the poor wanderer with shelter— when you see the naked, to clothe them, and not to turn away from your own flesh and blood? (isaiah 58:6-7) the book of isaiah is not the only place in the scripture that condemns inaction in the presence of injustice and overt acts of injustice. for instance, similar themes and language are used by both the prophets amos and micah. these passages reveal aspects of god’s character and his will for his people. he detests the hypocrisy of personal piety that is blind to injustice or that participates in injustice. his will is that his people actively engage in overcoming injustice both individually and corporately. isaiah’s vision of shalom and the new jerusalem in chapter 65 of the book of isaiah, the prophet paints a literary picture reflecting an eschatological image of the new jerusalem and the complete sense of wellness or shalom that will characterize this new kingdom. he describes a place where work will continue, but without exploitation. people will enjoy 13 aronson may 2019. christian journal for global health 6(1) the fruits of their labor and live in peace and harmony with others. health and longevity will characterize the lives of the people who reside there. passages such as this provide a window into the future kingdom of god, so that when we pray, “thy kingdom come, on earth as it is in heaven,” we will have some insight into what god has in mind. jesus’ teaching on the kingdom of god as a foundation for christian living the kingdom of god is considered the central message of jesus’ life and teaching.25 as a central message, it is reflected in jesus’ birth, his life, and ministry, his death and resurrection, and his future coming. the books of the old testament end with the book of malachi, in which the people were waiting expectantly for the return of elijah who would call god’s people to obey god’s law and conform to their calling as god’s holy nation.26 after 400 years of waiting, god broke into history with the urgent call of john the baptist, saying, “repent, for the kingdom of heaven has come near.” (matthew 3:2) the gospel of mark begins with the recognition that john the baptist represents the elijah that the people were waiting for, and that he was the prophet about whom isaiah had prophesied. ... as it is written in isaiah the prophet: “i will send my messenger ahead of you, who will prepare your way”—“a voice of one calling in the wilderness, ‘prepare the way for the lord, make straight paths for him.’” (mark 1:2-3) the kingdom of god was a central theme in jesus’ teaching. matthew and luke both refer to the proclaiming of the kingdom of god as a summary of his ministry. jesus went throughout galilee, teaching in their synagogues, proclaiming the good news of the kingdom, and healing every disease and sickness among the people. (mat 4:23) but he said, “i must proclaim the good news of the kingdom of god to the other towns also, because that is why i was sent.” (luke 4:43) the kingdom of god is both now and in the future. the timing of the fulfillment of the kingdom has been debated for centuries, with views reflecting either non-eschatological or eschatonlogical interpretations.25 the implications of these views can be seen in the lives of christians and the ministry of the church. perhaps this is reflected in the differences between those who wait for the rapture of the church and the second coming as the start of the kingdom, and those who work tirelessly to establish god’s kingdom here and now. some with a pietistic interpretation may see the kingdom in purely spiritual terms, while others may view it as the impetus for social reforms.26 or perhaps it is reflected in the differences between those who see the central mission of the church as social action and those that see it as the preaching leading to personal salvation. many evangelicals now see the kingdom as both already inaugurated and waiting for its consummation.25 luke records an encounter with the pharisees in which jesus addresses some of their misconceptions about the kingdom and what it would look like. once, on being asked by the pharisees when the kingdom of god would come, jesus replied, “the coming of the kingdom of god is not something that can be observed, nor will people say, “here it is,” or “there it is,” because the kingdom of god is in your midst. (luke 17: 20-21) furthermore, the scripture is clear that jesus is lord and that he rules over all things. in short, jesus rules over his kingdom, which is here right now. then jesus came to them and said, “all authority in heaven and on earth has been given to me. therefore go and make disciples of all nations, baptizing them in the 14 aronson may 2019. christian journal for global health 6(1) name of the father and of the son and of the holy spirit, and teaching them to obey everything i have commanded you. and surely i am with you always, to the very end of the age.” (mat 28:18-20) and, we are participants in his kingdom right now. for he has rescued us from the dominion of darkness and brought us into the kingdom of the son he loves, in whom we have redemption, the forgiveness of sins. (col 1:13-14) yet it is unmistakable that the kingdom is not manifest to its fullest; it awaits its complete consummation. jesus, in talking to his disciples about the day of his return, said: immediately after the distress of those days “the sun will be darkened, and the moon will not give its light; the stars will fall from the sky, and the heavenly bodies will be shaken.” then will appear the sign of the son of man in heaven. and then all the peoples of the earth will mourn when they see the son of man coming on the clouds of heaven, with power and great glory. and he will send his angels with a loud trumpet call, and they will gather his elect from the four winds, from one end of the heavens to the other. (mat 24:29-31) jesus’ teaching, as recorded in the gospels, provides us with insight into the nature of the kingdom of god. through parables recorded in matthew 13, jesus described some of the mysteries of the kingdom: 1) it will not be achieved by power but by hearing and believing (13:1-9, 18-23); 2) good and evil will continue to coexist until the end of the age (13:24-30), and, therefore, it is not about withdrawal; and 3) it begins almost imperceptibly but grows (like the mustard seed) and permeates (like yeast) (13:31-33). perhaps the richest passage about the nature of the kingdom is recorded in jesus’ “sermon on the mount.” in these passages, jesus’ teaching focuses on the ethics of the kingdom.25 once again, the debate seems to revolve around the issue of whether these ethics are eschatological or non-eschatological. in the beatitudes, jesus describes qualities of the heart and expressions of the heart that are blessed. “blessed are the poor in spirit, for theirs is the kingdom of heaven.” (mat 5:3) with each of these, there is the tendency to write them off as utopian ideals that will not be realized until the consummation of the kingdom. at the same time, it seems clear that jesus is calling his followers to embrace these qualities now and that the blessings are both now and for the future. the list is challenging to the way the world seems to work. they include those who are poor in spirit, mourning, gentle, hungry and thirsty for righteousness, merciful, pure in heart, peacemakers, and persecuted. (mat 5:3-11) jesus goes on to state, “unless your righteousness surpasses that of the scribes and pharisees, you shall not enter the kingdom of heaven.” (mat 5:20) more than just rules of behavior (which the pharisees were good at keeping), these reflect values of the heart, which result in lives of righteousness. the sermon on the mount redirects the intent of some of the commandments by focusing on the condition of the heart. this is an even harder standard to reach. rather than the commandment not to kill, jesus calls his people not to hate or be slanderous of others (mat 5:22). going further than the command not to commit adultery, jesus calls his followers not to look lustfully on another. because these directives seem to be so unreachable, many evangelicals will set these aside until the fulfillment of the kingdom.27 some of the other difficult themes of the sermon include the following: forgiveness, grace, faithfulness, integrity/honesty (no need to make an oath), non-resistance, love your enemy, love the unlovable, humility, and simplicity/nonmaterialism. teachings regarding the sabbath year and the year of jubilee, as well as the rebukes from isaiah to 15 aronson may 2019. christian journal for global health 6(1) the people for ignoring injustice while practicing personal piety, are instructive to us regarding values reflective of the kingdom. these focus on responsibilities to each other. the teachings of jesus on the kingdom instruct us on our responsibility toward relationships and society, and also add an emphasis on the attitudes of the heart. together (behavior and heart) they provide guidelines for righteous living. interestingly, early in jesus’ ministry he cited isaiah 61:1-2 when speaking in the synagogue in nazareth, saying: the spirit of the lord is on me, because he has anointed me to proclaim good news to the poor. he has sent me to proclaim freedom for the prisoners and recovery of sight for the blind, to set the oppressed free, to proclaim the year of the lord’s favor. (luke 4:18-19) he astonished everyone when he sat down and declared that, “today this scripture is fulfilled.” in effect, he was declaring a year of jubilee and the emergence of his kingdom. on a final note to tie some of these themes together, the apostle paul talks of the current and future work of reconciliation that god is performing both to us and through us. in 2 corinthians 5:16-20, paul clearly speaks of the reconciliation that has already taken place in believers, and the mission that god has for us as ambassadors of reconciliation. so from now on we regard no one from a worldly point of view. though we once regarded christ in this way, we do so no longer. therefore, if anyone is in christ, the new creation has come: the old has gone, the new is here! all this is from god, who reconciled us to himself through christ and gave us the ministry of reconciliation: that god was reconciling the world to himself in christ, not counting people’s sins against them. and he has committed to us the message of reconciliation. we are therefore christ’s ambassadors, as though god were making his appeal through us. we implore you on christ’s behalf: be reconciled to god. (2 cor 5:16-20) in romans 8:18-23, paul speaks of the future reconciliation that all of creation eagerly awaits: i consider that our present sufferings are not worth comparing with the glory that will be revealed in us. for the creation waits in eager expectation for the children of god to be revealed. for the creation was subjected to frustration, not by its own choice, but by the will of the one who subjected it, in hope that the creation itself will be liberated from its bondage to decay and brought into the freedom and glory of the children of god. we know that the whole creation has been groaning as in the pains of childbirth right up to the present time. not only so, but we ourselves, who have the firstfruits of the spirit, groan inwardly as we wait eagerly for our adoption to sonship, the redemption of our bodies. (rom 8:18-23) so, god has called his followers to a ministry of reconciliation in which we embody the values of his kingdom and work toward the redemption of all things which god himself will achieve upon the consummation of his kingdom. the christian, the church, and kingdom living equipped with insight into the heart of god from the book of leviticus, the prophet isaiah, and jesus’ teaching regarding the kingdom of god, how are christians called to live? if we have insight into god’s heart and the values that drive his kingdom, shouldn’t we reflect these as well? shouldn’t these values guide our lives and behavior? what seems to be diverting us from focusing on this? i will suggest at least three reasons. 16 aronson may 2019. christian journal for global health 6(1) evangelicals in the usa have historically placed a great deal of emphasis, and rightly so, on the importance of individual relationship with god and personal salvation. for many, this may mean personal time spent in prayer and worship in which the believer can experience the presence of god and his holy spirit. it also provides an assurance to the believer that a place is reserved for her/him in heaven after death. in addition, it may mean a commitment to sharing these truths with others so that they can also receive salvation. while these reflect critical aspects of kingdom living and discipleship, these aspects of the christian life tend to emphasize the spiritual over the physical and the individual over the societal. often ignored is the significance of life this side of heaven, except on viewing this life as a trial before real life begins. salvation is seen as something that individuals receive and not something that comes to creation and society. the important work of redemption extends beyond the soul or spirit of individuals, and includes the whole person (body, mind, spirit, and relationships), as well as all of existence (nature/creation, social systems, political structures). the passages from 2 corinthians 5 and romans 8 provide evidence that god wants redemption and reconciliation for people, all of creation, and the created order. secondly, the identities of many evangelicals are tied to their beliefs in jesus and their membership in his body, which is the church. very often it is in the context of the local church that the christian strives to live out her/his faith and where discipleship takes place. at times, this can lead to a protective insulation from the world and a focus on separateness. forays into the “world” may be brief, structured (as in the context of work), and as “sojourners, aliens, and strangers.” sometimes this results in an exaggeration of the differences in values between christians and non-christians, and an ignorance of the concerns, sufferings, and joys that we share with all of humanity. one more very important reason why we may not fully embrace kingdom living in the present, may be related to the absence of a robust theology of the kingdom within our churches or what carl henry describes as a deficient vision of the kingdom of god.20 according to russell d. moore, in carl henry’s publication the uneasy conscience of modern fundamentalism, henry created the platform for a differentiation of evangelical from fundamentalist.20 fundamentalism’s perspective of isolationism from engagement in addressing the broader concerns of human life stood as a contrast to the approach taken by the fully engaged social gospel orientation held by liberal theologians and mainline christians. with the leadership of carl henry as well as the national association of evangelicals and fuller theological seminary, evangelicalism sought to place itself as a third way distinct from these two camps. theological differences, however, resulted in significantly different understandings and visions of the meaning of the kingdom of god. dispensational vs. reformed theologies reflected contrasting views between “kingdom then” and “kingdom now” (p. 382).20 ongoing theological reflection has resulted in a much more widely accepted “third way” referred to as “inaugurated eschatology”, which recognizes the presence of the kingdom now and the final culmination of that kingdom in the future. this perspective is now visible in the greater engagement of conservative christians in addressing social concerns from hiv/aids, human trafficking, and orphan care to the protection of the environment. besides these three explanations for evangelicals’ difficulty in embracing broader kingdom living and kingdom values, a significant contributor is the american notion of individual autonomy and personal responsibility while denying the importance of systems and structures that impede or facilitate individual action. these notions appear to be thoroughly syncretized into american evangelicalism which neglects or opposes efforts to 17 aronson may 2019. christian journal for global health 6(1) engage in action focused on social or systems’ change to address such things as poverty and inequality. assistance to individuals who are willing to take responsibility is approved. conclusions: public health as work of the kingdom in this manuscript, i have described public health as having a mission “to create the conditions in which people can be healthy.” this broad view of public health is in response to the decline of infectious disease, the aging of the population, and the growth in importance of chronic diseases and diseases of civilization (including violence, inequality, oppression, etc.). in addition, advances in understanding risk factors for poor health outcomes and disappointment in the potential to impact population health through voluntary behavior change have led to increased consideration of structural and social contributors to health. public health has always been associated with progressive reform movements for the improvement of the environment and the conditions in which people live. with the emergence of “germ theory” came decades of focus on addressing the biological agents of disease through immunization, antibiotics, and interfering with the chain of transmission. the inability of germ theory to address diseases of lifestyle and living conditions moved public health activists to shift their attention to the social and environmental factors that produce poor health. in keeping with the tradition of progressive reform movements in public health, the field now seeks to reform and/or transform the systems that lead to inequality—those systems that grant advantages (privilege) to some and disadvantages to others. for many in the field, public health is driven by a quest for social justice with the aim of addressing the factors that produce inequity. in my review of the instructions regarding the sabbath, the sabbath year, and the year of jubilee, i refer to the view that this passage indicates that god is concerned about the wellbeing of individuals, of the land, and of the society. in the instructions regarding the jubilee, god provided a plan to prevent generational poverty and disadvantage. furthermore, the passages from isaiah describe god’s disgust with displays of personal piety while turning a blind eye to injustice and oppression. finally, the teachings of jesus declare the emergence of the kingdom, which is both now and yet to come. the fullness of the kingdom will appear with his final return that will bring redemption to all of creation. the point that i want to make is not that the work of public health is equivalent to the work of the kingdom, but that a christian engaged in public health work can be assured that efforts to reform the systems and structure of society based on kingdom principles can reflect the christian’s responsibility to be an ambassador of reconciliation. this ministry can take place through individual redemptive acts to bring about reconciliation of people to god, to each other, and to the creation. it can also be expressed through working together as the body of christ to bring about transformation of people, places, and policies. finally, it can also be through christians joining in societal efforts (such as through the mechanisms of the public health system) to create the conditions needed for people to live healthy lives. references 1. tesh sn. hidden arguments: political ideology and disease prevention policy. 4th ed. new brunswick: rutgers university press; 1996. 2. porter d. health, civilization, and the state: a history of public health from ancient to modern times. new york: routledge; 1999. 3. rosen g. a history of public health. new york: md publications, inc.; 1958. 4. mckeown, t. the modern rise of population. academic press; 1976. 5. omran ar. the epidemiologic transition: a theory of the epidemiology of population change. milbank 18 aronson may 2019. christian journal for global health 6(1) quarterly. 2005;83(4):731-57. https://doi.org/10.1111/j.1468-0009.2005.00398.x 6. wilkinson rg, marmot mg. 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perspectives. am j commun psychol. 2013;51(34):315-31. https://doi.org/10.1007/s10464-012-95524. 12. beauchamp, de. public health as social justice. inquiry. 1976;13(1),3-14. available from: http://www.jstor.org/stable/29770972 13. beauchamp de, steinbock b (eds). new ethics for the public's health. new york, ny: oxford university press; 1999. 14. buchanan dr. an ethic for health promotion: rethinking the sources of human well-being. new york, ny: oxford university press; 2000. 15. hofrichter r. (ed.). health and social justice: politics, ideology, and inequity in the distribution of disease [vol. 11]. san francisco, ca: jossey-bass; 2003. 16. levy bs, sidel vw. social injustice and public health. new york, ny: oxford university press. 2013. 17. donohoe m. public health and social justice [vol. 31]. san francisco: john wiley & sons. 2012. 18. emerson mo, smith c. divided by faith: evangelical religion and the problem of race in america. new york, ny: oxford university press, usa; 2000. 19. tranby e, hartmann d. critical whiteness theories and the evangelical “race problem” extending emerson and smith's divided by faith. j sci study relig. 2008;47(3): 341-59. https://doi.org/10.1111/j.1468-5906.2008.00414.x. 20. moore rd. the kingdom of god in the social ethics of carl fh henry: a twenty-first century evangelical reappraisal. jets. 2012;55(2):377-98. available from: https://www.etsjets.org/files/jets-pdfs/55/552/jets%2055-2_377-397_moore.pdf 21. henry cf. the uneasy conscience of fundamentalism. grand rapids: eerdmans; 1947. 22. pew research center. u.s. public becoming less religious[internet]. 2015. available from: http://www.pewforum.org/2015/11/03/u-s-publicbecoming-less-religious/ 23. bediako dk. the biblical sabbatical year and its implications for ecology: an exegesis of exodus 23: 10-11. j environ sci eng. 2013;2(6a):377. available from: https://www.researchgate.net/profile/cajka_peter/publ ication/321295385_hivaids_as_a_current_demogr aphic_security_problem/links/5a19cb6ea6fdcc50adea e830/hiv-aids-as-a-current-demographic-securityproblem.pdf#page=45. 24. branca g, lipper l, mccarthy n, jolejole mc. food security, climate change, and sustainable land management. a review. agron sustain dev. 2013;33(4): 635-50. https://doi.org/10.1007/s13593013-0133-1 25. ladd ge. a theology of the new testament. grand rapids: william b. eerdmans publishing company; 1993. 26. naugle dk. jesus christ and the kingdom of god. chuck colson ministries; 2010. [as cited by willson tr]. reclaiming the kingdom of god metaphor for the twenty-first-century church. 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https://www.researchgate.net/profile/cajka_peter/publication/321295385_hivaids_as_a_current_demographic_security_problem/links/5a19cb6ea6fdcc50adeae830/hiv-aids-as-a-current-demographic-security-problem.pdf#page=45 https://www.researchgate.net/profile/cajka_peter/publication/321295385_hivaids_as_a_current_demographic_security_problem/links/5a19cb6ea6fdcc50adeae830/hiv-aids-as-a-current-demographic-security-problem.pdf#page=45 https://doi.org/10.1007/s13593-013-0133-1 https://doi.org/10.1007/s13593-013-0133-1 https://digitalcommons.georgefox.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1086&context=dmin https://digitalcommons.georgefox.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1086&context=dmin https://digitalcommons.georgefox.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1086&context=dmin 19 aronson may 2019. christian journal for global health 6(1) 27. ladd ge. the gospel of the kingdom. grand rapids: william b. eerdmans publishing company; 1959. peer reviewed: submitted 20 aug 2018, accepted 29 nov 2018, published 31 may 2019 competing interests: none declared. correspondence: robert e aronson, professor, public health program, taylor university, upland, in, usa. bob_aronson@taylor.edu cite this article as: aronson re. public health, systems change, justice and the work of the kingdom. christian journal for global health. may 2019; 6(1):7-19. https://doi.org/10.15566/cjgh.v6i1.239 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:bob_aronson@taylor.edu https://doi.org/10.15566/cjgh.v6i1.239 http://creativecommons.org/licenses/by/4.0/ original article nov 2016. christian journal for global health, 3(2): 38-49. outcomes of a faculty development conference in mongolia deborah a kroeker a , anne walling b a md, associate professor, department of pediatrics, university of kansas school of medicine, usa b mb, chb, ffphm, associate dean for faculty affairs, ku school of medicine, wichita, professor of family and community medicine, usa abstract background: medical education international (mei), an organization that provides faculty development to medical educators in developing countries, wanted information on the program effectiveness of its faculty development conferences. objectives: to assess the outcomes of an mei faculty development conference in mongolia on the knowledge, confidence in applying new skills, and attitudes of participants. methods: a retrospective pretest survey of participants was used to assess the outcomes of a 3-day faculty development conference given twice at the mongolian national university of medical sciences. the survey assessed participant views on their ability to meet the objectives of the conference, the perceived overall value of the conference, and their suggestions for improvements in future mei conferences. results: twenty participants (65%) completed surveys. participants reported significant changes in agreement with their ability to meet the objectives of the conference in all of the pre-post measures (pre-post p<0.001). the value of attending the conference was ranked at a mean score of 4.05 on a likert scale from 1 to 5, with 1 indicating “strongly disagree” and 5 “strongly agree.” conference attendees indicated interest in additional training on more advanced topics. conclusion: overall, the findings indicate that conference attendees gained knowledge and confidence in applying new skills and valued the training received from a faculty development conference led by physicians from the usa. further research is needed to determine long-term impact on residency education in mongolia. 39 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. introduction the last three decades have brought a significant increase in the number and type of professional development programs for medical school faculty members, but the outcomes of many of those programs are not well studied. 1 this leaves faculty members and educational leaders without strong evidence to guide decisions about optimal faculty development activities for institutions and individuals. increasing faculty and university time and financial constraints require that resources are used in the most productive manner possible. medical education international (mei, online at https://cmda.org/missions/detail/mei) is an organization that provides conferences on request to faculty members in developing countries on clinical or faculty development topics. the dean of the mongolian national university of medical sciences in mongolia, a developing country in central asia, requested a conference on faculty development. after discussion about content and logistics, mei agreed to provide this university with two identical faculty development conferences, each lasting three days, on residency education. the outcomes of mei conferences have not been previously studied, and this project aimed to assess conference outcomes. mongolian medical education has experienced significant change in recent years. mongolia was a communist country until the dissolution of the ussr in 1990, with centralized control over education and clinical services. since then, the country has been rapidly advancing technologically and in the depth and breadth of its clinical services. many new, high-technology hospitals have opened. to keep up with these new opportunities and challenges, higher education has expanded and the number of faculty members in mongolian universities doubled in ten years between 1997 and 2007 to 6,818 full-time faculty. 2 mongolia has a long history of having medical schools. however, the first residency training programs were not started until the mid1990s. the duration of residency training for most specialties has increased from 18 to 24 months. fellowship programs have also been started, although they can be as short as 6 months. because of the rapid expansion in medical education, many new faculty members have little experience in the faculty role. all faculty members, regardless of country, require faculty development to meet the needs of the changing medical and educational environments. 3 for mongolia, the dramatic changes and growth make faculty development for residency program directors and other educational leaders imperative. in general, active learning strategies are less commonly used in asian schools, and courses are often lecture-based. 4 formal faculty development in teaching and programs to promote strong educational leadership are also more limited in asia than in westernized countries. the leaders of the mongolian national university of medical sciences (mnums) have identified the improvement of residency training programs as a goal. faculty development is essential to achieve this priority. to date, faculty development at mnums has been provided through sabbaticals, grants, awards, mentoring, visits to observe in other countries, and workshops. 2 staff and faculty members of mnums report that many international visitors from diverse groups travel to mongolia to deliver conferences on clinical topics but none have addressed faculty development in education. previous studies have addressed the outcomes of faculty development conferences, predominantly in westernized countries. outcomes have been assessed mainly by changes in faculty attitudes towards teaching, increases in knowledge, and improvement in teaching skills and behaviors. 5 the outcomes of one conference were assessed at a higher level on kirkpatrick’s levels of training evaluation by identifying the percentage of participants who successfully implemented faculty development projects at their home institutions. 6 little information is available on the outcomes of faculty development conferences in developing countries, especially those using a https://cmda.org/missions/detail/mei 40 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. program conducted by individuals from western countries. a pubmed literature search identified no information on the utility of such faculty development conferences in mongolia. one study by wong and fang describes the outcomes of a western-based faculty development seminar in a developing country in asia. 7 this study provided the model for the assessment of this mongolian mei conference. further research on this topic will provide useful information for the development of future mei programs in developing countries and provide information for other educational organizations that offer similar conferences. this study seeks to answer the broad research question, “what are the outcomes of the mei faculty development conferences on the knowledge, confidence in applying new skills, and changes in attitudes of the faculty participants?” the study of conference attendees identifies the extent to which they agree conference objectives were met, their perceived value of the conference, and their suggested areas for improvement. faculty development can be defined as “a planned program designed to prepare institutions and faculty members for their various roles and to improve an individual’s knowledge and skills in the areas of teaching, research [and] administration.” 8 as learner requirements and innovative techniques for teaching, evaluation, and assessment evolve, faculty members must be well-prepared in both the theory and application of appropriate methods to effectively guide and evaluate learners. 3 according to the accreditation council of graduate medical education (acgme), program evaluation is defined as the ‘‘systematic collection and analysis of information related to the design, implementation, and outcomes of a resident education program, for the purpose of monitoring and improving the quality and effectiveness of the program.’’ 9 the hypothesis is that this three-day, mei faculty development conference will enable participants to gain knowledge and confidence in developing residency training programs, enhance positive attitudes towards educational techniques, and report that time at the conference was valuable. methods the conference presenters were volunteers selected by mei from a list of board-eligible or board-certified physicians from the usa who had indicated interest in presenting at conferences and whose areas of expertise corresponded to the needs identified by the host organization (mnums). the team presenters for this mongolian conference included an academic otolaryngology physician who served as an international residency program director, an academic psychiatrist who was previously a residency program director, an associate program director of a pediatric residency program, a retired academic general surgeon with expertise in teaching in mission hospitals, and a hepatobiliary surgeon who was a recent fellowship graduate. the conference took place in the capital city of mongolia, ulaanbaatar, at the mnums. faculty attendees were chosen by the deans of the university and consisted of heads of departments in the university and directors of the residency programs in several specialties and subspecialties, including general surgery, otolaryngology, urology, orthopedics, internal medicine, ophthalmology, pediatric gastroenterology, pulmonology, and hematology/oncology. the 3-day conference was given twice in one week to accommodate schedules for two different groups of faculty. in total, about 18 faculty members participated in the first conference and 13 in the second conference. participants occasionally left and returned to the conference during the day as needed based upon their other professional responsibilities. the conference format (see table 1) was composed of lectures and small-group workshops in which faculty members worked together to discuss and expand on different conference topics. following each small group breakout session, the large group reconvened and discussed the ideas from the small groups as a large group. all participants who were 41 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. present at the end of each of the conferences were offered a paper survey to complete anonymously prior to leaving the conference room. because all faculty participants were offered a survey, the entire conference population was studied; sampling was not used. table 1: conference schedule time topic day 1 1:00pm introductions and conference outline 1:30pm history of residency training in mongolia 2:00pm history of residency training in the usa 2:30pm life as a resident in the usa 3:00pm break 3:15pm lecture on needs assessment for developing a residency program 3:45pm small group discussions on the ideal residency program (duration, assessments, etc.) 5:30pm report by small groups 5:45pm wrap up and discussion 6:00pm adjourn day 2 1:00pm lecture on competencies 1:45pm small group discussions on competencies 2:15pm lecture on how to implement competencies 3:00pm small group discussion on the implementation of competencies in mongolia 3:30pm break 3:45pm lecture on the administration of a residency program/block schedules 4:30pm small group work developing ideal block schedules 5:00pm lecture on how to develop program goals and objectives 5:30pm small group development of program goals and objectives 6:00pm adjourn day 3 1:00pm lecture on how to develop a competency-based curriculum 1:30pm small group development of rotation goals and objectives 2:00pm lecture on educational activities within residency 2:30pm small group development of an educational schedule for program 3:15pm break 3:30pm lecture on assessments (formative vs summative, end of training assessments, giving feedback, etc.) 4:30pm small group discussion on giving feedback in current residency program 5:30pm report by small groups 5:45pm wrap-up and evaluation of conference 6:00pm adjourn a mixed-methods survey was developed in conjunction with the faculty participants on the team. the data were obtained concurrently and each type of data was given equal weight. the interpreter reviewed the survey and provided feedback prior to use. the survey was written in english, while participants were able to respond in english or mongolian. the cross-sectional study was based upon the results of a retrospective pretest method that used both a likert-type scale to provide quantitative information and short answer questions to provide qualitative data. a retrospective pretest consists of a survey given to conference participants at the end of the conference. it asks the participants to rate themselves on how much they knew about specific topics before the conference began and then to rate 42 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. themselves again based upon how much they know at the end of the conference. the difference between the two responses indicates knowledge gains during the conference. 10 this method of assessment can improve the accuracy of the data obtained by a traditional pretest/posttest format. participants who rate their knowledge using a traditional pretest may be unaware of what they don’t know, and be unable to accurately assess their knowledge level before the conference. in contrast, at the end of the conference, participants can better judge how knowledgeable they were before the conference. 10 validity of the qualitative results was ensured by relaying the qualitative results in rich, descriptive language to ensure a realistic portrayal of the situation. additionally, two reviewers, one with no connection to mei or the conference, reviewed the data independently. the reviewers analyzed the data until they came to mutual agreement on the themes and results. the principal investigator was open to finding areas upon which to improve for future conferences and open to negative opinions and findings. this provided an opportunity for voices with negative opinions to expand the available data. grounded theory, a research design in which a theory is generated from the perspectives of participants, was used for analysis of the qualitative data, and reliability of the qualitative data was ensured. 11 the survey reports were rechecked for errors during analysis. themes were identified and coded. any disagreements between coders were discussed until consensus was reached. validity of the quantitative data was also protected. the survey used was developed specifically for this project using the retrospective pretest methodology that has been used for similar studies. the survey questions were previewed by the mongolian interpreter who provided feedback on the instrument prior to implementation. the survey was also reviewed by multiple physicians with suggestions incorporated into the survey prior to use. the survey (see appendix a) was printed on a double-sided sheet of paper and given to the participants at the end of each of the three-day conferences. the purpose of the survey was described so the attendees were aware that the sole purpose was to improve future conferences for other attendees; no additional incentives were offered for completion of the survey. the surveys were written in english, but the participants could complete the surveys in english or mongolian, according to their preferences. the interpreter was available for participant questions or clarification on the meaning of any of the english words or phrases. no identifying information was collected or requested on the surveys to ensure anonymity. completion of the survey implied consent for inclusion in the study. the attendees left the surveys in the room for collection after they had completed them. the anonymous surveys were placed in a manila envelope for return to the united states for analysis. all answers in mongolian were translated into english by the conference interpreter who was fluent in both english and mongolian. the surveys were analyzed by the university of kansas school of medicine office of research members of the study team. this study was done with the approval of both the mei director and the leader of the conference. conference attendees were invited to participate, but participation was optional. while the participants completed the surveys without benefiting immediately, they may benefit if they attend any future mei conferences that are improved in response to their feedback. additionally, the survey results will benefit other future mei conference attendees in mongolia and other developing countries. no harmful or identifying information was collected, and the individual surveys will not be shared with those in authority over the participants. because this was a program evaluation rather than a research project, it received irb exemption status. the study team analyzed the results for statistical differences between the “before” and 43 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. “after” responses of the participants using the wilcoxon signed rank test. all tests were 2-tailed and alpha was set at 0.05. the short-answer data was reviewed for emergent themes using grounded theory, a theory in which meaning is gleaned from the information provided by the participants through their responses on the surveys. 11 themes were identified independently by two reviewers and final themes determined by consensus. the results of the qualitative and quantitative sections were analyzed in a convergent manner to determine how the results relate to one another. the data provided information on the outcomes of the mei conferences on the knowledge, skills, and attitudes of faculty participants in mongolia. results eighteen faculty leaders participated in the first conference, and thirteen participated in the second conference. of the 31 participants, 20 completed the survey for a response rate of 65%. all faculty members who were present at the end of the conferences completed the survey. analysis of the survey results indicated significant changes in the faculty level of agreement in all of the pre-post measures with a p<0.001 (see table 2.) the most significant change was noted in familiarity with competency-based medical education, with an average pre-conference score of 2.5 and an average post-conference score of 4.5. the areas in which faculty most strongly indicated agreement at the end of the conference were those of being able to build a needs assessment (mean 4.7) and being able to develop goals and objectives for a rotation or class (mean 4.7). the area that faculty ranked as the weakest at the end of the conference was that of being able to give effective summative assessments (mean 4.3). even this, however, is still a significant increase from a mean pre-conference response of 3.1. table 2: attendee self-reported knowledge before and after conference (1-5 scale) mean (sd) before after i am familiar with competency-based medical education 2.5 (0.8) 4.5 (0.5) i can develop a needs assessment for a course in residency 2.8 (1.1) 4.7 (0.5) i can write overall goals for a residency program 3.0 (1.0) 4.7 (0.5) i can develop goals and objectives for a rotation or class 3.0 (0.9) 4.6 (0.5) i can create a block schedule for resident rotations 3.0 (1.2) 4.6 (0.6) i can give effective feedback to a resident 2.9 (1.1) 4.6 (0.5) i can give effective summative assessments 3.0 (0.9) 4.3 (0.6) i value giving feedback to residents 3.1 (0.9) 4.6 (0.6) note: all p values are significant at <0.001 participants ranked the value of attending the conference at a mean score of 4.05 (see table 3). they ranked the helpfulness of the small group discussions with colleagues between 4.26 (discussion on how to implement competencies into the medical education system) and 4.63 (discussion on the ideal structure of residency training). participants rated the helpfulness of the small group discussions higher than they rated the value of attending the conferences. table 3: impact of conference on attendees (1-5 scale) n mean (sd) i value attending this conference 20 4.1 (0.9) small group discussions with colleagues on the ideal structure of residency training were useful 19 4.6 (0.8) 44 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. small group discussions on how to implement competencies in our medical education system were helpful 19 4.3 (0.7) small group discussions on how to give feedback will change how i give feedback in the future 18 4.5 (0.5) small group discussions on how to give assessments will change how i use assessments in the future 19 4.5 (0.5) respondents indicated that they had received between 0 and 10 days of faculty development on similar topics in the past, with an average of 2.3 days of previous training (see table 4). there was a wide range of responses when asked about the percentage of material that was new to participants. two (10%) respondents indicated that 20-30% of the material was new, while four (20%) indicated that 80-100% of the material was new to them (see table 5). on average (mean 57%, [range 20100%]) about half of the conference material was reported as new to the attendees. table 4: number of days of similar faculty development training number of participants 0 days 5 1-2 days 1 3-6 days 4 7-10 days 1 table 5: percent of material that was new number of participants 20-30% 2 40-50% 1 60-70% 4 80-100% 4 the most common participant response to the question asking which part of the conference was most helpful was the response “all” (see appendix b). while participants were reluctant to report anything negative, one response was that some parts of the conference were not sufficiently advanced for the group; the other respondents indicated that there were no negative outcomes. participants suggested the conference could be more useful by using a translator who was familiar with residency education, by including more details and examples in the presentations, and by having more small group sessions. they suggested the conference could be more culturally appropriate by including “more education and practice.” elsewhere, participants reported that more examples would be helpful; this could mean that participants would like examples from their local universities and contexts. respondents also suggested that the provision of continuing education for participants at different levels would be desirable. when asked how mei could support the faculty in further development of their residency programs, responses included access to all the curriculum and documents used during the conference, and more training. when asked about specific topics for additional training, participants indicated topics specific to their disciplines, education methods for residency programs, and learner assessments. discussion we used a retrospective pretest survey method with additional qualitative questions to evaluate the outcomes of a faculty development conference for medical educators in mongolia. the qualitative questions also provide information to inform future faculty development conferences, as the responses have information on what was perceived as helpful or not, and suggestions on how to improve similar conferences in the future. overall, we found that participants valued and learned from the conference. the most common respondent answer to the question, “what part of the conference was most helpful?” was “all.” participants had received minimal training in residency education (mean of 2.3 days) in the past, indicating a gap in previous faculty development 45 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. training. this was consistent with their relatively low self-rating on the “before” section of the survey. many participants also requested more training in the future, and participants requested the handouts and presentations used in this training for future reference. while one person wrote that “we have so many needs and issues,” others indicated that they would like more advanced training, including more “detailed information on different educational methods.” this, as well as the comment that participants would like education specific to participants of different levels of experience, indicates that many mongolian faculty members already have a basic level of knowledge and would like to expand that knowledge. it also shows their passion for professional growth and development. the only negative outcome of the conference identified was one person’s response that “some part[s were] not advance[d]” enough. requests for additional training included “more detailed information and examples on training,” and “practice from another country.” prior to planning any future faculty development conference, conference leaders would benefit from surveying potential participants on their level of training and comfort using various skills. the assessment of conferences in nonwesternized developing countries requires an awareness of the cultural context and how this might impact both the conference and the validity and reliability of an assessment. in the confucian belief system, which is common in mongolia, hierarchy is respected, and a strong power differential exists between teacher and learner. in contrast, westernized cultures have a much more individualistic paradigm, with power differentials playing a much smaller role in organizations. 12 these cultural differences have many implications for the educational environment of a conference. in westernized cultures, questioning a professor is not only acceptable; it is often viewed positively as a demonstration of critical thinking. for a student from an eastern culture, questioning an authority figure is disrespectful; students are less likely to ask questions since that might insinuate that the teacher had not adequately explained the topic. presenters with a western mindset may assume that all learners understand the material if no questions are asked, whereas the learners may have many questions that they do not ask out of respect for the westerners. if presenters from the west are not aware of and responsive to these different perspectives, learning can be impacted. to modulate this challenge, the conference was arranged with frequent workshops after a presentation (see table 1). during the workshops, the participants worked together to discuss and apply the material that had just been presented. leaders of the conference were available to provide feedback to attendees during those sessions, and participants provided feedback to each other as well. this provided a non-threatening environment in which participants asked many questions. one respondent commented on the importance of a having a content-knowledgeable interpreter for the conference. a highly-trained physician was the interpreter for the first conference, and she facilitated clear communication. the first day of the second conference, we were given two interpreters, and neither was as familiar with residency education; they occasionally asked for clarification of terms. on the second and third day of the second conference, another interpreter completed the interpretation for us, and this was more effective. the presenters adapted to these challenges by speaking more slowly and using descriptors to assist the interpreter with technical terms. this study had several limitations, confounding factors and barriers. the first is that the study population was only those faculty members who participated during the entire three days of the conference and were still present at the end of the third day. this could have led to a sampling error biased positively towards the utility of the conference since those who attended the entire conference were likely to be those who perceived it 46 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. as most beneficial. this could also have impacted the number of surveys completed since some participants left early without completing a survey. additionally, the study population could have been depleted of the busiest faculty members who needed to attend to other responsibilities during parts of the conference. language was another barrier. the survey was written in english, while mongolian is the participants’ primary language. the participants indicated that they read in english and declined having the surveys translated into mongolian. participants were informed that they could answer the survey in mongolian; mongolian responses were translated into english by a mongolian physician who is fluent in both english and mongolian. while this should result in an accurate translation, there is a possibility of a loss of some of the nuances between the mongolian and english languages. also, as discussed above, a contentknowledgeable interpreter is imperative for optimal communication. providing a conference for participants from a different culture is challenging. one response indicated that the system in mongolia is significantly different from the western system with which the presenters were accustomed, stating, “in my opinion our philosophy and goals is different from western countries.” this can have implications on the transferability of the information presented on the usa’s residency education system. additionally, several comments mentioned the need for administrative leaders to participate in the conferences and to make changes in the mongolian residency education system. the assessment of conferences in nonwesternized developing countries requires an awareness of the cultural context and how this might impact both the conference and the validity and reliability of an assessment. since learners from eastern cultures are careful not to shame their instructors, they may have withheld criticism and felt obliged to indicate that they learned a lot and appreciated the conference, regardless of their true opinions. to ensure that research is reliable, it is imperative that researchers work within the cultural belief system in a manner that can obtain accurate information. using a neutral third-party to obtain feedback may improve the accuracy of data obtained from faculty participants. strengths of this study included the ability of attendees to provide written, anonymous, qualitative data without having to give feedback verbally to presenters. additionally, the survey could be completed in english or mongolian, based upon participant preference. finally, all participants who were present at the end of the conference participated in completing the surveys. as a result of this project, mei faculty development conferences have introduced surveys to evaluate the outcomes of conferences. this affirms that mei leadership values the information provided by the survey and has taken action to evaluate the outcomes of conferences. based upon feedback from the surveys, mei has changed how conferences are led by making sessions more interactive. the compilation of feedback from additional conferences will provide information that is more valid and generalizable. it might be helpful if teams providing a faculty development conference survey participants in advance of the conference to obtain information on the current level of participant knowledge and specific areas of need. this would help presenters tailor the conference to the needs, level and interests of the participants. it could also serve to stimulate interest in and provide realistic expectations for the conference. conclusions overall, our findings indicate that conference attendees valued the faculty development conference led by physicians from a westernized country. our findings also indicate the importance of including administrative leadership from the host country in faculty development. this will facilitate discussions regarding changes in the training system at the structural level and foster a 47 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. conference environment that is culturally relevant. further research needs to be done to determine long-term effectiveness of the conferences through changes in residency education and patient outcomes. this survey can be modified and used to evaluate the outcomes of other faculty development conferences in developing countries. references 1. newman l, pelletier s, lown b. measuring the impact of longitudinal faculty development: a study of academic achievement. acad med, advance online publication. 2015. http://dx.doi.org/10.1097/acm.0000000000001016 2. baasandorj d. faculty development program needs at mongolian state universities: content and strategies [doctoral dissertation]. 2010. retrieved from proquest (dai-a 71/09) 3. hegde p. faculty development trends in medical education: a review. se asian j med educ. 2013;7(2),11-6. 4. majumder m. issues and priorities of medical education research in asia. ann acad med singap. 2004;33(2),257-63. 5. steinert y, mann k, anderson b, barrnett bm, centeno a, naismith l, et al. a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: beme guide no. 8. med teach. 2016;38(8),769-86. http://dx.doi.org/10.1080/0142159x.2016.1181851 6. houston t, ferenchick g, clark j, bowen j, branch w, alguire p, et al. faculty development needs. j gen intern med. 2004;19(4), 375-9. http://dx.doi.org/10.1111/j.1525-1497.2004.30619.x 7. wong j, fang y. improving clinical teaching in china: initial report of a multihospital pilot faculty development effort. teachlearnmed. 2012;24(4),355-60. http://dx.doi.org/10.1080/10401334.2012.719801 8. bland cj, schmitz cc, stritter ff, henry rc, aluise jj. successful faculty in academic medicine: essential skills and how to acquire them. new york: springer-verlag; 1990. 9. acgme. 2010a. accreditation council for graduate medical education: glossary of terms. accreditation council for graduate medical education. [updated 2013 july 1; cited on 2016 sept 21.] available from: https://www.acgme.org/portals/0/pdfs/ab_acgm eglossary.pdf 10. lamb t, tschillar r. evaluating learning in professional development workshops: using the retrospective pretest. journal of research in professional learning. 2005;1,1-9. 11. cresswell, j. research design: qualitative, quantitative and mixed methods approaches. los angeles: sage. 2014. 12. kikukawa m, stalmeijer, re, emura s, roff s scherpbier aj. an instrument for evaluating clinical teaching in japan: content validity and cultural sensitivity. bmc med educ. 2014;14,179-86. http://dx.doi.org/10.1186/1472-6920-14-179 appendix a: retrospective survey on faculty development conference thank you for completing the following survey, which measures how useful and effective you feel this conference was. your responses will be anonymous. the information will be used to improve future medical education international conferences both in mongolia and in other countries. we appreciate honest responses since they will help us improve. this survey is optional. you do not have to answer it if you do not want to. if any of the questions make you feel uncomfortable, you may skip them. the data from the surveys may be presented in a paper, a poster, or another form of dissemination. participation in the survey indicates agreement with this. please select your level of agreement with each of the following statements on a scale from 1 to 5, with 1 being “strongly disagree,” 2 being “disagree,” 3 being “neutral,” 4 being “agree,” and 5 being “strongly agree.” with each statement, please select your level of agreement with the statement before the conference began and after the conference was over. 1.) i am familiar with competency-based medical education. before: 1 2 3 4 5 http://dx.doi.org/10.1097/acm.0000000000001016 http://dx.doi.org/10.1080/0142159x.2016.1181851 http://dx.doi.org/10.1111/j.1525-1497.2004.30619.x http://dx.doi.org/10.1080/10401334.2012.719801 https://www.acgme.org/portals/0/pdfs/ab_acgmeglossary.pdf https://www.acgme.org/portals/0/pdfs/ab_acgmeglossary.pdf http://dx.doi.org/10.1186/1472-6920-14-179 48 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. after: 1 2 3 4 5 2.) i can develop a needs assessment for a course in residency. before: 1 2 3 4 5 after: 1 2 3 4 5 3.) i can write overall goals for a residency program. before: 1 2 3 4 5 after: 1 2 3 4 5 4.) i can develop goals and objectives for a rotation or class. before: 1 2 3 4 5 after: 1 2 3 4 5 5.) i can create a block schedule for resident rotations. before: 1 2 3 4 5 after: 1 2 3 4 5 6.) i can give effective feedback to a resident. before: 1 2 3 4 5 after: 1 2 3 4 5 7.) i can give effective summative assessments. before: 1 2 3 4 5 after: 1 2 3 4 5 8.) i value giving feedback to residents. before: 1 2 3 4 5 after: 1 2 3 4 5 9.) i value attending this conference. before: 1 2 3 4 5 after: 1 2 3 4 5 10.) small group discussions with colleagues on the ideal structure of residency training were useful. 1 2 3 4 5 11.) small group discussions on how to implement competencies into our medical education system were helpful. 1 2 3 4 5 12.) small group discussions on how to give feedback will change how i give feedback in the future. 1 2 3 4 5 13.) small group discussions on how to give assessments will change how i use assessments in the future. 1 2 3 4 5 14.) please answer the following questions in english or mongolian:  what part of the conference was most helpful?  were there any negative outcomes of the conference, and if so, what were they?  what could be done differently to make future conferences more useful?  how could the conference be more culturally appropriate?  how could we support you in further development of your residency programs?  what faculty development topic would you like further training on in the future?  how many days in the past have you spent studying similar themes in other training programs or conferences?  approximately what percentage of the material covered in this conference was new to you? appendix b: qualitative data: themes from survey responses 1. what part of the conference was most helpful? a. entire conference b. lectures c. how to write program goals and objectives 2. were there any negative outcomes of the conference, and if so, what were they? a. none b. some parts weren’t advanced enough. 49 kroeker & walling nov 2016. christian journal for global health, 3(2):38-49. 3. what could be done differently to make future conferences more useful? a. more small group study b. utilize a content-knowledgeable translator c. provide more details and examples d. have more administrators attend 4. how could the conference be more culturally appropriate? a. education and practice b. provide continuous education at different levels 5. how could we support you in further development of your residency program? a. curriculum materials/documents/milestones/lectures for the participants b. continued training, some in collaboration with other countries c. research work d. participation of president and others e. our philosophy and goals are different from western countries 6. what faculty development topic would you like further training on in the future? a. topic specific: e.g. family medicine, internal medicine b. education methods for residency programs (with block education mentioned once) c. assessment, evaluation peer reviewed competing interests: none declared. acknowledgments: cari ahlers-schmidt, phd, associate research professor, office of research, university of kansas school of medicine-wichita contributed to the design of the work and was instrumental in the analysis of the data, and matt engel, mph, research associate, university of kansas school of medicine-wichita for data analysis. correspondence: dr. deborah kroeker, university of kansas school of medicine, usa deborah.kroeker@wesleymc.com cite this article as: kroeker da, walling a. outcomes of a faculty development conference in mongolia. christian journal for global health (nov 2016), 3(2):38-48. © kroeker da, walling a. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:deborah.kroeker@wesleymc.com http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ original article identification of current best practices for short-term medical mission trips and adherence to current common principles and guidelines susan andrewsa a dnp, rn, cpn, cne, assistant professor of nursing, vanderbilt school of nursing, nashville, tn, usa abstract background: recent reviews of published guidelines for conducting short-term medical missions (stmm) identify significant concerns about the lack of adherence and of formal regulations concurrent with the increasing number of individuals and organizations participating in stmm. method: a descriptive survey methodology was used. a 44-item survey that identifies current practices utilized by healthcare providers (hcp) who have participated in stmm was used based on the literature and prior research, and distributed electronically to hcp participating in stmm to identify current best practices and compare findings with the most recent recommendations for short-term global health activities. a focus on current operational practices was surveyed and analyzed to develop operational recommendations for the ethical and safe care provided during stmm. results: eighty-seven surveys were included in the final analysis with 33% (n=29) serving as coordinators for the trip. the majority of the respondents were female (67%), and the primary roles represented were: md (n=17; 20%), nurse practitioner (n=20; 23%), and registered nurse (n=18; 21%). a majority (n=48; 67%) traveled to south america or latin america with 38% (n=33) having participated in four or more stmm. language proficiency was reported as deficient (n=35; 40%) along with little or no knowledge of the basic culture (n=39; 45%). additional data were collected on trip preparation, clinic operations, and outcomes follow up. conclusions: using a convenience sample, the results of the survey provide information on the current practices utilized by hcp who have participated in stmm and compare the findings to assess for adherence with the most recent recommendations for shortterm global health activities. there was variation in the degree to which hcps were knowledgeable about specific aspects related to knowledge of local culture, language proficiency, and adherence to recommended practices for stmm. additional research on stmm is needed, along with further exploration of how evidence-based practices for stmm can be implemented to improve access and safety to the care provided while in the host country. 68 andrews key words: short-term medical missions, guidelines, best practices, global health, medical mission introduction over the past decade there has been an increased focus and participation in short-term medical mission trips (stmm). approximately 6000 trips are taken each year by interdisciplinary teams comprised of medical and non-medical volunteer participants to provide medical care in low-income countries.1 the term "short-term medical mission" was developed to identify travel by healthcare providers (hcp) for less than two weeks to underserved areas to provide medical services.² healthcare team members may face language and cultural barriers, difficult environmental conditions, and may often lack the appropriate resources to provide quality care. resources such as access to medical records, lab facilities, and referral services for follow-up care are often suboptimal or nonexistent. these barriers may affect the long-term sustainability of medical services within the community and may have negative effects on the overall host healthcare system.1 a systematic literature review identified limited standardized formal guidelines for regulation, credentialing, or procedures for coordinating stmm. improved data collection and reporting and quality improvement could improve the process for organizations supporting missions. due to the altruistic nature and volunteerism equated with stmm there remains a lack of regulations and reporting of outcomes. without data to substantiate the services provided by these volunteer groups, implementing standards and improvement processes is challenging. this finding is supported in the literature; several authors identify a lack of practice recommendations for stmm.2-4 guidelines established by the working group on ethics guidelines for global health (weight) focus on trainees sent to work in global health and are not specific to stmm. additionally, guidelines and reported outcomes for surgical missions are more prevalent in the literature than global standards for stmm.4 published systematic reviews on stmm are primarily descriptive and emphasize monitoring and evaluation of outcome data as best practice for organizations to evaluate the services provided.3,5 an integrative systematic review of the literature revealed a lack of evidence in the literature that supports the use of practice guidelines that have been evaluated for stmm occurring outside of the united states (us).6 the short time frame of the stmm with a primary focus on the provision of care is seen as a barrier to the lack of structure, outcome measurement, and guideline adherence. it has been identified that lack of clear definitions and standards can affect the coordination of sttm and may even harm the host community and perpetuate global health inequities.7 current published guidelines and core principles the world health organization (who) has numerous evidence-based guidelines developed in collaboration with us-based faith based organizations (fbos) to provide quality care in the current dynamic global healthcare environment. the best practices for global health missions (bpghm) and international standards and guidelines (is&g), based on the who standards, are readily available to provide practice standards to meet the legal requirements, medical standards, and practice guidelines from the varying host countries.8 one of the most important publications to date that gave insight to current practices and guidelines for stmm was a study conducted by catholic health association (cha). 9 the survey with over 500 respondents provided data to identify current practices of participants in effective stmm and provide the basis for the development of recommendations for practice. these recommendations focused on the areas of partnerships, funding, orientation and selection of volunteers, volunteer activities, evaluation, and sustainability.9 the most recent published evidence 69 andrews was a mixed methods study that revealed similarities and differences between the preferences of the organizers and host communities relevant to length of the trip and selection and preparation of volunteers. the data from this study which combined three surveys and four interviews from 2012 to 2015 were used to revise the cha recommendations and create the guiding principles for international health work.10 despite current research focused on identifying current practices of stmm organizers and preferences of the host communities to add to the current literature and provide recommendations for groups participating in stmm, gaps are present and adherence to these recommendations are still lacking. countries are in various stages of adopting and enforcing the published is&g.8 current published guidelines for stmm practice primarily address the establishment of a system for planning and organizing teams for travel. the recruitment and orientation of volunteers, collaborative relationships with host community, and outcome reporting are outlined to provide recommendations or core principles for guidance of ethical and sustainable mission practice.7,11,12 however, insufficient evidence remains on the implementation and adherence to these recently published guidelines, as well as recommendations for operational best practices on these humanitarian and faith-based stmm. with an increasing number of medical and non-medical providers participating in stmm, a focus on current practices for caring for patients in medical clinics during these short-term humanitarian trips is warranted. a review of the literature revealed little evidence in best practices or on adherence to recently published recommendations that would provide vulnerable communities access to quality, sustainable, and culturally sensitive care. this paper reports the results of a descriptive survey that identified current practices utilized by hcps who have participated in stmm and compared the findings with the most recent recommendations for short-term global health activities. current operational practices of the hcp surveyed will be reported to add to the growing body of evidence and recommendations developed for more ethical and safer care provided during stmm. methods and materials a comprehensive review of the literature, an environmental assessment, and key informant interviews of providers who participate in a stmm using a convenience sample were used to identify the problems with current practice and survey development. using an electronic survey reporting system, completed data were collected and analyzed for demographics, description of current practices, and comparisons to current published recommendations. survey instrument a study survey was compiled based on a comprehensive review of the literature and published results from previous surveys to gather data related to current best practices of stmm.9,11,12 the survey consisted of 44 questions that were organized into four different themes: demographics, preparation, operations, and outcome measurements. demographic data on gender, age, education level, primary role, type and number of trips, and continent traveled to were collected. the type of care provided was assessed to include medical, preventive health, dental, eyeglasses, or other. assessing whether or not the participant was the coordinator of the trip was obtained. this information was deemed important when looking at data collected on needs assessment, orientation, and outcomes measurement. preparation was assessed by asking respondents specifics to the receipt, type, and length of an orientation. open-ended responses were allowed for participants to describe what information was provided in the information sessions. participants’ knowledge of the language and culture, as well as use of interpreters including local interpreters were collected. additional ethical and legal considerations were addressed in the preparation section through questions related to the registration of healthcare providers with the host 70 andrews country’s ministry of health (moh) or equivalent, establishment of a memorandum of understanding (mou), completion of a needs assessment or site survey, and inclusion of local providers in the planning and provision of care. the collection of data on current practices of clinic operations were the focus of the survey. the analysis of operations data will provide the basis for recommendations for future practice and to fill the gaps in the current guidelines. recruitment of participants and survey distribution hcp and coordinators of organizations based in the southeastern us who were known to participate in stmm through personal or professional affiliation were contacted for study participation. additionally, an internet search was conducted and emails sent to organizations who participated in stmm. the assessment survey was distributed electronically to a convenience sample of hcp who met the criteria for the identified sample population. inclusion criteria included 1) licensed health care provider, 2) participation in at least one previous medical mission trip of two weeks duration or less, and 3) english as the primary language. disaster and relief missions, military, and government sponsored medical missions were excluded. because the focus of the study was on medical missions, research and data collected on surgical missions were excluded from the data analysis. participation in the survey was voluntary and anonymous. a response rate is unable to be calculated as it is not known how many participants received the email invitation for the study. no compensation was provided to participants and institutional review board approval was obtained from samford university. data analysis one hundred and sixteen surveys were collected and 87 were selected for analysis. surveys were excluded if they did not meet the inclusion criteria or were less than 50% complete. surveys meeting the inclusion criteria were collected and analyzed for demographic data of key stakeholders and identification of current practices of the hcp surveyed. the current practices identified were compared to the most current published recommendations and core principles for ethical, responsible, and safe stmm. additional data collected related to clinic operations and the more technical aspects of the clinical services provided during stmm were evaluated to begin to establish core operational recommendations for clinic practices. results demographics approximately two-thirds of the respondents were female (n=55; 68%), and almost half of the respondents reported their role in the stmm as that of hcp (providing medical diagnosis and treatment). other roles included religious advisor, emergency medical technician, optometry, clinic administrator, and pharmacy student. a majority of the participants had a master’s degree or above (n=60; 69%) followed by a bachelor’s degree (n=18; 21%), associate’s degree (n=4; 5%), and a high school diploma (n=5; 6%). the majority participated in a faith-based trip (n=73; 84%), and 54% (n=47) reported self-pay for funding their travel. additional demographics are located in table 1. 71 andrews table 1. demographics (n=87) n n(%) gender 81 male 26 (32.1) female 55 (67.9) age (years) 86 20 – 30 21 (24.4) 31 – 40 12 (14.0) 41 – 50 16 (18.6) 51 – 60 22 (25.6) >60 15 (17.4) education 87 high school diploma 5 (5.7) college – associate’s degree 4 (4.6) college – bachelor’s degree 18 (20.7) master’s degree or above 60 (69.0) type of mission trip 87 faith based 73 (83.9) humanitarian 14 (16.1) primary role 87 physician 17 (19.5) nurse practitioner 20 (23.0) physician’s assistant 2 (2.3) pharmacist 10 (11.5) nurse 18 (20.7) other 20 (23.0) short-term medical mission trips past five years 86 1 27 (31.4) 2 18 (20.9) 3 8 (9.3) 4 or more 33 (38.4) continent (most recent trip) 87 africa 13 (14.9) south america 32 (36.8) central america 26 (29.9) other 16 (18.4) type of care provided medical 87 81 (93.1) community/preventive health 87 38 (43.7) dental 87 29 (33.3) eyeglasses 87 53 (60.9) other 87 8 (9.2) funding 87 fully funded by sending organization 9 (10.3) partially funded and self-pay 28 (32.2) self-pay 47 (54.0) other 3 (3.4) trip coordinator or supervisor 86 no 57 (66.3) yes 29 (33.7) preparation the trip preparation assessment included orientation, knowledge of local culture, language proficiency, as well as pre-trip planning and registration of hcp (see table 2). receiving orientation prior to the trip was reported by 86% (n=72) of the respondents with the median number of training sessions as three. overall, 46% (n=40) of the hcp reported a basic fluency in the local language, however language proficiency was relatively deficient as 40% (n=35) did not speak or understand the language, followed by conversational (n=10; 12%) and proficient (n=2; 2%). over fortyfive percent (n=39) reported knowing little or 72 andrews nothing about the culture. local interpreters were used (n=81; 93%) and each hcp had an interpreter (n=70; 81%) a majority of the time. it was reported that local providers were involved in the planning and provision of care 80% of the time. a majority reported they did not know if the group completed a memorandum of understanding (mou) (n= 60; 70%), and less than 26% (n=22) reported to have a mou with the host country. less than 22% (n=19) reported hcps were registered with the ministry of health (moh). although 41% (n=35) of the hcps reported a needs assessment was conducted prior to the stmm, of concern was 45% (n= 39) of the respondents did not know if a needs assessment was completed prior to travel. the authors hypothesized that those serving as a trip coordinator (n= 29; 34%) were more likely to have knowledge of the completion of these preparations. however, the survey identified that 19 (66%) trip coordinators were not aware of the completion of a mou and 10 (34%) did not know if the participants were registered with the moh. additionally, 12 trip coordinators (41%) did not know if a needs assessment was conducted prior to the trip. table 2. preparation* (n=87). n n(%) orientation or training prior to trip 84 no 12 (14.3) yes 72 (85.7) median [iqr] # of training sessions 72 3.0 [1-4] fluency in local language 87 basic 40 (46.0) conversational 10 (11.5) proficient 2 (2.3) did not speak or understand the language 35 (40.2) did each healthcare provider have an interpreter? 87 no 16 (18.4) yes 70 (80.5) don’t know 1 (1.1) were local interpreters used? 87 no 4 (4.6) yes 81 (93.1) don’t know 2 (2.3) knowledge of local culture 86 knew nothing about the culture 13 (15.1) knew little about the culture 26 (30.2) average knowledge 24 (27.9) very comfortable 23 (26.7) # of healthcare providers on trip 87 <5 32 (36.8) 6 10 32 (36.8) >10 23 (26.4) needs assessment or site survey completed prior to travel 86 no 12 (14.0) yes 35 (40.7) don’t know 39 (45.3) local providers included in the planning and provision of care 87 no 10 (11.5) yes 70 (80.5) don’t know 7 (8.0) organization had memorandum of understanding with host country 86 no 4 (4.7) yes 22 (25.6) don’t know 60 (69.8) 73 andrews all short-term medical mission trip licensed healthcare providers registered with the ministry of health in the host country (or equivalent) prior to travel to the host country 87 no 19 (21.8) yes 19 (21.8) don’t know 49 (56.3) * all respondents reported use of interpreters on mission trip. clinic operations clinic operations were assessed to identify common practices among varying mission teams and results are detailed in table 3. forty-five percent (n=39) reported that patients were recruited by word of mouth with 61% (n=53) of the clinics being held in a church building or school. less than 22% (n=19) provided care in an existing clinic or hospital. a majority of the patients (n=78; 90%) were required to register prior to seeing a provider and 57% (n=48) of those patients were triaged during registration to determine the level of care needed. on average, it took zero to ten minutes (n=72; 85%) to register a patient using a standardized paper form (n=57; 66%). blood pressure was taken in 87% (n=69) of the stmm and other vital signs or medical information were documented such as height, weight, temperature, respirations, heart rate, blood pressure, and allergies greater than 50% of the time. forty percent stored the collected data and paper files were the most common method utilized (54%). a majority of the clinics lasted an average of five days with up to 1000 patients seen during that time. the respondents reported that 50% of the time was spent in patient care activities with 50% of that in curative treatment and only 20% in preventive care and education. table 3. clinical operations n n (%) patient recruitment 87 word of mouth 39 (44.8) local advertisements/flyers 10 (11.5) local representative 29 (33.3) other 9 (10.3) location of clinic 87 existing health clinic or hospital 19 (21.8) school 36 (41.4) vacant building 28 (32.2) church 53 (60.9) other 15 (17.2) were the patients required to register prior to seeing a provider? 87 no 5 (5.7) yes 78 (89.7) don’t know 4 (4.6) during registration was the level of care (triage or prescreening) needed by each patient determined? 84 no 15 (17.9) yes 48 (57.1) don’t know 21 (25.0) on average how long did it take to register a patient? 85 0 5 minutes 57 (67.1) 6 10 minutes 15 (17.6) 10 15 minutes 6 (7.1) not applicable 7 (8.2) did you use a standard form or protocol for screening patients? 86 no 12 (14.0) yes 57 (66.3) don’t know 17 (19.8) information collected from patients seen at the clinic 79 74 andrews height 32 (40.5) weight 41 (51.9) temperature 52 (65.8) blood pressure 69 (87.3) respirations 37 (46.8) heart rate 56 (70.9) allergies 53 (67.1) other 13 (16.5) did you collect and store demographic data? 86 no 22 (25.6) yes 35 (40.7) don’t know 29 (33.7) how was patient data stored? 82 paper/file 44 (53.7) computer 2 (2.4) not stored 14 (17.1) don’t know 22 (26.8) average # of patients seen per day 85 <50 7 (8.2) 51 150 40 (47.1) 151 200 15 (17.6) 201 300 14 (16.5) >300 9 (10.6) average # of patients seen over course of trip 84 <250 14 (16.7) 251 500 23 (27.4) 501 750 16 (19.0) 750 1000 15 (17.9) >1000 16 (19.0) did you provide meds to patients during the medical mission trip? 84 no 6 (7.1) yes 77 (91.7) don’t know 1 (1.2) how are medications procured for the trip? 83 brought to host country 34 (41.0) purchased in host country 9 (10.8) both 36 (43.4) don’t know 4 (4.8) what were the most common medications provided? 82 antibiotics 69 (84.1) contraceptives 7 (8.5) multivitamins 69 (84.1) anti-parasitics 55 (67.1) analgesics 64 (78.0) topical creams and lotions 50 (61.0) other 10 (12.2) median [iqr] # of days medical clinic ran 84 5.0 [4-5] % of time spent on activities during the mission patient care 79 50.0 [40-70] patient health education 72 10.0 [5-14] team building 77 15.0 [10-20] religious activities in the community or clinic 72 10.0 [5-20] other 37 15.0 [0-30] % of time spent in areas during clinic curative medicine 80 60.0 [35-80] preventive health 73 20 [10-40] spiritual counseling 65 10.0 [5-30] other 23 10.0 [0-40] 75 andrews medications ninety-two percent (n=77) of the respondents surveyed provided medications during the trip. when questioned about procurement, 41% (n= 34) brought medications into the country, and only 11% (n= 9) purchased in the host country. the most common medications provided included antibiotics (n=69; 84%) and multivitamins (n=69; 84%). respondents also indicated additional medications provided including analgesics (n=64; 78%), anti-parasitics (n=55; 67%), and topical creams and lotions (n=50; 61%). outcomes measurement to determine whether organizations were focused on outcomes measurement, several questions were asked related to post stmm questionnaires for both the participants and host communities (see table 4). forty-two percent (n=35) reported that hcps who participated in the survey were asked to complete a post mission questionnaire to determine the impact/satisfaction of the trip participant. an additional 23% (n=19) did not know if they were requested to complete a questionnaire. thirty-seven percent (n=31) denied the host community completed a post mission questionnaire, and 35% of the trip coordinators (n=10) reported they were not aware of a host post trip questionnaire to evaluate the impact of the stmm. table 4. outcome measures n n (%) healthcare providers who participated in the short-term medical mission trip asked to complete a post mission questionnaire for determining the impact and/or satisfaction of the individual participating in the trip 84 no 35 (41.7) yes 30 (35.7) don’t know 19 (22.6) host community completed a post mission questionnaire to evaluate the impact of the medical mission 84 no 31 (36.9) yes 9 (10.7) don’t know 44 (52.4) discussion the responses from the study add information to the characteristics of stmm found currently in the literature. as participation in stmm continues to grow, it is imperative for stmm to be held to a standard of care to do good and prevent harm to the community they serve. the recent publication of effective practices and guidelines for culturally sensitive, safe, and sustainable medical care is the first step in providing evidence organizations can utilize to develop their models of care to improve outcomes and sustainability of their programs.11 however, a gap in the literature was identified in the area of clinic operations as previous studies primarily focused on the selection of and preparation for teams to travel on stmm. lasker et al. (2018) emphasized, in a review of existing guidelines, a need to focus on general guidelines for safe and ethical care and to translate these guidelines into “action” in order to improve the quality of stmm. the findings from this study were compared to the published guidelines to determine adherence. trip participants these demographic statistics are consistent with the published research findings. there are a large number of people who are seeking to travel on stmm and willing to use personal financial resources to fund the trip. the cha study 76 andrews reviewed reported over one-fourth of those surveyed had been on one trip, and 44% had gone on four or more trips in the past five years.9 the type of trip, religious motivation, and educational preparation of the respondents were most likely influenced by the researchers’ professional affiliations with a private christian university. lack of preparation a majority of the respondents reported the stmm sponsor organization offered an orientation, however, there was great variability in the type, length, and content provided. only 2% of respondents (n=2) reported language proficiency. previous studies identified the hosts’ desire for volunteer preparation to include a stronger focus on knowledge of culture, language, and environmental conditions of the host country.12-14 the results of this study support the assumption that adherence to orientation guidelines are not being met. it is recommended that organizations focus on providing volunteers with face-to-face training, preferably with host orientation facilitators with content focused on language, culture, local customs, and practices (including dress and behavior), and environmental conditions.10,11 implementation of standardized orientation for volunteers regardless of experience, though challenging, should also include information on the religious and political climate and principles of community development.1,2 lough et al. (2018) concluded that organizations participating in stmm can establish better partnerships, and the care delivered is perceived as more effective when the participants are well prepared and care is evidence-based.14 another key component identified in the guidelines addresses the involvement of local host partners in the needs identification and planning of the care provided on the stmm.11-14 the pre-trip planning activities rely on establishing a relationship and maintaining contact with the host community partner to plan, recruit patients, and operate the clinic on-site. these activities are best accomplished through a site survey with the completion of a needs-assessment followed by the development of mission objectives.15 the survey identified a lack of adherence by trip coordinators to complete a needs-assessment and establish a mou as part of the pre-trip planning activities. best practice supports the need to involve the local community in the planning phase and have a mou that clearly outlines the services to be provided, delineates the roles and expectations as well as establishes a mutual understanding of a partnership between the host community and mission organization.9,11-16 the results of this study identify that those serving in a coordinating role were more knowledgeable about the registration of the hcps with the moh yet a large percentage of the hcps still reported that they did not know if they were registered. providers have an ethical responsibility to provide care within their scope of practice. the laws of the host country should also be obeyed which may include registering with the country’s moh or equivalent. this information should be included and completed as part of the providers’ trip orientation. the lack of knowledge by trip coordinators and providers in these areas could have significant ethical and safety implications. outcomes measurement the who organization recommends a systems-thinking approach as a core principle to plan and evaluate interventions to maximize the health of the global community. a systems approach involves collaboration with the host community in the pre-trip planning as well as appropriate follow up for quality improvement.16 a strong systems approach is imperative to provide safe, effective, quality care.16 it is interesting to note that only approximately onethird of the respondents were asked to complete a post trip evaluation. stmm coordinators and trip planners cannot adequately address issues, 77 andrews concerns, or problems if trip participants are not given the opportunity to voice their experiences. multiple outcomes should be measured that go beyond the number of patients seen and the number of prescriptions dispensed. stmm participants and host country partners should discuss what went well and what needs to improve at each clinic site. input from host partners is valuable because they know the population being served and what is appropriate in the culture. we need to be respectful of other hcps in the host country and involve them as much as possible and appropriate the goals and purposes of the stmm sending organization.11,13,14,16-17 the key to building sustainable and collaborative relationships with the host countries requires a shift in focus on participant experiences to assessment of the host community outcomes and experiences to encourage improving the identification and quality of needed services. clinic operations recommendations an analysis of the survey data was used to make recommendations on clinical operational practices for stmm (see table 5). specific data on clinic operations help to close the gap on guidelines for the “boots on the ground” work the mission organizations provide in the host country. commonalities exist between a stmm medical clinic and the operation of a free medical clinic in the us. according to the legal and operational guide for free medical clinics, free medical clinics provide a variety of primary care medical services to low income residents in an underserved area. these clinics staffed by volunteers provide care for minor medical problems, some pharmacy, dental services, and referrals for emergency and more medically complex problems.18 free medical clinics in the us have the advantage of sustainability of services for follow-up and legal safeguards in place for pharmacovigilance that are not consistently evident in stmm. table 5. recommendations for clinical operations for stmm • a standardized orientation providing volunteers with face to face training, preferably with host orientation facilitators with content focused on language, culture, local customs and practices (including dress and behavior), religious and political climate • hcps should be registered with the moh or equivalent and should only provide care within their scope of practice • involve local health care practitioners (hcp) as partners to the team who would be willing to provide trip planning, onsite operations, and continuity of care to foster communication and sustainability • a medical director should be appointed who is responsible for the oversight of the health services provided during the stmm • patient intake utilizing a standardized form is essential to obtain the information needed for safe, effective, and equitable care • local interpreters should be used for patient intake, triage, and with hcp for establishing trust and obtaining accurate health history information • standards for minimal demographics and health data, including allergies should be developed • organizations participating in stmm should adhere to the who published guidelines for medicine donations which state there should be no double standard in quality • the establishment of a portable medical record to provide for safety, sustainability, and continuity of care • maximize time and resources by addressing the needs of the community’s most vulnerable populations by shifting care to focus on health promotion and disease prevention (hp&p) rather than drug based curative care clinic operational data collected revealed common practices in the recruitment of patients (word of mouth), clinic location (existing structure like a church or school), and the registration of patients using a standardized form. prior to the trip, input for the local partners should be obtained as to the type of services provided, location for the clinic and the recruitment of patients. guidelines exist for international medical teams responding to disasters that provide the minimal standards of 78 andrews care for initial assessment, triage, and pharmacy services.18 the who (2013) states a field hospital can be set up in an existing or temporary structure during emergency humanitarian relief operations.19 these evidence-based recommendations may serve as a starting point for stmm. providing care in a non-health care setting without adherence to standards may lead to system failures that can cause harm to the patients and communities served.16 though not always feasible in the stmm setting, every effort should be made to provide care in an established clinic or healthcare facility. additionally, a medical director should be appointed who is responsible for the oversight of the health services provided during the stmm and serve as a resource responsible for the supervision of the clinic hcp and staff.18,20 information collection and storage patient intake utilizing a standardized form is essential to obtain the information needed for safe, effective, and equitable care. the form must be clear and concise. the challenge is determining how much data is needed and if the information provided is accurate and dependable.18 cultural and language barriers are the biggest obstacles to establishing trust and obtaining reliable information. for these reasons, host providers and local interpreters should play a key role in clinic operations. questions to obtain personal and confidential healthcare information should be asked as they appear on the form in an objective, unbiased, and respectful manner. using local interpreters or community representatives to assist patients to complete intake forms may be helpful in this process. local interpreters should be used to facilitate communication with individuals who have limited language proficiency and each hcp should be assigned an interpreter. health data and medication management most respondents reported collecting general patient demographics and vital signs; however, of concern was that with 92% reporting the distribution of medications, less than half assessed allergy status on the patients seen. the institute for healthcare improvement (ihi) recommends that allergy information be collected at the time of admission to the healthcare setting, recorded immediately, and made available in multiple locations to anyone who may order or administer medications.21 standards for demographics and health data, including allergies, should be developed. based on the survey results, the authors recommend the name, date of birth, allergies, weight, temperature, heart rate, respiratory rate, and blood pressure should be assessed and documented on every patient. understanding individual patient factors, including knowledge of allergies, are imperative for providing treatment and safely prescribing medications. the survey reported a low adherence to the storage of medical records with approximately half utilizing a paper form. it is most useful to establish the portable medical record and electronic database as these would provide for a safer and more efficient process. in communities with internet capability and resources to maintain internet service, utilizing electronic databases would be an ideal method for documenting patient information and health service encounters as well as for providing continuity of care. a systematic review of the literature revealed limited availability of electronic systems for medical data collection on stmm.21,22 several systems have mobile capabilities; however, the interoperability in low resource settings is challenging. increased use of smartphones internationally provides future opportunity for use of applications such as quickchart, notesfirst, and ichart. accurate data collection and storage would provide much needed data for increased accountability, outcomes measurement and provide evidence for future quality improvement in stmm.22 the procurement, management, and distribution of medications in resource-limited 79 andrews settings has significant ethical and safety implications. the risk of adverse drug events even in the most ideal conditions with safeguards in place has gained national attention. the stmm setting places a patient at a much greater risk for a medication error due to a multitude of factors, including time constraints, lack of patient health information, deficient or absent testing capabilities, and cultural and language barriers.24,25 free clinics in the us who receive drug donations must follow explicit federal and state guidelines, reporting, record keeping, registration, and licensure requirements.18 organizations participating in stmm should adhere to the world health organization’s (who) published guidelines for medicine donations which state there should be no double standard in quality.24 there has been increased attention on the harm from drugs provided during stmm and strong recommendations that drug based care not be provided until appropriate pharmacovigilance and patient safety systems are established.25 yet, 92% of hcp surveyed reported the provision of medications during the stmm. this lack of adherence to established guidelines is alarming. international practice standards and guidelines as well as local laws of the host community should be adhered to if drugs are going to be distributed to a community.24-25 pharmacies should be staffed with consistent well-trained staff and interpreters.14,25 establishing a formulary of essential medicines is a critical component of preparation for a medical mission. the formulary should be evidence-based and developed with regard to disease prevalence, efficacy, antibiotic resistance, safety, and cost-effectiveness.23 in accordance to the who guidelines, all medications should be properly labeled, using international non-proprietary name (inn) or generic name, batch number, dosage form, strength, name of manufacturer, quantity, storage instructions, and expiration date.24 providers should consider the use of a pictogram to prevent administration errors.23 future research is warranted on the dangers of drug based stmm on the patients they serve, the lack of compliance with the who guidelines for medical donations, and the justification for providing non emergent pharmacy services during stmm.24,25 care considerations it is difficult for hcps participating in stmm to effectively medically manage patients with acute and chronic conditions without appropriate infrastructure, reliable communication with host partners and referral networks within the host country. treating common bacterial infections requires minimum laboratory capabilities to properly diagnose for effective treatment. a typical occurrence is that patients request treatment for conditions they are not currently experiencing to obtain access to medications and this poses a dilemma for hcps and host partners. the reporting of non-existent chief complaints has been observed in the researcher’s experience in stmm. despite these challenges the hcps surveyed reported 50% of their time was spent on curative care and only 20% on preventive health education. an approach that might support the goal of helping people obtain optimum health is to shift the effort from curative care to health promotion and disease prevention (hp&p) activities. redesigning the clinic services with a focus on hp&p rather than curative medicine to address the community’s priorities can foster sustainable safe and ethical care.12,26 groups can maximize time and resources by addressing the needs of the community’s most vulnerable populations by shifting away from curative services.7,11-13,26,27 a focus on preventive health education and training for ongoing health education programs that are sustainable after the mission teams have left could better benefit the communities they wish to serve. study limitations there are several limitations to the study. the convenience sample of participants primarily came from faith-based organizations as reflected 80 andrews in the type of trip participated demographic. with the surge in for-profit stmm making travel more accessible to hcp and competing with faith-based trips, future research is warranted to compare the impact of the different groups. the online survey format relied on participant self-report or recall of the stmm and is not representative of an actual practice audit. data were not collected to reflect the amount of time that had passed since the participant had participated in the stmm. the study response rate is not able to be calculated and is another study limitation. the researcher reviewed all the raw data and eliminated all respondents that did not meet inclusion criteria prior to statistical analysis; however, this does not guarantee all responses were from non-surgical providers. additionally, the questions specific to clinic operations related to tasks and procedures unique to medical clinics, not surgical care. conclusion this study identified variation in the degree to which stmm trips incorporated recommended best practices related to preparation, pre-trip needs assessment, onsite management of care including medication administration, documentation of data obtained during the visit, and post-visit surveys from participating hcps. in comparing hcps to those who served to coordinate the stmm, it was found that trip coordinators were more knowledgeable about the registration of hcps with the moh. however, a lack of knowledge regarding host partner involvement in planning and the completion of a needs assessment in trip preparation were identified as areas needing improvement for all participants in stmm. additionally, a majority of hcps were unaware of their own registration with the host country moh, a legal and ethical responsibility. the collection of clinical operations data provided common practices and areas needing improvement to fill the gaps in the preparation, operation and outcome evaluation of stmm. implications for future research and practice adherence to guidelines for drug-based stmm needs to be addressed. a shift from curative care towards a more holistic hp&p approach could address many of the systemic problems and fragmentation in care. the standardization of these processes and additional operational practices could contribute to improved outcome measurement and enhanced sustainability to improve access to safe and effective care during stmm. additional research is 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https://www.healthlawyers.org/hlresources/pi/doc uments/legal_and_operational_guide_for_free_ medical_clinics.pdf 19. world health organization. classification and minimum standards for foreign medical teams in sudden disasters [internet]. geneva: who; 2013. available from: www.who.int/hac/global_helath_cluster/ 20. suchdev p, ahrens k, click e, macklin l, evangelista d, graham e. a model for sustainable short-term international medical trips. ambul pediatr. 2007;7(4):317-20. https://doi.org/10.1016/j.ambp.2007.04.003 21. institute for healthcare improvement. improve core processes for administering medications [internet]. boston, ma: 2019. available from: http://www.ihi.org/resources/pages/changes/impro vecoreprocessesforadministeringmedications.asp x 22. dainton c, chu ch. a review of electronic medical record keeping on medical mobile trips in austere settings. int j med inform. 2017;98:33-40. https://doi.org/10.1016/j.ijmedinf.2016.11.008 23. werremeyer ab, skoy et. a medical mission to guatemala as an advanced pharmacy practice experience. amer j of pharm ed. 2012;76(8)(article 156):1-6. available from: https://www.ajpe.org/doi/abs/10.5688/ajpe768156 24. world health organization. guidelines for medical donations [internet]. geneva: who; 2011. available from: http://www.who.int/medicines/publications/med_d onationsguide2011/en/index.html 25. gorske a. harm from drugs in short term missions: a review of the medical literature. best practices in https://doi.org/10.1111/tmi.12675 https://doi.org/10.1097/acm.0000000000001009 https://www.bpghm.org/wp-content/uploads/2017/05/isgsandhealthmissions.pdf https://www.bpghm.org/wp-content/uploads/2017/05/isgsandhealthmissions.pdf https://www.bpghm.org/wp-content/uploads/2017/05/isgsandhealthmissions.pdf https://www.chausa.org/docs/default-source/international-outreach/short-term-medical-mission.pdf?sfvrsn=0 https://www.chausa.org/docs/default-source/international-outreach/short-term-medical-mission.pdf?sfvrsn=0 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http://www.ihi.org/resources/pages/changes/improvecoreprocessesforadministeringmedications.aspx http://www.ihi.org/resources/pages/changes/improvecoreprocessesforadministeringmedications.aspx https://doi.org/10.1016/j.ijmedinf.2016.11.008 https://www.ajpe.org/doi/abs/10.5688/ajpe768156 http://www.who.int/medicines/publications/med_donationsguide2011/en/index.html http://www.who.int/medicines/publications/med_donationsguide2011/en/index.html 82 andrews global health missions. november 2016. available from: https://www.bpghm.org/wpcontent/uploads/2017/07/harmfromdrugsinstm.p df 26. hawkins j. potential pitfalls of short term medical missions [internet]. j christ nurs. 2013;30(4):e16. available from: https://nursing.ceconnection.com/ovidfiles/000052 17-201312000-00023.pdf 27. bajkiewicz c. evaluating short-term missions: how can we improve? j christ nurs. 2009;26(2):110-4. http://dx.doi.org/10.1097/01.cnj.0000348272.27924 .24 peer reviewed: submitted 17 jan 2020, accepted 1 april 2020, published 23 june 2020 competing interests: none declared. correspondence: susan andrews, nashville, tn, usa. susan.p.andrews@vanderbilt.edu cite this article as: andrews s. identification of current best practices for short-term medical mission trips and adherence to current common principles and guidelines. christian j global health. june 2020; 7(2):67-82. https://doi.org/10.15566/cjgh.v7i2.341 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://www.bpghm.org/wp-content/uploads/2017/07/harmfromdrugsinstm.pdf https://www.bpghm.org/wp-content/uploads/2017/07/harmfromdrugsinstm.pdf https://www.bpghm.org/wp-content/uploads/2017/07/harmfromdrugsinstm.pdf https://nursing.ceconnection.com/ovidfiles/00005217-201312000-00023.pdf https://nursing.ceconnection.com/ovidfiles/00005217-201312000-00023.pdf http://dx.doi.org/10.1097/01.cnj.0000348272.27924.24 http://dx.doi.org/10.1097/01.cnj.0000348272.27924.24 mailto:susan.p.andrews@vanderbilt.edu https://doi.org/10.15566/cjgh.v7i2.341 http://creativecommons.org/licenses/by/4.0/ short communication june 2020. christian journal for global health 7(2) historical note: a missiologist’s view of medical missions from 1978 paul j hudsona a md, mph, facp, health consultant, sim international, charlotte, nc, usa in 1978, who’s alma ata declaration was a major milestone for public health and primary health care, heavily influenced by the work of christians arising from the tubingen consultation on the healing church 1 a decade earlier. while the emphasis on primary health care has been a healthy trend among christian missions over the past 40 years, it has left some hospitals and medical missionaries unclear about their role. what has been lacking is a robust theology of medical missions that embraces both hospital care and primary health care as integral ministries in our service for the king. missiologist professor j. verkuyl, from amsterdam, wrote contemporary missiology, an introduction 2 in 1978, the same year as alma ata. his chapter on the “ways and means” of mission contains six pages on “social-medical diaconia” and offered wisdom in creating such a theology of medical missions. although we are living more than four decades later, there is much to still gain from his perspective. he wrote in 1978, “gone is the time when missions had a virtual monopoly on hospitals on the mission field.” he urged that mission agencies stop “. . . pretending that they are still in the pioneer stage when medical help was their virtually exclusive domain.” with advanced medical education an integral part of public universities, he encouraged us to create new models of public private partnership in order to influence entire nations. he then said, “but in many areas government is devoting all of its resources and personnel to curative medicine and neglecting the preventive aspect. why should a christian agency not take up the slack?” he wanted us to be flexible “ . . . so that love can find those neglected areas and begin to tackle the problems.” he specifically mentioned maternal and childcare, rehabilitation work, and gerontology, giving “. . . priority to programs and projects which allow us to address persons in the totality of their existence,” since healing is but part of christ’s total program of salvation. he reminded us that our concern, like that of our lord, should put care for the poor at the center of our efforts. as to how to accomplish these noble goals, he exhorted us to explain what we are doing “. . . in the framework of god, man, the cosmos, sin, sickness, life, and death. “to perform this service, close teamwork between medical doctors, cultural anthropologists, and theologians is of utmost importance.” he could hardly have been more prophetic. he reminded us that “. . . we are not doing very much hard thinking in what is today called medical “macro-ethics.” we, today, are in a better position to study how medical help is distributed over the globe, and the statistics show it: the division is lopsided and unjust.” and finally, he asked us to consider the tubingen consultation of 1964, which published the healing church. he wrote, “the very title is a plea for a ‘comprehensive understanding of the church’s concern with all forms of healing’ and a warning against a fragmented approach to medical care which results from over-specialization. recovery of health and victory over death are not totally separate entities. one could conceivably fail to recover his physical health and yet discover an inner integrity, a unity of life, and authentic human existence which the bible calls “life.” 154 hudson june 2020. christian journal for global health 7(2) the reverse is also possible: one could be delivered from his physical pain and yet continue to be plagued with a much deeper ailment. thus, total care for a patient involves so much more than attending to his physical needs. a patient facing death may need reassurance that the gates of the eternal kingdom are wide open to him.2 it is urgent to continue to build a professor verkuyl’s missiological understanding of our work in christian medical missions to provide a framework for the strategic role of the mission hospital today and to keep a balanced perspective of clinical and preventive care working together synergistically — and with churches around the globe. references 1. the healing church. the tubingen consultation. world council studies. 1965:34–43. available from: https://difaem.de/fileadmin/dokumente/publikatione n/dokumente_aerztliche_mission/tuebingeni_engli sch.pdf 2. verkuyl j, cooper d. contemporary missiology: an introduction. grand rapids, mi: eerdmans; 1978. 212-8. submitted 15 june 2020, accepted 17 june 2020, published 29 june 2020 competing interests: none declared. correspondence: paul hudson, charlotte, nc, usa. paul.hudson@sim.org cite this article as: hudson pj. historical note: a missiologist’s view of medical missions from 1978. christ j for global health. june 2020; 7(2):153-154. https://doi.org/10.15566/cjgh.v7i2.405 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/tuebingeni_englisch.pdf https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/tuebingeni_englisch.pdf https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/tuebingeni_englisch.pdf mailto:paul.hudson@sim.org https://doi.org/10.15566/cjgh.v7i2.405 http://creativecommons.org/licenses/by/4.0/ short communication dec 2019. christian journal for global health 6(2) big picture, small picture, and a conversation with habakkuk and god lois joy armstronga a bsc, mphtm, phd(c) melbourne school of theology, public health consulting and writing healthy words, australia write down the revelation and make it plain on tablets so that whoever reads it may run with it. (habakkuk 2:2, niv) habakkuk, i am so thankful that you wrote down this conversation with god. you wrote it on a tablet of some sort, but today i have your words on paper in a book. others might be reading it on an electronic tablet! over the years, i've returned to this conversation many times, and it speaks to me again and again. you begin with a lament and you end with a song. you and god had discussions about the big picture of the nations, but you also offer me some clues on how to live in my limited time and place when i feel overwhelmed with all the injustice and brokenness i see around me. how many times have i wept with you over injustice? for the women who suffer at childbirth for want of a skilled birth attendant, for lack of companions, for lack of transport, for lack of knowledge. for the girls who are not valued as a gift from god but are, instead, considered a burden, a continuing debt. for young men who get electrocuted or lose a limb in workplace accidents all because their employer does not care about safety, only profit. i, too, have asked god, "how long are you going to put up with this?" i want to see things improve in my own health-related work, but i feel powerless to bring about change, real change. then along come new programs, new systems, and new governance. these are intended to improve the situation, to care for the people. sometimes they help; sometimes they seem to make things worse than the original situation; sometimes the amount of work to implement the changes does not seem commensurate with the improvement in outcomes. then, at other times, what i thought was a profitable project has its funding withdrawn, and i cry out, "god, what are you doing?" then, habakkuk, i remember your cry, "what? you are going to send the babylonians?" so, i wonder, "god, if you can use the babylonians to bring about your purposes, maybe you can use these changing circumstances and limited programs well? the powerful people instituting these programs don't seem to know you, sometimes they even don't seem to like your people, but perhaps you can use them too in the big picture of your purposes." i will join you, habakkuk, as you sit on the city wall and watch to understand the big picture of how god is at work. woe to you him who piles up stolen goods and makes himself wealthy by extortion! (2:6) woe to him who builds his house by unjust gain, setting his nest on high to escape the clutches of ruin! (2:9) woe to him who builds a city with bloodshed and establishes a town by injustice! (2:12) woe to him who gives drink to his neighbours, pouring it from the wineskin till they are drunk, so that he can gaze on their naked bodies! (2:15) habakkuk, thank you so much for writing god's message down. you give me the reminder of the big picture – god will always deal with injustice. i don't know if you ever got to see it; i know i may not in my lifetime. the message god gave you seems to emphasize the punishment of the ruthless babylonians, but it also speaks of your 56 armstrong dec 2019. christian journal for global health 6(2) grace toward your people. let me return to this part of god's message a little later. after hearing god's message, you pray a big prayer: lord, i have heard of your fame; i stand in awe of your deeds, lord. repeat them in our day, in our time make them known; in wrath remember mercy. (3:2) god, i too, have heard of your fame and stand in awe of your deeds. your work in creation, your work in history, amaze me, but i must admit i am reluctant to pray with habakkuk: "repeat them in our day, in our time make them known." as i read on about god's actions, they can be rather disturbing and even frightening in their nature; your power is beyond my imagination, and your holiness leaves me standing trembling in awe. all the earth needs to be silent before you, listening, as you speak from your holy temple. (2:20) habakkuk, i understand exactly why you wrote, "in wrath, remember mercy." (3:2) without mercy, we would have no hope. despite my apprehension, i know the only way that justice and healing and shalom will come on the earth is when the earth is filled with the knowledge of god (2:14), and so i make this my big prayer, "god, make your glory known in all the earth. may people know your power and holiness, may people also know your mercy and a sense of hope. may your kingdom come on earth as it is in heaven." habakkuk, thanks for your faithfulness. amid great injustice, you remained faithful to the task of being god's messenger. you exemplify the message of encouragement that god gave you "but the righteous person will live by his faithfulness" (2:4b). your message was not an easy one. understanding injustice in god's world is always difficult. i still struggle with it today, but i am greatly obliged to you for reminding me of my task—as a health care professional and a messenger sent by god—my duty is faithfulness. faithfulness and patience are required to continue to serve and trust, even when there is no visible fruit, no signs of blessing. (3:17–18) how much we like to see the fruit of our work! a worker deserves to see good outcomes as a result of his or her labour. however, one of the tasks given to me is to be joyful in god my saviour even in drought and seemingly unfruitful situations. god, give me strength to be joyful as i await the big picture of your purposes being worked out. god, you are my strength; you were habakkuk's strength, too. with you as my strength, i might be surprised—you may enable to me to go to places i never expected to go, to see the big picture, and to do things i never expected to do! the sovereign lord is my strength; he makes my feet like the feet of deer, he enables me to tread on the heights. (3:19) submitted 11 nov 2019, accepted 26 nov 2019, published 23 dec 2019 competing interests: none declared. correspondence: lois joy armstrong, public health consulting and writing healthy words, australia. loisjarmstrong@gmail.com cite this article as: armstrong lj. big picture, small picture, and a conversation with habakkuk and god. christian journal for global health. december 2019; 6(2):55-56. https://doi.org/10.15566/cjgh.v6i2.315 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:loisjarmstrong@gmail.com https://doi.org/10.15566/cjgh.v6i2.315 http://creativecommons.org/licenses/by/4.0/ short communication dec 2019. christian journal for global health 6(2) from central africa to egypt: a surgeon’s journey david carl thompsona a md, facs, fwacs, paacs regional director of north and east africa, chief of surgery, harpur memorial hospital, egypt from 1977 to 2012, i served as a volunteer, church-supported general surgeon at the bongolo hospital in the central african country of gabon. during that time, i oversaw the development a 150-bed hospital and helped create the pan-african academy of christian surgeons (paacs), which between 1997 and the 2013 established 9 surgical residency programs in 8 countries in africa. in 2013, i accepted an invitation to open a 10th paacs training program at harpur memorial hospital in egypt, a 100-year old anglican institution in the delta of egypt that had been entirely directed by egyptians for the previous 40 years. little did i know how drastic the change would be to my surgical practice and how much i would have to change to adapt! a failure to communicate when i arrived in egypt i couldn't speak, understand, or read a word of arabic. in central africa, i spoke french and communicated easily with our medical staff and my patients. this was possible, because early in my career, i had learned both french and a local african language as part of my orientation to central africa. i was no longer a young man when i arrived in egypt, and after six months of intensive arabic study, i could not function without a translator in my clinic, in the operating room, on rounds, and when talking with nurses, pharmacists, or patients’ family members. what i was able to do was greet people in arabic, shop for food, and get around in a taxi without confusing the driver too seriously. because most egyptian doctors speak english and because on most of my days i worked with bilingual residents who translated for me, i managed a bit better in the hospital. inability to speak and understand what nurses, other physicians, and patients are saying is fertile ground for misunderstandings and misperceptions. a week or two after i arrived, i was asked to see a young woman who had undergone a laparoscopic cholecystectomy in cairo a week earlier. her abdomen was mildly distended, and she was septic. an ultrasound showed a dilated common bile duct with two stones in the head of the pancreas. a gastroenterologist had performed an ercp and a sphincterotomy, but the stones had not passed. with the family’s permission, we took her to the operating room and found 1000 ml of infected bile and generalized peritonitis. a surgical clip had come off of the cystic duct after the surgeon removed the gallbladder. i eventually found the leak and tied it off. after irrigating her abdomen copiously, we left suction drains and closed. after she woke up she was taken to the intensive care unit. the family was very anxious to find out from me what happened, but at that moment i could not find anyone to translate. what i managed to say to them in broken arabic still makes me blush. literally translated, i said “she ok now, much, much!” i will leave it to the reader to imagine how much confidence that gave her family! no matter how well trained or experienced we are, if we speak like 2 yearolds, we will be seen as a bit stupid! when we can’t talk or understand, the trust so essential to successfully manage sick patients will be weak at best. effective communication is so important to building trust that time spent in learning the predominant language is time well spent. where it is not possible, spending the 51 thompson dec 2019. christian journal for global health 6(2) money to hire full-time translators is worth every dollar. building trust in gabon, i was one of only a few trained surgeons for more than 200,000 people in an area the size of massachusetts. i regularly operated on patients who had traveled more than 350 miles from the capital city, but because surgeons were in such short supply, they were willing to wait a month or longer for an elective procedure. the result was that complaints and challenges to my medical opinion were unusual. a local proverb that worked in my favor stated, “offend the witch doctor and end up dead!” even as late as 2012 when there were other surgeons on our staff, we were able to control most aspects of our surgical practice. but when i arrived in menouf, egypt, i was an outsider and an unknown, and like any other surgeon starting a practice i had to present my credentials, prove my competency, and earn the trust of the hospital director and the surgical team. this is true anywhere in the world, but is magnified when a stranger comes to town from another country, especially one who doesn’t understand the language and understands even less the way people think! humility, patience, and a willingness to listen to local surgeons and to patients go a long way towards building trust. an outside surgeon’s skill in the operating room and on the wards is helpful, but it can take up to a year to gain the confidence of others to make major changes. it takes both competence, humility, and time to establish a foreign surgeon’s reputation. unlike most of the rest of africa, egypt has no shortage of hospitals, doctors, or surgeons. the country graduates 20,000 mds a year and the vast majority of them are not able to enter specialty programs. residency programs in egypt are poorly organized, lightly supervised, and usually completed in three years if a resident successfully passes a government written “master’s examination.” residents have to be self-motivated and selfdirected in their learning, since curricula are vague, formal teaching is limited, and operative experience is all too often limited to assisting the professor or operating on small cases without adequate supervision and teaching. although there are some excellent and reputable egyptian surgeons, all too often surgeons who have passed the written and oral government examinations learn to operate after they have been licensed, and with inadequate or non-existent supervision by more experienced surgeons. this is true in many developing countries, not just egypt. to hone their skills, these young surgeons learn by reading or by trial and error, unless they can work with a more experienced surgeon. however, working with “experienced” surgeons who were not well supervised or systematically trained themselves has serious drawbacks as well. these training programs are more like apprenticeships and are not conducive to evidence-based learning. surgical traditions that are passed down from one surgeon to another are then considered “best practices,” often with catastrophic results. to limit the damage when there are complications and to protect their reputations, surgeons are tempted to blame their patients for complications that occur and refuse further treatment. these practices do not allow young surgeons to learn how to prevent or treat surgical complications when they occur. not surprisingly, patients and their families respond by distrusting most, if not all, surgeons. perceptions and the impact of worldviews surgery in egypt is a different paradigm from surgery in sub-saharan africa, and population density is one of the most important contributors to that. during my first six months, i thought egypt was experiencing an epidemic of appendicitis. every other day or so, i found myself removing an inflamed appendix. eventually, it occurred to me that egypt, with its population at 90 million, might not have 10 times the frequency of appendicitis as gabon but simply more people. it turns out that the population of egypt is 64 times greater 52 thompson dec 2019. christian journal for global health 6(2) than the population of gabon (90 vs. 1.4 million)! there are no reliable figures about the incidence of appendicitis in egypt, and the who doesn’t track that information. worldviews are also hugely important in determining which paradigm of surgery is the most broadly accepted. the worldview in most of sub-saharan africa is animistic, which translates into the widespread belief that disease and accidents are primarily caused by sorcerers who for hire, direct evil spirits to harm others. animistic people accept that modern medical care and surgery are helpful to resolve medical problems that sorcery cannot help; but they fault our methods because we can’t explain why a particular disease or incident occurred in their body, as opposed to someone else’s. animists claim that they are able to ascertain the answer to the question “why did this happen?” with the help of “good” healers who consult “good” spirits. surgeons who openly mock these beliefs are considered by animists to be fools. despite these beliefs, most animists will respond positively when asked by a christian healthcare worker if they would like prayer for healing or prayer for god’s protection. they honestly believe that there are evil spirits lurking around them who might harm them. they may not believe in jesus, but they are hopeful that jesus is more powerful than the demons that constantly threaten them and their families. muslims believe in the power and the malevolence of shayateen (demons) as well, but the concept that demons might be the cause of surgical disease is less accepted than among animists. such belief also contradicts orthodox islamic teaching that nothing happens apart from the will of allah. muslim patients are not above consulting a spirit guide or pinning a verse of the qu’ran on their clothing for protection from the “evil eye,” but if they follow the teachings of the qu’ran, they are more likely to be fatalistic about bad outcomes. i will never forget the response of a muslim father when i sorrowfully told him that his newborn son had died in surgery from overwhelming sepsis. placing his hand on my shoulder, he smiled and said in front of his weeping wife, “don’t feel bad, doctor. it was allah’s will!” he meant it and thought it would comfort me, but i was too shocked by his insensitivity to reply. nevertheless, it would be a mistake to assume that in islamic countries fatalism will protect surgeons from lawsuits and claims of malpractice! muslim patients in egypt are far more likely to accept medical and scientific explanations for disease than elsewhere in africa, and islam is strongly supportive of modern medical care and generally accepting of scientific explanations of diseases and their management. i have been surprised at how quickly my egyptian patients switch from trusting our team to accusing us of malpractice, after their family member experiences a complication. they are far more likely to challenge the medical advice of their doctors than their western or central african counterparts. on many occasions, family members without any medical training overruled or challenged my treatment suggestions. on one occasion, an 18-year-old construction worker cancelled his sister-inlaw’s emergency c-section, despite the fact that she was hemorrhaging, preferring to take her home until her husband finished work that evening! the husband of a 20-year-old woman who had injured her hand and cut a tendon while harvesting a crop decided she could wait a week while he decided what to do! this is one of the most difficult aspects of practicing surgery in muslim countries and is a reflection of the low esteem and trust for surgeons and the prevailing view that women cannot make decisions about their own bodies. in addition to animists and muslims, there are significant christian populations throughout africa whose worldview embraces both spiritual and medical views of disease. christians in africa generally accept spiritual cures, such as healing through prayer and casting out evil spirits in jesus’s name. at the same time, they accept advanced medical treatment. their faith that god can heal them in response to prayer, either miraculously or through a physician’s skill and knowledge, 53 thompson dec 2019. christian journal for global health 6(2) often leads them to seek out capable christian healthcare providers who integrate their faith and practice. unlike muslims and animists, christians understand the concept of serving in mission out of love, and why an expatriate doctor might give up wealth, fame, and family to serve the poor in a foreign land. other imprints on the surgical environment the city of menouf boasts three government hospitals and, at last count, four or five private hospitals, one of which is harpur memorial hospital. if one includes all of the surgical specialties, there are approximately 50 surgeons in menouf! five or ten of them have operating privileges at harpur memorial hospital. with just three operating rooms and one or two anesthetists providing coverage each day, the competition to start a case can be brutal. unfortunately, competition does not mean that high standards are widely applied in the city’s operating rooms. in fact, competition encourages them to cut corners. in our hospital in gabon, i had full control over our operating rooms and could insist on high standards. the rooms were regularly cleaned, sterilization procedures were rigorous, and the rooms were well-staffed with trained or nurses. anesthesia was part of the department of surgery and worked closely with our surgeons. surgical cases were scheduled on a first come, first serve basis and could be booked with confidence weeks in advance. the surgery scheduling system in a hospital always reflects cultural norms and practices. when i began practicing in egypt, i was surprised to learn that the surgeon who got into the operating room first was determined by his reputation, his friendships, the preferences of the anesthetists, and the operating room nurses. my efforts to institute a system based on the urgency of the case or a first-come, firstserve basis were welcomed with polite smiles and nods of acceptance, but complete noncompliance. eastern culture reveres elders, so much so that o.r. nurses are ashamed to make older surgeons wait. however, this does not include older expatriate surgeons! the scheduling problems finally came to a head one day when five surgeons showed up at 9 am to operate on a combined total of more than 15 cases, each one having been told he could start at 9 am! by the end of the day, everyone was frustrated and angry! after that, we made moderate progress in instituting a more rational system, though there were frequent lapses. the key to success in these situations was to enlist the full support of the o.r. team for change. that, however, took time, patience, steady pressure, and a willingness to listen. the shortage of anesthesiologists and the lack of nurse-anesthetists created other problems, because anesthesiologists have operational control over scheduling and can choose which surgeon will be served first. the anesthesiologists in egypt were a law to themselves, and had strong financial incentives to run two or even three general anesthesia cases simultaneously. this was especially true if the anesthesia machines were equipped with working ventilators. the surgeons had no choice but to agree to share their anesthetists with one or two other rooms, unless they wanted to wait until all the other cases on the docket were finished. in every country in the world, culture influences written and unwritten operating room priorities, operating room policies, and the roles of doctors, nurses, and ancillary personnel. egypt’s best hospitals may be comparable to community hospitals in the united states, but the vast majority of them, including the hospital in menouf when i first arrived, seem to be primarily focused on providing surgical services with speed, simplicity, and economy. these would be laudable priorities if they were designed for the best interest of the patients. but from what i observed, the or policies were primarily designed to meet the needs and desires of the surgeons and the anesthesiologists. there was at times little concern for patient safety, as evidenced by frequent breaks in sterile technique, limited cleaning of the or before and after operations, and a near-total absence 54 thompson dec 2019. christian journal for global health 6(2) of formal training in these critical areas for the or nurses and ancillary personnel. these lapses were not intentional, but occurred because over time, other culturally rooted issues gradually and imperceptibly became more important than patient safety. culturally-related issues are, for the most part, invisible to insiders and difficult to expose without pushback. most of the egyptian surgeons and anesthesiologists that i worked with vociferously disagreed when i challenged their attitudes towards patient safety. another cultural issue is the wide gap in authority and responsibility between doctors and nurses. this is probably the result of the even greater difference in their educational levels. or nurses and or techs often don’t even have high school degrees. as a result, they do not see themselves as important team players whose performance or lack of performance affects patient outcomes. instead, they see themselves as employees whose job is to serve doctors quickly and without discussion. if they see practices that adversely affect patient care, it is not up to them to point them out, unless they want to lose their jobs. that leaves doctors as the sole guardians of patient safety in the operating rooms. most of the surgeons and anesthesiologists i worked with were not even aware of the major safety issues i saw until i brought them up. but because egyptian culture is highly sensitive to public shaming, i could never bring up issues in the presence of nurses or conscious patients. changing the negative cultural influences of the surgical environment takes a great commitment to not publicly shame an errant colleague. as the writer of proverbs stated, “there is a time and place for everything.” i learned that the time and place to institute cultural change in the surgical environment was when. i had tight control over my emotions and could make gentle observations and suggestions. over time and with repetition my suggestions eventually become someone else’s idea, making their adoption even easier. other ways forward were to humbly ask for advice on how to make the operating room safer for patients, and to be scrupulous in modeling best practices. conclusion when medical professionals step out of one culture into another to serve in mission, the transition is far more complex and difficult than even those with wide international experience may realize, especially if it involves a change between widely divergent cultures, the need to learn a new language or work through a translator, and understanding a completely new worldview. understanding how these issues affect medical practice requires a mixture of humility, curiosity, and perseverance. done well, it can bring about successful transition and widen doors to successful ministry. peer reviewed: submitted 5 may 2019, accepted 29 aug 2019, published 23 dec 2019 competing interests: none declared. correspondence: dr david thompson. thompsonafricagray@gmail.com cite this article as: thompson dc. from central africa to egypt: a surgeon’s journey. christian journal for global health. december 2019; 6(2):50-54. https://doi.org/10.15566/cjgh.v6i2.28 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:thompsonafricagray@gmail.com https://doi.org/10.15566/cjgh.v6i2.28 http://creativecommons.org/licenses/by/4.0/ commentary may 2019. christian journal for global health 6(1) a biblical reflection on the passion of jesus christ as it relates to 20 years of treatment-resistant ministerial depression hunter yorka a cross-cultural development worker, philippines. abstract this is a reflective commentary on the article entitled, understanding refractory depression: a missionary’s autobiographical case report. it is a focus on a spiritual therapy to minimize the debilitating symptoms of long-term refractory depression when other conventional and non-conventional treatments have been ineffective. though not suggested as a cure, a focused faith on our identity with christ and his with us can help us transcend some of the negative impacts refractory depression brings to the life of its sufferers. this is particularly relevant regarding christ’s identification with our human sufferings. it can be categorized as a spiritual discipline where benefits improve as the sufferer becomes more adept at the practice. key words: depression, suffering, jesus, faith, hope, spiritual disciplines, identification introduction my previous article, understanding refractory depression: a missionary’s autobiographical case report, was intended to show depression as a major global health problem and to reveal the inner life of a sufferer of treatment-resistant depression.1 there is a pain associated with depression that belies definition. the difficulty in articulating the condition makes it almost too abstract for our minds to effectively grasp and understand. pain is, by its very nature, isolating, but the scriptures can bring us out of isolation and into a new level of understanding and transcendence. job is an entire book dedicated to examining one man’s journey through intense suffering and loss. in addition to insights on how job was sustained by his faith, we also see how his pain was compounded by the inability of those closest to him to understand his suffering. ultimately, after fulfilling their well-intentioned empathetic duties of comfort in their comparatively trouble-free lives, job’s friends lost patience. the stubborn realities of job’s problems did not resolve quickly and conveniently. we often see this same pattern of reaction by non-depressed people to the pain of depression sufferers today. humans are impatient by nature, and this innate human quality led to what we often see today in the treatment of chronic illnesses without visible signs, especially when there is no response to therapies. when job’s suffering took a lot longer than his friends thought necessary, they offered simplistic advice on how to expedite the fixing of his problem. job was too honest to pretend the advice 52 york may 2019. christian journal for global health 6(1) was helping, and this presented a problem to onlookers. his wife and friends could not understand or identify with what he was going through and could not connect with him in a way that made sense to them. their advice eventually devolved into judgement and disdain, and with their attitudes and words, they wrote him off as a hopeless case, guilty of pathetic unconfessed sin, self-pity and introspection. proverbs 14:10 states, “each heart knows its own bitterness, and no one else can share its joy” (niv). each of us, in our way, can identify with this. the apostle paul expands the concept of the exclusionary isolation of suffering in philippians 3:10: “i want to know christ, and the power of his resurrection, and the fellowship of sharing in his sufferings, becoming like him in his death, and so, somehow, to attain to the resurrection of the dead.” (niv). christians read this and easily identify with the sentiments of the first and second statements. but when we come to the “sharing of his sufferings,” we unconsciously backpedal and circumnavigate to the next verse. the reason paul associates profound, experiential knowledge of christ with suffering is because the nature of suffering is intimate. nothing is more personal. when we are trouble free and prosperous, it is easy for people to want to be with us even if they are not emotionally close or committed to us. but when a person is in pain, when there is serious suffering, then there seems to be no upside to spending time with the sufferer. only the closest, most committed friend can share those moments because only they have the capacity and willingness to share the burden of the pain even when sharing the pain does not solve the problem. this level of relationship identifies with another’s pain simply because love compels them. there does not need to be resolution for the connection to have meaning. i have been emotionally impaired for the better part of two decades. but, i refuse to surrender as long as god gives me faith. faith is a gift that is essential to my survival. at times, i can barely conjure the will to go on and can only toss inarticulate, monosyllabic pleas out to god. “in the same way, the spirit helps us in our weakness. we do not know what we ought to pray for, but the spirit himself intercedes for us through wordless groans” (romans 8:26 [niv]). sometimes, there are desperate, simple words of supplication. sometimes, there is only a silent pleading for comfort, but as long as i can turn my heart upward, there is hope. the proposed result of my autobiographical case report was to enable friends, family, and medical professionals to “see” more clearly into the pain of the depressed sufferer and, hence, be enabled to offer more effective therapy, counselling, connection, and comfort. in the end, there are no complete or definitive solutions to the intractable problem of treatment-resistant depression. depression is a condition that sometimes can be cured, sometimes improved, and sometimes managed—but not always. despite the severity of major depressive disorder (mdd) and the increase of the condition globally, medical professionals still have not come up with a standardized definition of treatment resistant depression (trd) or a standardized procedure to determine if a person truly suffers from trd. workers in service occupations like medical professionals and the clergy are particularly prone to burnout and depression. it is generally agreed that healthy lifestyle improvements are important to supplement the treatment of depression sufferers.2 in long-term trd cases, a study conducted by the methodist counseling and consultation services, north carolina, suggested that a positive faith could help minimize the generalized negativity of chronic depression if the sufferer cognitively and consistently exercised it.3 this paper is insufficient to answer the question as to why so many depressed ministers permanently distance themselves from the ministry or have been led to missionary attrition. there is a biblical precedent, especially in the psalms, for the experience of depression to be seen not as a weakness, but as an experience of the human condition and as an opportunity for enhancing 53 york may 2019. christian journal for global health 6(1) ministry effectiveness through trust in god as healer and redeemer. some examples of these psalms of lament are chapters 3, 6, 13, 22, 28, 56, 102, and 142. these psalms generally represent the writer in near impossible conditions, some kind of doubt or conflict, or deeply questioning about god’s purposes. usually the psalmist is able to talk through his problem with brutal honesty until he comes full circle to the character and faithfulness of god. even in pain, sometimes caused by mistakes or sin, the psalmist in these laments clings to the character of god instead of the weakness of himself and often appeals to be delivered from their extremities so that god will be glorified by showing his power, love, and faithfulness to those in covenant with him and to all the nations of the world (ps. 22:27; 86:9, 102:15). in a modern context, some of these psalms can seem strangely self-serving, but the reality is that their faith in god’s promises to them ultimately overcame their doubts and fears. verbalizing these desperate cries to god and others seems to be therapeutic and a witness to the grace of god. when medicine fails: managing the pain of depression through faith and our identification with christ we have the accounts of job, david, paul, and the list of saints and martyrs to visit the problem of personal pain. they are extremely helpful and encouraging in our confusing and bumpy pilgrimage of life. they are the top examples, but the supreme example of the emptying that comes with depression is jesus. as christians, we easily embrace his suffering for us and our identification with him in our suffering. but have we contemplated the possibility that beyond understanding that jesus suffered for us in the past, he also suffers with us today? our identity in him binds us to him, and he will never leave us nor forsake us when we struggle with hard things (heb. 13:5). when we are in the throes of debilitating anguish, we naturally feel isolated. it is not uncommon for us to feel that we are the only ones who have ever experienced our kind of suffering. our prayers reach desperation, and our hearts cry out in confusion, “where are you god?”, “don’t you see my pain?”, “why don’t you answer me?”, “do you even care about me?” honest prayer is the purest form of prayer. when we openly share our pain with god, we not only honor him with our faith, we begin to walk the calvary road with jesus himself. in the synoptic gospels, there is more identification of jesus with our powerlessness and separation from god than there is even with important directives like the great commission to make disciples of the nations (matt. 28:18). what is god trying to communicate to us through his incarnational suffering? jesus not only suffered for us, he suffers with us. “if one part suffers, every part suffers with it; if one part is honored, every part rejoices with it. now you are the body of christ, and each one of you is a part of it” (1 cor. 12:26, 27 [niv]). walking the path with jesus through depression in contemplating the final days of jesus’ human life and work, we can see how he intimately identified with those who suffer from depression, and how he invites us to identify with him. jesus was sorrowful unto death. (matthew 26:38, mark 14:34) faith is not a vaccination against despair. elijah wanted to die, david was emotionally depressed often, paul despaired of life, and jesus, our lord, who identified with the weakness of humanity, was sorrowful to the point of death. this kind of despair and sorrow is not viewed as weakness in the scripture. these are honest expressions of the human condition in a fallen world where entropy reigns and relationships are broken. jesus embraced both the good and the bad in the human experience. we can identify fully with him only because he first 54 york may 2019. christian journal for global health 6(1) fully identified with us. without the humanity of christ, we could never have fully appreciated his deity. jesus prayed for deliverance but god answered, “no”. (matthew 26:39, 42; mark 14:32; luke 22:43) the “no” of god’s silence is something we have all experienced if we have ever pursued a regular prayer life. it is easy to understand when god seems not to get involved answering our prayers about an entrance exam, a job application, or a romantic interest. it becomes much more difficult to understand when god’s honor is at stake among people who have never heard of him, when a young, promising missionary develops a chronic illness, or when a child suffers needlessly. these are lifethreatening, eternity-threatening issues, and we are often confused by what appears to be indifference from god when we are in trouble. regarding depression, i often think about the fruit of the spirit which is supposed to characterize the authentic christian experience. in the list found in galatians chapter 5, the first three qualities cannot be conjured by faith, choice, or obedience. they are gifts from god: love, joy, peace. the following six qualities: patience, kindness, goodness, faithfulness, gentleness, and self-control, can be attained by making righteous choices. in my first fifteen years of ministry, i experienced near constant positive supporting emotions and a deep passion and love for my work. the past twenty years or so, this passion has been replaced by a commitment to finish well and hear the words, “well done, good and faithful servant . . . come share in your master’s happiness!” (matt. 25:21 [niv]). in a sense, it is a case of delayed gratification. in hebrews 11, especially verses 32-38, the list of spiritual heroes has two categories—those who were very successful and victorious, and those who suffered, lived, and died horribly. yet, verses 39 and 40 state, “these were all commended for their faith, yet none of them received what had been promised, since god had planned something better for us so that only together with us would they be made perfect.” this is helpful because it reminds us that despite our experience in this world, pleasant or painful, our true hope is in eternity with god where, together, all the saints will receive the promise of god’s complete joy of our salvation (ps. 51:12). but now, consider that the son of god, the eternal logos by whom the cosmos was created, calling out to his father from the desperation of his humanity. based on the results, it did not seem like the father was moved to answer jesus’ primary prayer for deliverance (matt. 26:42). did not jesus say that if he wanted to, he could have called legions of angels to help him? (matt. 26:53) this seemingly impossible scenario of god not responding to the impending unjust death of his son has a deeper meaning than his plan of salvation for mankind and the redemption of all of creation. in this identification with our suffering, jesus shares our pain of powerlessness, hopelessness, fear, a sense of complete separation from god, and possibly even doubt. regardless of what depression may try to tell us, god is not aloof and indifferent. “the lord is close to the brokenhearted and saves those who are crushed in spirit” (ps. 34:18). not only does he understand our pain, our lostness, our darkness, our sadness, and our confusion and bewilderment at conflict, he has experienced them himself as a man (isaiah 53:5). he has entered the ultimate realm of intimacy with us. because he has borne our pain, we have a confidant, a consoler, and a deep, faithful, and intimate friend. when we call out in our suffering to a god who we think is not listening, jesus is with us sharing our pain. jesus shares our pain not only through his infinite knowledge as god but with an understanding and empathy of personal human experience (heb. 4:15). it was not only on the cross that he bore our pain and identified with our suffering and weakness. jesus felt the pain of disconnection from god and all that is good: “my god, my god why 55 york may 2019. christian journal for global health 6(1) have you forsaken me?” (matthew, 27:46, mark 15:34) depression destroys your connections. association with all you value erodes, and a barren landscape of infinite hopelessness and distance emerges. your positive feelings of connection with god and others dissolve, and you are left with a fading memory straining to recall what used to be. in the lord of the rings: the return of the king trilogy movie, frodo describes his diminished state to samwise as “naked in the dark.” i can imagine that this is the greatest pain of hell, never being able to connect with anyone ever again. when we call out to god in this state and he does not answer, only faith can give us the hope on which we need to hang. theologically, we can understand christ’s separation from the father as he bore our sin on the cross. on a personal level, it is profound to realize that before the actual atoning work of the cross, jesus looked to god for help, but god did not seem to be there. jesus’ identification with us was total. when he was afraid, vulnerable, and confused, he called out to his father for help and was met with silence. this level of identification with us is almost incomprehensible. when god is silent in our pain, we need to remember that we are not alone. jesus experienced this same kind of desperation for us. god had not abandoned jesus, but in jesus’ human emotions, it felt that way. it was for that moment jesus’ human reality. god does not abandon us, but our feelings can make it feel that way. jesus’ pain was misunderstood. “he is calling elijah.” (matthew 27: 47, 48; mark 15:35, 36) when we think of poor comforters, it is natural to remember job’s friends. historical references aside, we usually do not need to look very far to see infinite variations of job’s scenario. it is at great risk that the christian honestly bares his heart and publicly shares his struggles with depression. predictably, the initial response is some form of sympathy. since true understanding of depression is impossible for anyone who has not personally experienced it, there is usually a difficulty to respond effectively. pain is compounded when people misunderstand it. if someone today cried out in searing agony, “my god, why have you forsaken me,” he would almost certainly receive some kind of theological correction from well-intentioned christians. this heart cry of jesus was not about theology. it was about pain. imagine how jesus’ lowest moment got even lower when people misunderstood the sincerest expression of the most heart-felt feeling he had ever uttered. jesus surrendered his spirit. (matthew 27:50; mark 15: 37; luke 23:45) this is going to be the most controversial segment in this article. anyone who has experienced chronic depression knows what it is like to run out of strength to fight on. depression can be a war of attrition. it only takes. it never replenishes. when you lose the motivation or mental ability to continue to shore up the leaky dike of your will, you are in a very dangerous place. in the end, there often is no energy to want to keep going. you want to care, but you just cannot conjure enough energy to make it happen. suicide is not only an attempt to stop the pain but a surrender to the seemingly inevitable disintegration of our humanity. this is the hardest concept for non-sufferers to understand. in this state, escape may seem like a pathway to a more peaceful existence. this is not a rational state for those in a truly depressive condition. jesus was rational and in complete surrender to his father’s will at the time he willfully surrendered his spirit and life. i mention his surrender to his inevitable death, not to debate that his work was or was not finished. he himself declared, “it is finished” (john 19:30). he had borne the sins of mankind and received the just wrath of god for our sake. i mention this because at this critical moment jesus was also human. simultaneously, he was the son of god and the son of man. the torture definitely made him weak beyond description physically. but in addition to this, in his humanity, i believe he was completely 56 york may 2019. christian journal for global health 6(1) spent emotionally. with the understanding that he had completed his purpose, and there was no more reason to continue suffering, he committed his spirit to the father (luke 23:46). in the midst of depression, a person is not usually considering the pain that will be caused by his or her death. in the irrational state of impending suicide, the mind can twist all kinds of seemingly logical justifications for taking one’s own life. “i have already lived a full-life,” “no one really cares anyway,” “i can’t take this pain anymore,” and/or “what’s the point?” it does not matter what the justification is, it insidiously gives him or her an irrational justification to terminate the life god has given. this is a time when the disease has worn the sufferer down and figuratively has its foot on the throat. the sufferer may feel an inability to fight back and definitely a loss of desire to try. many people who attempt suicide experience a return of energy to care, then call a friend or emergency services. friends and family are baffled by this apparent contradiction. the common misunderstanding is that they were just looking for attention. it is critical here not to misunderstand that i am claiming jesus was even remotely in the category of people i just described. jesus was not looking for attention, and he certainly was not trying to commit suicide. but jesus’ trauma had drained him, and the draining quality of trauma is something most of us experience at some point in our lives. he could have summoned the will to remain alive on the cross longer, but there was no point for that since he had already fulfilled the goal of his suffering as a substitutionary sacrifice for our sins. his death would complete that willing sacrifice. unfortunately, many people who have been traumatized by abuse, tragedy, and depression can progressively slip into an emotional malaise that drains the energy to fight to stay alive. jesus did not hasten death, he simply surrendered to the inevitable process of dying. “and when jesus had cried out again in a loud voice, he gave up his spirit” (matthew 27:50). jesus was literally emptied for us (phil. 2). he had every drop of life drained from him. he understands emptiness. he has been there. the scripture and the creeds teach us that jesus was fully god and fully man. this is a concept that is impossible to understand comprehensively. because we acknowledge his deity, it seems disrespectful to believe that he shared all our weaknesses in human form. it is easy for us to accept that jesus got hungry, needed sleep, or felt sadness, but his incarnation was far deeper than that. jesus willingly submitted to all the weaknesses of the human condition. he experienced fear, despair, desperation, abandonment, and vulnerability, and he experienced it for us. he walked in our weakness for us, and he continues to walk with us in our weakness today. and he will walk with us until the day when pain and weakness will cease to exist and our redemption will be complete. for while we are in this tent, we groan and are burdened, because we do not wish to be unclothed but to be clothed instead with our heavenly dwelling, so that what is mortal may be swallowed up by life. now the one who has fashioned us for this very purpose is god, who has given us the spirit as a deposit, guaranteeing what is to come. therefore, we are always confident and know that as long as we are at home in the body we are away from the lord. for we live by faith, not by sight. (2 cor. 5:4-7 [niv]). as with all aspects of our relationship with christ, while we still live in these fragile bodies and fractured communities, we live by faith. this is never truer than it is for a christian with depression. faith is even more essential when we have no sight at all. paul tells us that for now we see as through a darkened glass. but for someone with depression, that darkened glass has been painted black and is in a dark room with no windows. faith is what tethers us to a god we cannot see when all our senses tell us he is not there, or he does not care. god promises never to leave us or forsake us (josh. 1:5). he is with 57 york may 2019. christian journal for global health 6(1) us in our sufferings, and he has a sympathy and a unique understanding, because for our sakes, he has known the frailty and pain associated with the human experience. he is omniscient and knows we are but dust (ps. 103:4). he understands our weakness and does not condemn us for it. developing a spiritual discipline that focuses on being present with him and regularly affirming god’s stated favor for you will help when the selfloathing gets heavy, when the pulse begins to race and the urge to hyperventilate begins. i highly recommend brother lawrence’s the practice of the presence of god.4 without faith, there is no hope, and without hope depression cannot be overcome. faith is more than a claim to the promises of god. faith is what allows us to cling to our savior through the frequent and sometimes very long trials in life. faith is what enables us to contemplate the suffering, incarnational christ and his unwavering presence with us in our own sufferings during the times of despair when it feels like he has abandoned us. we share the psalmist’s cry: “restore to me the joy of your salvation and grant me a willing spirit, to sustain me” (ps. 51:12 [niv]). conclusion in the end, there is much in life that we cannot control. much of depression is related to our broken world and the demands we place upon ourselves or accept from others. when, by faith, we can learn to trust god to do what is ultimately best for us and his kingdom purposes when we are unable to control events that trouble us, we open ourselves up to a level of peace and trust based upon a rational acceptance of reality. this acceptance often does not remove the pain or cure the ill, but it redirects our focus from the hopelessness of things we have no power over to the one who loves us and has all power. this acceptance is a form of comforting surrender. during those moments when we can resign ourselves to desire nothing but the will of god, it does not matter if that will is pleasant or grievous because our delight is that it is the good, pleasing and acceptable will of god (rom. 12:2). we are all a work in progress. it is especially difficult when a depressed person is besieged with doubt, guilt, and self-loathing. my personal journey with refractory depression has progressed from denial, to acceptance that it is only a phase that will pass, to dejection and discouragement, to confusion, some unhealthy self-medication, absolute despair, desperation, and, finally, to an acceptance and hope that i will someday see the goodness of the lord in the land of the living (ps. 27:13). the constant, cognitive practice of faith through spiritual disciplines that bring us into a better awareness of god is a lifelong journey but is essential to manage and transcend the trial of treatment resistant depression and learn to worship god with our imperfect lives. isolation exacerbates depression, so i actively seek out christian fellowship and counsel. adele ahlberg calhoun’s spiritual disciplines handbook: practices that transform us5 is a helpful tool for a serious christian’s personal journey to progress from the often-unhealthy control of our subconscious to developing a more conscious, controlled, and focused faith. guided christian mindfulness meditation sessions are exercises that i often find helpful in refocusing my overstressed mind on my redeemer. some of these are more guided prayers and some are deeper meditations.6 one of the names of jesus is emmanuel, which means, god with us. to the degree we are able to internalize this reality by faith, our hope in this life and for the next helps us transcend the unpleasant trials of chronic emotional pain and to remain effective instruments of god’s mission. references 1. york h. understanding treatment-resistant depression: a missionary’s autobiographical case report. christ j global health. may 2019;6(1):43-50. https://doi.org/10.15566/cjgh.v6i1.275. https://doi.org/10.15566/cjgh.v6i1.275 58 york may 2019. christian journal for global health 6(1) 2. berk m, sarris j, coulson ce, jacka fn. lifestyle management of unipolar depression. acta psychiatr scand suppl. 2013;(443):38-54. 3. golden j, piedmont rl, ciarrocci jw, rodgerson t. spirituality and burn out: an incremental validity study. j psychol theol. 1 june 2004;32(2):115-25. https://doi.org/10.1177/009164710403200204 4. brother lawrence. the practice of the presence of god. london: epworth press. available from: https://www.basilica.ca/documents/2016/10/brother% 20lawrencethe%20practice%20of%20the%20presence%20of%2 0god.pdf 5. calhoun aa. spiritual disciplines handbook: practices that transform us. downers grove, il: ivp books. 2005. 6. spiritual exercises for mindfulness meditation examples [internet]. be at peace: feeling god's presence through guided christian meditation and prayer. available from: https://www.youtube.com/watch?v=qtcg7bkevew&t =3s. christian mindfulness loving embrace meditation. available from: https://www.youtube.com/watch?v=swzqwhxhl6a& t=18s. mindfulness meditation: being still in the presence of god available from: https://www.youtube.com/watch?v=826gdm79uza. peer reviewed: submitted 29 jan 2019, accepted 13 april 2019, published 31 may 2019 competing interests: none declared. correspondence: hunter york, philippines. hunteryork68@yahoo.com. note that for reasons of patient privacy and security, a pseudonym was used for the author. cite this article as: york h. a biblical reflection on the passion of jesus christ as it relates to 20 years of treatment-resistant ministerial depression. christ j global health. may 2019; 6(1):51-58. https://doi.org/10.15566/cjgh.v6i1.279 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1177/009164710403200204 https://www.basilica.ca/documents/2016/10/brother%20lawrence-the%20practice%20of%20the%20presence%20of%20god.pdf https://www.basilica.ca/documents/2016/10/brother%20lawrence-the%20practice%20of%20the%20presence%20of%20god.pdf https://www.basilica.ca/documents/2016/10/brother%20lawrence-the%20practice%20of%20the%20presence%20of%20god.pdf https://www.basilica.ca/documents/2016/10/brother%20lawrence-the%20practice%20of%20the%20presence%20of%20god.pdf https://www.youtube.com/watch?v=qtcg7bkevew&t=3s https://www.youtube.com/watch?v=qtcg7bkevew&t=3s https://www.youtube.com/watch?v=swzqwhxhl6a&t=18s https://www.youtube.com/watch?v=swzqwhxhl6a&t=18s https://www.youtube.com/watch?v=826gdm79uza mailto:hunteryork68@yahoo.com https://doi.org/10.15566/cjgh.v6i1.279 http://creativecommons.org/licenses/by/4.0/ field reports nov 2014. christian journal for global health, 1(2):92-94. helping hands or comforting the soul? maria colon-gonzalez a a md, assistant professor, mcallen family medicine residency program, department of family and community medicine, university of texas health science center, san antonio it was an early morning on the first day of the year. i was scheduled to work my first 24-hour shift in an underserved medical facility in ecuador. as a foreign physician, the attendings advised me to expect anything and a little bit of everything. the day started with a rush of adrenaline. i was sitting at the nurses’ station when the first phone call of the shift was received. it was a from a government hospital calling to request a transfer. a pregnant woman had arrived at their hospital with significant vaginal bleeding, diagnosed with placenta previa. the government hospital was open for business, but without a surgeon or anesthesiologist they needed to transfer the patient to our facility. she walked in and passed the nurses’ station, smiling with her long black hair, young, strong, and ready to have her baby. her family was walking behind her, happy and full of confidence. without discussion, they walked directly to the operating room to prepare for the c-section. the operating room was hot, humid, and very much available. all the helping hands arrived entirely energetic: a german general surgeon, an american anesthesiologist, and an ecuadorian medical intern. i continued working from the emergency area to the inpatient area, completing tasks as quickly and efficiently as possible. i returned to the nurses’ station, looking at the time. “something was wrong." i told myself. “was i right? had it been two hours since the team went into the operating room?” i exchanged thoughts with the attending. as we stood there, the phone rang. the nurse explained that the staff in the operating room was requesting blood. our patient was in trouble. after six hours of my first 24-hour shift in the beauty of the andean ecuador, i realized how the lack of resources, the acuity, and the number of the patients change your practice. in the midst of this amazonian scene, this meant finding blood, somewhere, from somebody. the sole laboratory technician informed us there was not enough blood in the red cross bank; thus, the family members would become our primary donors. as a resident physician, i did what i am trained to do best, continued seeing patients, aware of the time just by the brightness thru the windows. there, i did not need a pager, patients arrived at the doorway screaming and calling for help post celebration of new year’s eve. the doors of the operating room opened, mom was intubated, and family members were crying in the hallway. they had many questions, but we had few answers. their anguished faces lined the long white 93 colon-gonzalez nov 2014. christian journal for global health, 1(2):92-94. hallway, seeming to salute the intubated mother as she processed through the midst of them. we rushed to the patient, helping in whatever way we could: our hands helped the nurses, our minds helped the attendings and our souls, where were our souls? we were impersonal, concerned with fulfilling our duty; feelings and empathy were professionally suppressed. the patient’s black hair was pulled back and her eyes were shut. i realized the life of this young healthy mom had taken a turnaround. in the long hallway, the team of physicians explained to the family members that she had severe bleeding during surgery, and her uterus had been removed in hopes of saving her life. the team leader calmly explained the need for more blood. as he spoke, the family agreed to be tested as possible donors. “please do everything to save her. it does not matter how much it costs.” the family members shouted. the long night began. as the temperature dropped with the sunset, so did the patient’s blood pressure. a dopamine drip was started. after a few hours, we reported to the attending: “her blood pressure is not improving, there is no urine production, and her abdomen is inflated and hard." a long discussion took place between the attendings. would taking this young mother to the operating room for a second time be the best decision? would it mean giving the family false hopes? what about the staff and hospital resources? the patient was again taken to the operating room, the family crying and screaming in the hallway, begging god to deliver her from death: “it's too soon. she just became a mommy." it was dark outside and hot inside. i continued to attend to my many responsibilities. one of the nurses told me they needed more hands in the operating room. as i changed and scrubbed, i thought, “ok, let me go and help, maybe my extra hands can be of some help." she was bleeding profusely. with my hands inside her abdominal cavity, i realized we could not stop the bleeding. what could we do? my hands were of no help, my mind understood what was happening, but my soul was far away. i could not connect emotionally or spiritually with this critically ill patient. as i walked out of the operating room, the family was standing aligned in the hallway, looking into my eyes to find hope. “please tell us doctor, how is she? you were able to save her, right?” i did not know what to say. my mind was present, but my soul was absent, unable to transcend the physical and temporal situation. the attending physician announced, “she continues to bleed.” the young mother was brought back to her room. the family entered quickly to accompany her. as i walked into her room, i found the family on their knees, singing with hands extended up towards the sky praying to god, awaiting a miracle. i looked at the patient, intubated. there were no more smiles on her face. her hair was wet and her abdomen distended. we were called at five in the morning. the nurses were concerned that the patient’s clinical situation had worsened. we evaluated the patient and called the attending. we decided among ourselves not to perform any resuscitative measures. it was now the second day of the year. she would die in less than 24 hours. all of a sudden, my soul returns and speaks to me. now, in full awareness of it, i am in shock. what has happened? what hope or comfort could i provide? my hands were of no help to the patient, so i left them behind. 94 colon-gonzalez nov 2014. christian journal for global health, 1(2):92-94. i asked myself: “can you comfort their soul? how do you answer the family’s why questions when you do not have answers?” her family saw her as a mother, daughter, and sister. i had seen her as a patient. as i turned around, i saw my attending praying with the family, and i realized that i was not trained for this. i cannot reach the soul, but god can through us. from life to death in less than 24 hours: do we really comprehend how fragile life is and become stronger physicians, able to live these and other stories? when we cannot stop death from visiting our patient, we can continue to be servants of god by comforting the souls of those remaining alive. i learned not only how vulnerable humans are, but also the importance of stopping our business to attend those left behind. after this experience i learned it is appropriate to ask family members if we can pray for them. it is at this moment that we recognize the need to provide comfort and reach their soul in time of pain. it is this time that we acknowledge the power of the holy spirit and our limitations as physicians. competing interests: none declared. correspondence: maria colon-gonzalez. colongonzale@uthscsa.edu cite this article as: colon-gonzalez m. helping hands or comforting the soul? christian journal for global health (november 2014), 1(2):92-94. http://dx.doi.org/10.15566/cjgh.v1i2.43 © colon-gonzalez m. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:colongonzale@uthscsa.edu http://dx.doi.org/10.15566/cjgh.v1i2.43 http://creativecommons.org/licenses/by/3.0/ opinion piece may 2019. christian journal for global health 6(1) judeo-christian influence on global health, human rights, and justice john patricka a mbbs, bs, mrcp, md, president and professor of the history of science, medicine and faith, augustine college, canada we were asked to look into what accounted for the... pre-eminence of the west all over the world... at first, we thought it was because you had more powerful guns than we had. then we thought it was because you had the best political system. next, we focused on your economic system. but in the twenty last years, we have realized that the heart of your culture is your religion: christianity. this is why the west has been so powerful. the christian moral foundation of social and cultural life was what made possible the emergence of capitalism and then to democratic politics. we don’t have any doubt about this. only by accepting [christian] understanding of transcendence as our criterion can we understand the real meaning of... freedom, human rights, tolerance, equality, justice, the rule of law, universality and environmental protection.1 -chinese scholars quoted by niall ferguson universal global health, human rights, and justice are all problematic ideas. they are not an inevitable development of civilization, but a consequence of previous religious and philosophical influences. definitions, distinctions, and limitations are, therefore, necessary preliminary steps. human rights and justice are very different in different cultures. in a tribal society, loyalty to family, clan, and tribe are far more important than any universal concepts, such as the practice of truth-telling. both loyalty and truth are virtues, but which one trumps makes a lot of difference. where loyalty dominates, everything depends on “who you know.” where truth dominates, “what you know” prevails. only jews and christians, and then only at their best, have managed to put truth first, and it has played a large part in the development of science and medicine in particular. the more fatalistic a society is, the less the sense that things can really change. the idea of fate and reincarnation makes it very easy to rationalize doing nothing for those whom our world calls the under-privileged. indeed, hinduism can legitimately say that no one should interfere with karma; let reincarnation work everything out. three and a half millennia ago, the people of israel were given the torah and were told obedience would lead to flourishing. it included codified rights for the foreigner, but they were not the same as those for the native born. christianity soon promulgated the idea of equality in christ—neither jew nor greek, neither male nor female in christ (gal 3:28). although still working out what this means, the west has led the world in implementing equality. we have our problems with utopian dreams. even when we acknowledge rights politically, we 21 patrick may 2019. christian journal for global health 6(1) still have a parochial hierarchy of who gets what. the elite in their gated communities have a very different view of rights from those who are pushed out of their traditional communities by militant immigrants forming their own ghettos. universal human rights do not come naturally; neither is the problem merely one of ignorance. without the will and cultural norms supportive of the concept of rights and the capacity to enforce them, mere declarations will only raise expectations that will be frustrated and produce envy and resentment. a good start is to distinguish real rights, with obvious and undeniable reciprocal duties, from pseudo-rights, with no such undeniable obligations. rights and responsibilities the more christian concept would be to talk about human responsibilities, which were set out in the torah as being founded in loving god with all our hearts, souls, and minds and in loving our neighbours as ourselves. unfortunately, we do not live like that. our wills are too weak (think about how long new year’s resolutions last). note however, we do not have a deficit of knowledge. we have all been taught a lie: that we can do whatever we set our minds to do, that the only barrier is ignorance. the university is almost necessarily committed to this view but, sadly, the barrier is the will, not ignorance. a simple example in the western world is how in the last 50 years the cause of most disease has changed. it used to be that god or nature was thought to be the cause for all diseases except sexually transmitted infections, or stupid accidents and alcoholism. but now, at least in part, human behavior is the cause; not ignorance, but simply diminished character and will. no great scientific advances are needed; we just need to do what we already know. everyone knows that if you do not eat excessively you will not gain weight, but we have a global epidemic of obesity that is tragically destroying many lives. education programs do not work well. even if weight is lost, it returns in a few years. what is even more astonishing is the utter incapacity or, more precisely, unwillingness of the medical profession and the political and public health elite to connect the dots and acknowledge the spiritual factor in global health. if one is ill because of behavior and those you love are suffering with you because of that behavior, it is impossible to avoid an ongoing burden of guilt. if the guilt entailed is not acknowledged and dealt with spiritually, no cure will be achieved. just scan the index of any textbook of medicine to find a discussion of this guilt, and you will search fruitlessly. the politically correct world does not like to realistically discuss human nature. nevertheless, as chesterton put it—surely the only incontestable judeo-christian doctrine is the fall.2 any coherent understanding of health, justice, and rights must start from that reality. starting from a utopian view of human nature, we will get to false and very expensive policies. the fact is that the decline of the christian ethos in the west has been associated with a dramatic increase in diseases with major behavioral components. we used to be ashamed of these, but this ought not to be a surprise but an expectation. the logical inverse that those who live in traditional believing communities should be much healthier than those who do not is true. that “truth” has huge implications and is now extensively documented.3 one obvious demonstration of the tacit acknowledgement of the cultural crisis we are facing is the introduction of ethics courses into professional training. they do not work for perfectly logical reasons. the current teaching of ethics in medical school illustrates what cs lewis recognized a long time ago, that most heresy is a good thing in the wrong place. the georgetown mantra of autonomy, justice, beneficence, and non-maleficence are almost never taught as ordered goods. the order they are in is drawn from our cultural preferences, but believers should see that the reverse is the biblical sequence. 22 patrick may 2019. christian journal for global health 6(1) when the israelites were given the law, the ten commandments were things not to do! nonmaleficence is the foundation from which the desirable but often unachieved beneficence can be set as a target. only then is justice possible and necessary if autonomy is not to degenerate into anarchy. the real problem is the erosion of trust which can only be based on knowledge of character, which is what one does even when no-one is watching. robert fogel, university of chicago nobel laureate in economics, has discussed this in his book the fourth great awakening.4 justice needs more space than i have been allotted but, fortunately, arthur leff gave a magnificent account 40 years ago in the duke law journal. here is my shortened version of his opening statement of the problem of justice in the modern world: i want to believe and so do you, in a complete transcendent and comprehensible set of rules directing us how to live our lives righteously. [he understands if the law does not come from god there is no authority to control the judges.] but i also want to believe and so do you in no such authority but rather that we are wholly free to decide for ourselves what we believe and what we will do. what we want, heaven help us, is to be at the same time to be perfectly ruled and perfectly free; that is to simultaneously invent and discover justice.5 he goes on to brilliantly discuss this conundrum. thus, the jews gave us justice but we are steadily eroding its transcendent foundations. when lenin said it will be necessary to legalize terror, he was merely describing what all “utopian” regimes do. universal or relative human rights rights, too, are not so culturally transposable as we would like to think. to have a functional theory of universal human rights, we must be able to trust that a degree of a particular form of altruism exists in all societies. we live in a time where the fear of god is rapidly diminishing and, without it, only utilitarian ethics can be realistically proposed, but that system cannot support altruism. it is much more an ethics of “what can i get away with?” than one of “what ought i to do?” the best discussion of this problem i know is by david stove.6 moral relativism is the inevitable result. it is received with mother’s milk. the following quotation makes my point: if relativism signifies contempt for fixed categories and men who claim to be the bearers of an objective and immortal truth... from the fact that all ideologies are of equal value, that all ideologies are mere fictions, the modern relativist infers that everybody has the right to create for himself his own ideology and attempt to enforce it with all the energy of which he is capable.7 we really must recognize that choices come with logical consequences, whether we recognize them or not. if we deny real transcendent good, we have no valid arguments against the above comment or its fascist manifestation. the law becomes the pursuit of power rather than the pursuit of justice. respect for law and the practice of democracy are both fragile flowers; they flourish only in particular soils and are rare. every society has some sort of ethical code. moses reminded the children of israel in deuteronomy 4 that their god is greater than those of the surrounding tribes who will recognize that by seeing how wise the torah is. but he also reminds them that, despite the experience at mount sinai, they will not keep their promise to obey. the seduction of other gods, who command the kind of 23 patrick may 2019. christian journal for global health 6(1) sexuality which man is prone to desire, was as overwhelming as it is in our day where sexual libertarianism turns freedom into addiction. true freedom is not the freedom to do what you wish, but the freedom to do what you ought. in the abolition of man, cs lewis put it like this, “for the wise men of old, the cardinal problem of human life had been to conform the soul to objective reality, and the solution had been knowledge, self-discipline and virtue... [for modern man] the problem is how to subdue reality to the wishes of men and the solution is technique.” 8 why is it necessary to build a discussion of how to achieve global health, justice, and human rights by using history, theology, and philosophy? because these things do not come easily, and history helps us to understand their origins. christian conversion and the growth of a recognizably christian ethos have very different timelines. in the acts of the apostles, the church grew quickly, but it was not long before social problems came to the fore. conversion makes one redeemed, but paul’s epistles show how he had to labor long and hard for the mind and character of christ to be formed in the infant church. it was fortunate that by the grace of god the early church was dominated by those formed by the long history of israel, particularly, honouring and obeying the law, the prophets, and the writings. deepening for development the amazing missionary work of the 19th century successfully planted the gospel in places where it had never been heard, but training in righteousness was rather thin. making disciples takes time. rwanda is a tragic case study. mass conversions happened during the early 20th century rwanda revival, and one can still find people for whom it is still an event remembered with joy. but the joy of conversion was not followed up by anything approximating paul’s teaching. after the horrendous carnage of the tutsi and hutu conflict, i spent the summer of 1995 teaching in the hutu refugee camps. perhaps 80% of rwandans went to church, but it had not prepared them to deal with the tribal conflict of the rwandan civil war. the first question i was asked by repentant hutus was, “how could we, who called ourselves christians, kill people we knew?” the answer, of course, was, “welcome to the club.” all religious groups have been guilty of humanitarian injustice and secularists (also a belief system) have outdone them in the 20th century. knowing that history was exactly what they needed to hear. then, it was time to deepen their account of conversion, introduce them to discipleship and the formation of a christian character from a deep engagement with the sermon on the mount, and, most importantly, jewish child rearing practices as in deuteronomy 4-6. we do not know how to do development. so, we have largely useless courses in social sciences pretending that they know. if we knew, we would do it. most cultures flourish for a while and then fade away. toynbee proposed that it is possible to identify cultures about to decline and, by inference, identify some key factors in building a functional, materially successful culture. he placed moral consensus at the heart of the matter; once lost, the decline had begun.9 robert fogel said much the same in the fourth great awakening.4 moral consensus builds trust, and trust is essential to effective development work. the western moral consensus cannot be derived from a darwinian account of humanity, as atheist david stove has brilliantly demonstrated in darwinian fairytales.5 quite indubitably, we are in a phase of diminishing trust as the explosion of locks, keys, gratings, and surveillance cameras demonstrate. law is a codification of moral consensus, especially the miracle of common law. we used to be proud of our justice system; now we see far too often there is one law for the rich and another for the poor. the torah implies that we all know a lot of moral truth. cain was warned by god that he was about to do evil (gen 4:6-7). moral truth 24 patrick may 2019. christian journal for global health 6(1) and justice are written on our hearts. children know it; how else does one account for “not fair” being very close to the first words they speak. in the bible, there is no discussion of how justice develops but simply the injunction, “be just as i am just” (mat 5:48). god has written on our hearts the starting premises. our job is to think them out. at the american founding they knew this. harvard, yale, princeton, dartmouth, and the university of chicago all had protestant christian foundations, but we gave them away by dereliction of our intellectual duties as detailed by marsden. 10 universal foundations the central intellectual miracle of judaism is torah, and its central theses are presented as words spoken by god and, therefore, undeniable. because of it, they were thinking about morality and justice when europeans were constantly engaged in tribal carnage. this history is vitally important because, without the fear of god as transcendent law-giver, we sink into a swamp of values language. simply put, we cannot exist without authority. my values versus your values is a recipe for conflict in which power replaces justice. remember lenin’s comment about utopian states. in the soviet union, the kgb were feared and ubiquitous; thus, in the sixties, it was possible to walk the streets of moscow without fear of being mugged. fear controls, but it does not encourage or inspire. russia destroyed its proud tradition of independent enquiry. solzhenitsyn catalogued the debacle of the soviet revolution in the gulag archipelago, a must-read book for those interested in how government can get it wrong.11 so why do the jews survive and flourish? they win a disproportionate percentage of the nobel prizes every year. muslims win very few indeed. science, as we know it, started at the end of the 13th century, long before the so-called renaissance. culture matters. this is where our thinking about global health, human rights, and justice must start. if you question thoughtful, believing jews about their intellectual success, without any development programs (also a much undiscussed feature of the history of the usa), they will take you back to deuteronomy – the world’s greatest commencement address. moses is telling the children of israel what will be necessary if this rabble of ex-slaves are to become a just nation. obeying god’s grace-filled laws is where it starts, but that is not all. it must continue with the teaching of the stories of the bible to the children at the dining room table. children before the age of seven have incredible memories. if those early years are used to imprint all the stories of the bible in their minds, they will have a moral reference code for life. there is no need of any discussion of the meaning of the stories when they are young; that comes later. why are the jews so successful? because, unlike all other national histories, they tell the truth that we are all sinners, but god works with those who keep short accounts with him. everything in jewish history has consequences; no one gets away with anything! for a child to grow up knowing this truth in the depth of his/her being is an incredible asset in our lying world and a key to human flourishing. this is further developed in a talk entitled why are there no hittites on the streets of new york?12 so how are we doing? a test of biblical literacy is available at https://www.johnpatrick.ca/ meaningmetaphor-and-allusion/. westerners are increasingly post-christian people living in a softly nihilistic world. be afraid, be very afraid of hard nihilism. what comes next is brutal. conclusion development is dependent upon culture. we need to be culture builders starting with the old testament, which will change family structure at the earliest stages of the life cycle. america had no development programs, but it did accept judeochristian accounts of human nature and law. that https://www.johnpatrick.ca/%20meaning-metaphor-and-allusion/ https://www.johnpatrick.ca/%20meaning-metaphor-and-allusion/ 25 patrick may 2019. christian journal for global health 6(1) was enough. most americans have not read detocqueville’s democracy in america.13 he came from the french revolution to try and understand why america’s revolution succeeded and commented that it was only when he went into the churches of america did he understand. this success is fragile. biblically-informed teachers who know and love the story of how jesus changed the world are needed to give the world a love of god and neighbor, and provide sustainable learning which will lead to progress in development, global health, justice, and human rights for all. references 1. ferguson n. civilization: the west and the rest. london: penguin books; 2011. 2. chesterton gk. orthodoxy. new york: john lane; 1908. 3. koenig hg. religion, spirituality, and health: the research and clinical implications. isrn psychiatry. 2012 dec 16;2012:278730. https://doi.org/10.5402/2012/278730 4. fogel rw. the fourth great awakening. chicago: university of chicago press; 2000. 5. leff aa. unspeakable ethics, unnatural law. duke law j. 1979: 1229-49. https://doi.org/10.2307/1372118 6. stove dc. darwinian fairy tales. new york: encounter; 1995. 7. kreeft p. quoting benito mussolini in a refutation of moral relativism. ignatius press; 1995. 8. lewis cs. the abolition of man [reprint]. new york: harper one, 2001. 77. 9. toynbee a. a study of history. oxford: oxford university press; 1947. 10. marsden gm. the soul of the american university. oxford: oxford university press; 1994. 11. solzhenitsyn a. the gulag archipelago. new york: harper and row; 1973, 1974, 1976. 12. patrick j. why are there no hittites on the streets of new york. audio talk available from: https://cmda.org/product/just-add-water-dvd-whyethics-courses-why-there-are-no-hittites-in-newyork/ 13. detocqueville a. democracy in america. london: saunders; 1835. submitted 9 april 2019, accepted 26 april 2019, published 31 may 2019 competing interests: none declared. correspondence: dr. john patrick, president and professor, history of science, medicine and faith, augustine college, canada. (www.augustinecollege.org) johnsallypatrick@gmail.com cite this article as: patrick j. judeo-christian influence on global health, human rights, and justice. christian journal for global health. april 2019; 6(1):20-25. https://doi.org/10.15566/cjgh.v6i1.305 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.5402/2012/278730 https://doi.org/10.2307/1372118 https://cmda.org/product/just-add-water-dvd-why-ethics-courses-why-there-are-no-hittites-in-new-york/ https://cmda.org/product/just-add-water-dvd-why-ethics-courses-why-there-are-no-hittites-in-new-york/ https://cmda.org/product/just-add-water-dvd-why-ethics-courses-why-there-are-no-hittites-in-new-york/ http://www.augustinecollege.org/ mailto:johnsallypatrick@gmail.com http://creativecommons.org/licenses/by/4.0/ editorial sept 2018. christian journal for global health, 5(2):1-2. welcoming the stranger: responding to the global refugee crisis daniel w. o’neill a a md, ma(th), managing editor with 68.5 million people forcibly displaced worldwide, and 25.4 million refugees, there is a global need that is unprecedented in scale. 1 85% of the world’s displaced reside in developing countries, and the global church is faced with how to respond to this crisis. what does our lord require in response to this reality? i addressed this question at an inter-faith roundtable discussion at a conference at princeton university march 3-5, 2017 called seeking refuge: faith based approaches to forced migration. 2 from a christian perspective, i shared that all people are made in the image of god and deserve respect. abraham was blessed to be a blessing to all nations. foreigners (ger) were included under the same laws in the torah because of god’s love for them and the call to love our neighbor (lev 19:18). the messiah reaffirmed this as the sum of the law and the prophets (lk 10:27). one of the purposes of the shabbat was to refresh the foreigner living among the people of god. israel was considered a foreigner even in their own land and historically were refugees from egypt, which created solidarity with the displaced. “you and the foreigner will be the same before the lord,” with equality and unity in worship (num 15:13-16). inclusiveness is written into the structure of the temple, and john’s eschatological vision of the inclusive society included all peoples (rev7:9). “the leaves from the tree of life are for the healing of the nations.” (rev 22:2) yhwh directed the establishment of six levitical cities of refuge in palestine which showed a pattern of trans-cultural permanency in god’s intention for humanity (num 35:6-29). these cities were safe havens for jews and foreigners, and each carried significant hebrew names (“set apart”, “to carry a burden”, “fellowship/collaborative”, “protected”, “lifted up”, and “enfolding joy”), expressing the heart of god and the call to his people. these accessible cities allowed refugees to be assessed, then incorporated/protected from blood vengeance cycles, with the goal of repatriation. in the torah, justice, provision and a portion of the tithe were intended for the “fatherless, the foreigner and the widow” – specifying the most vulnerable. the law’s moral imperative was reiterated and read publicly. the prophets expounded social justice to the foreigner and spoke judgment against those who mistreat the foreigner. jesus, once a child refugee, identified himself with the foreigner, the oppressed – “if you support them, you’re supporting me” (mat 25). god himself is a refuge for the oppressed (ps 9:9), and the covenant community can become a refuge for others. paul calls for the practice of hospitality (philoxenia) “love to the stranger” in contrast to xenophobia. we (as well as the prophets) are sojourners, in solidarity with refugees, as we long for a permanent dwelling (phil 3:20). perfect love drives out fear, and is the moral imperative of christ followers (1 john 4:8). though there is an existing disconnect between belief and practice, fear and overcommitment to safety, and conflation of political loyalty with the gospel; there is emerging interdenominational commitment – a call 2 editors sept 2018. christian journal for global health, 5(2):1-2. to return to the character of god, the words of the prophets, unity and to the supreme example of the messiah toward the stranger. given the body of biblical support, in both the old and the new covenants, it is surprising that attitudes towards refugees in the christian community can at times be ambivalent, or at worst xenophobic. how can christian educators, leaders and practitioners justly and effectively respond to the challenge of displaced populations following the way of jesus? in this issue, we present several perspectives and approaches to responding to the current global refugee crisis. professor boan and colleagues present a novel distributive justice approach from a network of churches which address conflict in the kakuma refugee camp in kenya. costello and von kalm offer a commentary on the approach christians should take in response to asylum seekers on the shores of australia, which can be applied in many other geo-political contexts. suleiman, et. al. present a case report which analyzes a church-based health home care model which was applied in jordan among syrian and iraqi refugees. agner presents an inspiring field story of his experience in central europe along the stream of syrian refugee migrations. in addition, we offer reports from the annual meeting of the consortium of universities of global health, focusing on refugee care, climate change, a global health debate, gender and economic disparities, research and publication. we hope this overview gives a glimpse of some of the global health issues we are facing and which demands a faith-inspired and articulate response. in the face of nations reeling from conflict, disaster, and dislocations, we hope to be better equipped in order to participate in the healing of the nations. why do the nations conspire, and the peoples plot in vain? . . . blessed are all who take refuge in him. 3 references 1. united nations high commission for refugees. statistical yearbooks. figures at a glance. [internet] available from: http://www.unhcr.org/figures-at-aglance.html 2. office of religious life. princeton university. seeking refuge: faith-based approaches to forced migration. 3-4 march, 2017. available from: https://religiouslife.princeton.edu/programsevents/interfaith/poverty-peacemaking/pdfs 3. psalm 2. holy bible. new international version. www.cjgh.org http://www.unhcr.org/figures-at-a-glance.html http://www.unhcr.org/figures-at-a-glance.html https://religiouslife.princeton.edu/programs-events/interfaith/poverty-peacemaking/pdfs https://religiouslife.princeton.edu/programs-events/interfaith/poverty-peacemaking/pdfs short communications april 2020. christian journal for global health, 7(1) a biblical model for a christian hospital in india in the time of covid-19 vijay anand ismavela a ms, mch, former director, makunda christian leprosy and general hospital, bazaricherra, assam, india today is palm sunday, the beginning of the christian “passion week.” normally, today, christians all over the world would have walked streets outside their churches with palm fronds, enacting jesus’s entrance into jerusalem, leading on to the train of events that led to his death and resurrection. palm sunday 2020, however, is different. churches all over the world are closed. most villages, towns, and cities are under various restrictions — from social distancing to lockdowns. people are on their phones — talking, chatting, and posting on social media. the discussions are all about one thing — the covid-19 pandemic. as of today, over 1.2 million people are infected and over 65,000 have died.2 the jewish world is about to start their passover festival; this year it will also be celebrated across the world in similar conditions as passion week, from the 8th to the 16th of this month. we read the story of the passover in exodus 12:12-18. the nation of israel was in bondage to the egyptians. the ruler of the egyptians, the pharaoh, would not let them free; they were his source of cheap labor. the early chapters of exodus talk about this situation, the story of moses and god using him to deliver the israelites from the clutches of the egyptians through 10 plagues. the last plague was the death of every firstborn in the land. the israelites were pre-warned of the impending plague and were told to anoint their doorposts with blood from a sacrificial lamb. when the angel of death swept through the land killing the firstborn, he “passed over” the homes where there was blood on the doorposts. we too, like the israelites, should put our faith in the shed blood of the lamb. the world today is gripped by a powerful pestilence, killing large numbers of people from even the wealthiest and most powerful of nations; all their power and wisdom is unable to stop it. we too have no power over this pestilence, but like the israelites, we can put our faith in our god, who made heaven and earth. he sends his angels to watch over his people and like the israelites in the days of moses, we too can be at peace and without fear. our mission hospital in assam, india has started to approach this crisis situation with a biblical model. it comes from the first six chapters of the book of nehemiah. nehemiah started his story from the city of susa, where he heard about the sad predicament of the people of judah and the city of jerusalem. it is like our situation today, as we hear about the worsening crisis across the world. he knew that this situation was due to the unfaithfulness of god’s people (neh 1:8), but at that point in time, the priority was to restore the integrity of the city and its walls (neh 2:5). he approached the king and was given supplies and assistance to complete this task. he was given authority, in fact, he was made the governor. he inspected the city and its walls and took stock of the situation (neh 2:12-16). we too should understand and take stock of the situation. through electronic mass media, we can be up to date on what is happening around the world. we know that this pandemic originated in china and then rapidly spread across the world through traveling 28 ismavel april 2020. christian journal for global health, 7(1) infected people. it is now spreading from person to person. each infected person is expected to spread the disease to two others, if given the opportunity to interact with uninfected people. if nothing is done, millions will be infected, and many will die. scientists are constantly studying this disease as it evolves, and we are learning how to manage the situation and minimize morbidity and mortality. having understood what he was up against, nehemiah made elaborate plans. he appointed key leaders to take responsibilities for rebuilding different parts of the walls of jerusalem. when faced with ridicule by his enemies, he responded by ignoring them, showing single-minded determination to complete the task given to him and by prayer. when there was a threat of physical violence, he arranged for workers to continue working with construction materials in one hand and a weapon in the other (neh 4:1516). we too have the responsibility of treating our patients while protecting ourselves and others from getting infected. at our hospital, the local government has designated us as a non-covid emergency hospital. people need a safe place to go for their deliveries, strokes, and heart attacks, bowel perforations, and obstructed hernias. in the future, we may be called upon to work with covid patients, too, if government facilities are overwhelmed. our hospital has created a task force that has readied the hospital to tackle this situation. separate teams have been formed, personal protective equipment (ppe) is being made with what we have, different areas have been designated for different patients, and protocols are in place. we, too, are preparing to fight on two fronts. in the 5th chapter of the book of nehemiah, we see him hearing about the plight of the poor and needy. although his task was to repair the walls, that could not be his only priority. his target population was suffering, and they were the focus of the exercise, not the stone walls and wooden gates. therefore, he steps in and asks people to forgive the debts of the poor and give loans without interest. in this moment of crisis, let us also consider the people we have been called to serve. many of them were already poor and marginalized, this situation will make them destitute. they have just become financially vulnerable and in danger of losing their vital assets. if we force the poor to pay their bills for bringing their loved ones to our hospitals and their children to our schools, we would inflict greater pain than the virus. let us think about how we can be a blessing to the underprivileged communities we have been called upon to serve. we may ask, aren’t we running out of money too? we don’t have enough to pay our bills and salaries. we must remember that god is no man’s debtor. the bible tells us that when we treat the poor, he will pay their bills and reward us (proverbs 19:17). later in the 5th chapter, we see nehemiah counting the costs of the work entrusted to him. he finds that resources are short and the task is great. he decides to set a personal example by not claiming what is his due as a governor. when crisis situations arise, we (and our families and friends) should consider a period of austerity and sacrifice for the people we are called to serve. makunda went through periods of severe crisis in the past. each time, bills accumulated, due amounts were demanded by various people, salaries were deferred, and many staff donated from what they had to keep the work going. projects had been started which could not be closed, and staff contributed to enable them to continue. today, they are institutions on their own: the 1200 student makunda christian higher secondary school, the school of nursing, and the branch hospital at ambassa in tripura. to enable these to become reality, staff were willing to wait for 14 years for running water and electricity to 29 ismavel april 2020. christian journal for global health, 7(1) be supplied to their homes. some staff did not take their eligible leave so that the hospital did not have to pay for replacements. today, we too have an opportunity to help our institution continue to serve its target people by giving of our time, talents, and treasure. we are lending to god and will be repaid with things that money cannot buy, peace and contentment in this world and riches in heaven. we read in chapter six that nehemiah firmly denied lies from his enemies and finally completed the task in 52 days. only then did he start working on solving the root causes of the problem, the disobedience of god’s people. we too need to work hard and diligently to get through this crisis now. when the threat has passed, we can study the entire experience and put in place protocols and practices to help us do better the next time we face another crisis. we hear about fear in people facing this crisis, but we have nothing to fear. in romans 14:8, paul writes that whether we live or die, we are the lord’s. for christians, life does not end with our physical death but continues on forever. we are god’s ambassadors from the kingdom of heaven, temporarily posted to this world. we will all die one day, but we are at peace. we have handed over our lives into the hands of our loving commanding officer. we are dispensable, and he can choose the manner and timing of our deaths. our only concern is that during the time given to us in this world, we live lives that find approval in his sight by trust and obedience and to complete the tasks given to us. conclusion the 23rd psalm is a much-loved chapter in the bible. in verse 4 we read, “even though i walk through the valley of the shadow of death, i fear no evil, for thy rod and thy staff, they comfort me.” i remember suffering an acute myocardial infarction, rolling about in pain on 2008 october 12.3 i felt as if someone was trying to pull the life out of me, but i was held on because god told me that he had some more work for me to do before i go to be with him. in verse 6, we read, “surely goodness and mercy will follow me all the days of my life and i will live in the house of the lord forever.” may we submit our lives to him as we face this crisis and be found worthy of this promise, for this world and the one to come. references: 1. makunda christian leprosy & general hospital, assam, india. http://www.makunda.in/ 2. channel news asia. covid-19 map. accessed 4 april 2020. available from: https://infographics.channelnewsasia.com/covid19/map.html 3. ismavel va. an encounter with myocardial infarction. the sparrow’s nest. blog. 1 nov 2011. available from: https://thesparrowsnest.net/2011/11/01/an-encounter-witha-myocardial-infarction/ competing interests: none declared. correspondence: dr. vijay ismavel, assam, india. ivijayanand@yahoo.in cite this article as: ismavel va. a biblical model for a christian hospital in india in the time of covid-19. christian journal for global health. april 2020;7(1):27-29. https://doi.org/10.15566/cjgh.v7i1.371 © author this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://www.makunda.in/ https://infographics.channelnewsasia.com/covid-19/map.html https://infographics.channelnewsasia.com/covid-19/map.html https://the-sparrowsnest.net/2011/11/01/an-encounter-with-a-myocardial-infarction/ https://the-sparrowsnest.net/2011/11/01/an-encounter-with-a-myocardial-infarction/ https://the-sparrowsnest.net/2011/11/01/an-encounter-with-a-myocardial-infarction/ mailto:ivijayanand@yahoo.in https://doi.org/10.15566/cjgh.v7i1.371 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ references: historical review nov 2014. christian journal for global health, 1(2):48-62. global health after pentecost: toward theological reflection as a religious health asset matthew t bersagel braley a a ma, phd, assistant professor, college of business and leadership, viterbo university, usa abstract this article examines the recent turn on the part of global health leaders to christian communities as allies in the response to the hiv pandemic. a cursory survey of this turn highlights how global health leaders have used the language of religious health assets to revalue the activities of faith-based organizations, including christian churches. in this way, religious health assets — tangible and intangible — become valuable if they can be rendered intelligible and appreciated using the existing lexicon and logic of global health. as a result, the primary activity of religious entities in partnerships with global health institutions is limited to conforming their practices to the best practices of hiv programs. but a closer examination of this revaluation reveals how it obscures a distinctive dimension of christian participation, namely, critical theological reflection. the current turn to religion as a global health ally presents an opportunity to reimagine the spaces in which complex social phenomena are described, interpreted, and responded to. christians live into the role of co-participants in these spaces when they seek to develop a greater competence for engaging the complex arena of global health policy and programming. this competence emerges from demonstrating understanding of the empirical context in which global health is carried out as well as showing in an imaginative and compelling manner how the theological resources from their own tradition illumine the patterns and processes of human suffering. we have a unique presence and reach within communities. we have unique structures and programmes that are already in place. we are available. we are reliable. and we are sustainable. we were there long before aids came and we will still be there when aids goes away. rev. canon gideon byamugisha 1 introduction2 the 2008 international aids conference in mexico city began with a gathering of people witnessing an evocative religious ritual. reverend mark hanson, presiding bishop of the evangelical lutheran church in america and president of its global communion, the lutheran world federation, knelt down to wash the feet of two women 49 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. living with the human immunodeficiency virus, or hiv. the act, carried out in front of hundreds who had gathered for an ecumenical discussion on the theme, ―faith in action now,‖ rendered dramaturgically the participants’ regret over the failure of christian churches throughout the world to respond compassionately and courageously in an hiv-infected world. as hanson explained to those gathered for the conference, ―i am absolutely convinced that we as religious leaders and we in the religious community that so shunned and shamed people with hiv and struggling with aids . . . must begin by first engaging in public acts of repentance. absent public acts of repentance, i fear our words will not be trusted.‖ 3 for many at the pre-conference, as well as the many more attending the seventeenth international aids conference, it was a powerful and necessary image of the church penitent. for others, however, it was an image that had already been overplayed. yes, many churches had been slow to respond in the early years of the pandemic, but that initial hesitation had been more than matched by the zeal with which religious organizations had embraced and, at times, led the global response to hiv. the existence of a pre-conference event specifically for religious communities in and of itself suggested a formal recognition of what had been for years informal networks of religious leaders and communities providing support for persons and communities affected by hiv and aids. the suggestion that churches had not been sufficiently involved in the global response to hiv and aids must have seemed a bit strange to those who stuck around past the pre-conference as well. the workshops and presentations that constituted the much larger gathering of biologists, social scientists, community leaders, and dignitaries were animated by discussions of religion and the role of faithbased organizations in the response to aids, particularly as global health organizations and nation-states worked together to meet the millennium development goals’ ambitious — and behind schedule — plan for universal access to antiretroviral drugs by 2015. a special faith-themed pre-conference hardly seemed necessary. among global health leaders, the turn to religious entities as an ally, and not an obstacle, in the response to hiv had already taken place. and among religious leaders, hanson’s own lutheran communion, in particular, the turn of religion to global health organizations that could help them meet the pressing needs of persons living with hiv and aids (plwha) was well under way, as evidenced by denomination-specific publications and church-wide units focused on aids as well as the explosion of ecumenical meetings and workshops on the practical dimensions of scaling-up access to antiretroviral treatment. 4 bishop hanson was not the first religious leader to be featured so prominently at the international aids conference. four years earlier on the stage of the fifteenth international aids conference held in bangkok in 2004, reverend canon gideon byamugisha gave voice to the potential of religious entities as allies in global health. byamugisha became the first religious leader to ascend to the plenary dais of the international aids conference. reading from a statement of commitment signed by heads of african protestant churches in the run-up to the conference, byamugisha made clear that the churches and church networks have significant potential to be an asset to global health in the response to hiv and aids. he noted that the all africa conference of churches (aacc) represents over 140 million christians in africa. if, as aacc leaders resolved, every congregation becomes a ―centre for health, healing, and treatment‖ and all faithaffiliated health facilities ―havens of compassion,‖ then those 140 million christians become part of the frontline response to the pandemic. 5 churches and their networks, in this framework, become health assets — increasingly valuable assets — as ambitious global health targets for rolling out aids treatment come and go unmet. 6 this does not imply that religion is an unmitigated good for global health; byamugisha recognizes the friction points: ―some of us are still preaching condemnatory and stigmatizing sermons and approaches to hiv/aids.‖ 7 however, it does 50 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. suggest the practical reasons why partnerships between christian entities and global health organizations have increased in the past decade. 8 these practical reasons open up the possibility of a discursive shift, rendered metaphorically below as a move from global health after babel to global health after pentecost. that is, tensions between claims from theological and nontheological descriptions or interpretations of human suffering become catalysts for clearer thinking about the causes of the tension, rather than an indictment of the incommensurability of the different modes of knowing. to move towards doing global health after pentecost is to begin with the premise that theological and nontheological discourse describes the same phenomenon, in this case, human suffering related to hiv and aids. even though we continue to recognize varying degrees of compatibility between accounts from virologists, theologians, counselors, epidemiologists, etc., the meaning of the phenomenon emerges out of the mutually generative interaction among all those who participate in the discourse and seek to ―maximize coherence and minimize incoherence.‖ 9 religious entities as relevant: the turn to religion in the time between byamugisha’s bold claims from the plenary dais to hanson’s footwashing, a growing body of empirical research emerged documenting the activities of religious entities in the global response to hiv. 10 the first part of this article provides a snapshot of this research in order to show what christian entities are actually doing and, equally important, how the terms for revaluing christian participation in global health have been largely determined by scientific and policy discourses selectively attentive to religious activity. 11 there are now a significant number of correlational studies focused on understanding how religious entities affect persons and communities impacted by hiv and aids in sub-saharan africa. empirical studies and arguments published range across fields (and their subfields) as diverse as community psychology, sociology, public health, anthropology, medicine, nursing, sexuality studies, law, and, even, conservation biology. 12 this work suggests that many scholars in diverse fields now assume that religious entities are relevant or, minimally, that determining whether or not religious entities are relevant is a legitimate part of the research agenda. the empirical studies at both the individual and organizational level are often correlational, falling into categories familiar to the global health audience: prevention, care, and treatment. representative research questions focused on the individual include the following. is there a correlation between religious affiliation and engagement in risk behaviors associated with hiv transmission? 13 how does religious participation affect dynamics related to disclosing one’s positive status? 14 do persons on antiretroviral treatment benefit from church participation? 15 representative research questions focused on religious organizations include correlational studies. for example, what is the relationship between faith-based organizations and hiv-related stigma? 16 there are also what might be described as primarily descriptive studies. the latter seek to describe what specific religious entities are doing in response to hiv. 17 framed in these ways, the goal of the research is, largely, to clarify for global health practitioners and policymakers the ambiguity about the role of religion. through its identification of specific features of religious practices and beliefs that affect the health of, and health-related strategies employed by persons living in communities impacted by pandemic hiv, the research sheds light on the various ways religious entities contribute to and create obstacles for global health. the results of both the descriptive and correlational studies do not necessarily resolve the ambiguity of religious relevance to global health, however. while some studies suggest that religious participation correlates positively with hiv prevention measures, 18 other studies suggest that socioeconomic factors account for much of this correlation, rendering religious participation largely insignificant, 19 while still others note it is both/and. 20 similarly, at the organizational level, studies provide evidence both 51 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. of religious entities’ active involvement in providing direct assistance to plwha 21 and religious entities largely absent from the provision of direct assistance. 22 these differences in findings simply underscore what for many scholars in religious studies is commonplace: religious entities are not all the same. while this may be stating the obvious, it also serves as an important cautionary note as faith-based and secular global health leaders increasingly tout the ―untapped‖ potential of religion to scale-up the response to hiv. 23 what emerges from these studies, though, is a constellation of explicitly and nonexplicitly religious activities worth paying attention to in global health discussions. this constellation includes religious discourse about hiv and plwha (e.g., messages from the pulpit about hiv-related stigma) and spiritual support for coping with hiv/aids. it also includes attention to broader religious commitments and the activities through which they are enacted that impact the experience of plwha and the response of communities affected by hiv. for example, paying attention to the discourses on gender at play in religious entities can illumine the challenges religious leaders face in generating consistent messages about gender equality and hiv-prevention messages. 24 these activities are in addition to the less distinctively religious activities such as providing a building in which voluntary counseling and testing can be offered or visiting the homes of plwha. in many places throughout africa, these less distinctively religious activities may be provided exclusively by religious entities due to the absence of public health infrastructure. arguably, though, there is nothing about these activities that sets them apart as distinctively religious activities. to clarify, the framings and motivations for offering the church building for voluntary counseling and testing may be distinctively religious, but the activity itself could, presumably, be carried out by a nonreligious entity as well. 25 contrast this with religiously inflected messaging about the inclusion or exclusion of plwha from communion, for example. from the standpoint of global health, all of these activities are relevant. they suggest the potential of religious entities to complement, reinforce, or otherwise support two of the major global health goals in the response to aids: reducing stigma for plwha and increasing adherence to antiretroviral treatment regimens. for example, boulay et al. analyzed survey data from a stigma reduction program in ghana involving national and local religious leaders and concluded that ―attitudes related to a punitive response to plha both improved over time and were positively associated with exposure to the program’s campaign.‖ 26 with regard to increasing adherence, watt et al. showed that despite the persistence of stigma and the lack of church support for plwha, prayer practices supported adherence. 27 in less direct ways, perry et al. identified through a phenomenological study the important role of ―faith, spirituality, fatalism, and hope‖ in ghanaian women’s ―construction of the phenomenon of living with hiv/aids.‖ 28 religious leaders, practices, and meaning-making processes were, according to these studies, worth paying attention to. due to space limits, i have confined my literature review to empirical studies. this same time period witnessed a burgeoning of formal theological and christian ethical reflection on the hiv pandemic and the global response to it. much of the theological work took sub-saharan africa as the context for reflection. taken together, the recent empirical and theological work on hiv suggest a qualitatively different starting point for engaging questions about the positive role of religion in global health than was possible a decade ago. recognizing that diverse religious entities have been involved in a range of responses to hiv for the past three decades, the phrase ―turn to religion‖ is intended to capture something of this qualitatively different starting point as reflected in the increasingly public discourse about, and intentional programming in response to, the hiv pandemic. 29 out of this surge in both the scientific literature on hiv and religion, the concept of religious health assets has emerged as one of the primary frameworks used to understand why and how reli52 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. gious entities are being revalued as both relevant to global health and desirable as allies. 30 a religious health asset, most basically, is ―an asset located [in] or held by a religious entity that can be leveraged for the purposes of development of public health.‖ 31 the concept of religious health assets has been used to: (1) get a clearer picture of what religious entities are doing; (2) justify greater attention to religion on the part of global health actors; and (3) articulate in language accessible to global health the value of religious entities. religious entities as desirable: religion as a health asset the international religious health assets program (irhap) is an international, interdisciplinary group of scholars and practitioners interested in the intersection of religion and public health. 32 irhap has sought ―to address the general paucity of studies on faith-based organizations working in health.‖ 33 the initial founders shared a general understanding that ―the secularization thesis is in crucial aspects invalid; that humans have the capacity to exercise their own agency in dealing with their health; and that an assets-based approach is most appropriate for research in this field.‖ 34 the founders also shared a vision of extending the benefits of public health to all persons, especially those who are currently underserved, and an appreciation, grounded in their practical understanding of the complexity of global health issues, for the difficulty of making this vision a reality. 35 religious health assets (rhas) are defined as ―an asset located in or held by a religious entity that can be leveraged for the purposes of development of public health.‖ 36 in an attempt to clarify different kinds of rhas observed throughout sub-saharan africa, irhap distinguishes between tangible and intangible assets (see table 1). 37 irhap defines tangible assets as: ―the more visible and most studied religious health assets, including facilities, personnel, and activities, sometimes resembling those of secular entities.‖ 38 tangible assets include such things as church buildings, denominational networks, lay care workers, etc. in sub-saharan africa, the tangible rhas most visible to public health systems are church-affiliated hospitals and clinics as well as the national-level christian health associations common in many countries. while the concept of tangible religious health assets has gained purchase among global health leaders, concept of an intangible religious health asset is less well understood. that is, to ask whether religion makes a distinctive contribution to global health requires some attention to dimensions of religion or assets of religious entities that cannot simply be replicated by non-religious entities, such as a secular nongovernmental organization. if there is a distinctive contribution, it is likely to emerge, at least in part, from something like an intangible asset. irhap identifies intangible religious health assets as the “volitional, motivational and mobilising capacities that are rooted in vital affective, symbolic and relational dimensions of religious faith, belief, behaviour and ties.” 39 this intangible dimension has proven much more difficult to operationalize in irhap research, yet it remains at the heart of an inquiry into the impact (positive and negative) religious entities have had in the response to hiv. when these intangible dimensions of religious participation have been recognized in the response to hiv, they tend to be framed as a health liability, rather than an asset, for example, in the theologically resonant framing of disease as punishment. 53 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. table 1. religious health assets and health outcomes r e li g io u s h e a lt h a ss e ts intangible  prayer  resilience  health-seeking behavior  motivation  responsibility  relationship: caregiver and patient  advocacy/prophetic  resistance – physical and/or structural/political  individual (sense of meaning)  belonging (human/divine)  access to power/energy  trust/distrust  faith-hope-love  sacred space in a polluting world (aic)  time  emplotment (story) tangible  infrastructure  hospitals – beds, etc.  clinics  dispensaries  training – para-medical  hospices  funding/development agencies  holistic support  hospital chaplains  faith healers  traditional healers  care groups  ngo/fbo – ―projects‖  manyano and other fellowships  choir  education  sacraments/rituals  rites of passage (accompanying)  funerals  network/connections  leadership skills  presences in the ―bundu‖ (on the margins)  boundaries (normative) direct indirect health outcomes irhap identifies intangible religious health assets as the “volitional, motivational and mobilising capacities that are rooted in vital affective, symbolic and relational dimensions of religious faith, belief, behaviour and ties.” 39 this intangible dimension has proven much more difficult to operationalize in irhap research, yet it remains at the heart of an inquiry into the impact (positive and negative) religious entities have had in the response to hiv. when these intangible dimensions of religious participation have been recognized in the response to hiv, they tend to be framed as a health liability, rather than an asset, for example, in the theologically resonant framing of disease as punishment. what exactly the concept of intangible religious health asset refers to remains elusive — and not only for public health folks. for sociologists of religion and theologians involved in irhap projects mapping the religious health assets in communities, questions remain about what counts as an intangible asset, how to determine its presence in a community, how to measure its impact, etc. 40 in part, it is a problem of operationalizing theologically resonant concepts like hope. for example, if eschatological visions of a better world, a beloved community, or the great bye-andbye emerge from various theologies of hope within the christian tradition, do these theologies (and the practices they generate) suggest distinctive responses to hiv, perhaps even responses yet unimagined by global health actors? religious health assets: a critical appreciation discourse and practical actions on the part of global health actors have made explicit the relevance and desirability of religious entities as vital partners in response to hiv. the particular dynamics of hiv transmission and treatment in a community as well as the disease’s resistance to conventional public health 54 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. and medical interventions have been a catalyst for refocusing thinking at the who and elsewhere on the need to strengthen health systems and intersectional cooperation, recalling themes from the 1960s and 1970s that had been more muted in the intervening years. 41 health system strengthening involves all sectors of society, not just health professionals. and in most, if not all cases, building a strong, sustainable health system capable of meeting the needs of its citizens requires resources beyond the borders of any one nation-state. the need to coordinate the efforts of all sectors within societies and across nationstates in order to shore up health systems struggling to meet the demands of the hiv pandemic is one significant reason why the hiv work of local and transnational religious entities has become increasingly visible to global health leaders. global health institutions are seeking to partner with religious entities in carrying out specific hiv and aids prevention and treatment programs. but, to create viable partnerships, global health institutions must find ways to overcome actual and perceived tensions with religious entities. the hiv pandemic continues to serve as the context in which the persistent questions about the distinctive contributions of religious entities to global health can be seen in bold relief. but, greater attention to the role of religious entities in the response to aids surfaces longstanding debates about the status of and relationship between theo-ethical and scientific claims related to the broader field of global health. to state the problematic provocatively: in the current turn to religion as a global health ally, christian communities participate primarily by informing and conforming. religious leaders become informants in global health circles, sharing what they know about the beliefs and practices of a particular religious community and strategies for working with communities to make global health policies more effective. religious leaders also conform to the best practices as outlined by global health professionals, adapting first-order religious language to support the evidence-based programs promoted and legitimated by global health professionals. 42 to be sure, these forms of participation are important and, in and of themselves, represent a revaluation among global health professionals of why and how religion matters to the policies and practices of global health. however, an emphasis on these two forms of participation fails to account for what is at the heart of christian religious activity in the world: transforming existing structures, institutions, and practices that act as limits to the full expression of the kingdom of god. translated into the terms of global health, christian participation should lead to policies and practices more responsive to the actual ways persons experience and make sense of health as ―a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.‖ 43 the turn to religion may, in reality, only be a turn to religious entities and their value in scaling-up or otherwise mitigating the logistical demands and resource scarcity in the response to hiv. from the perspective of the who or gates that may be all that is necessary, perhaps even all that is possible. yet, i am arguing here that the turn to religion constitutes more than merely recognizing and then aligning the assets of religious entities with existing policies and commitments in the global health sector. religious entities are rarely empty shells. even an abandoned church building may still evoke certain histories, events, cultural practices in a community, etc. neither are religious entities perfect embodiments of doctrines, beliefs, etc. relationships between, in the language of irhap, tangible and intangible assets are complex and dynamic, seldom captured by the language of capacity-building or monitoring and evaluation templates. thus, attempts to render religion intelligible in global health-speak threaten to obscure important activities that are constitutive of religious entities, including processes of theo-ethical reflection on human flourishing. from the perspective of global health, research describing the religious health assets of a community, even intangible assets like a theology of hope, now becomes ―data‖ for use in making 55 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. existing global health policies related to hiv and aids more effective. how, for example, can religious health assets be leveraged in order to scaleup the provision of treatments more quickly? similarly, attempts to gain more accurate knowledge of a community’s religious beliefs and practices are seen as part of the overall commitment to sensitivity among global health professionals to cultural particularity and existing social institutions in designing interventions and responses. understood as ―data‖ in this sense, effectiveness in global health policies is determined by the degree to which any given health intervention succeeds in generating improved health outcomes for a given population while, at the same time, minimizing the cultural impact of a health policy. yet, it is also the case that religious entities have turned to global health institutions for assistance in living out their theo-ethical commitments to more inclusive and appropriate responses to plwha in and near their communities. for example, recognizing their lack of staffing and resources for effectively monitoring and evaluating the diverse and rapidly increasing number of church-affiliated hiv programs, christian communions have requested the unaids and who monitoring and evaluation toolkit be distributed more widely to church networks. similarly, with an increasing amount of global hiv funding being funneled directly to nation-states through what are known as country coordinating mechanisms (ccms), churches interested in scaling-up their own programs increasingly rely on assistance from global health institutions to gain access to and successfully navigate the complicated national-level grant proposal and reporting processes. 44 this practical dimension of the turn of religious entities to global health institutions serves a legitimating function as well. against the backdrop of bishop hanson’s dramaturgical footwashing at the international aids conference (described above), successful integration into secular global health networks moves communities of faith beyond the penitential posture in which their participation as partners remains probationary. penitence, though necessary, is ultimately an insufficient posture for moving from the paradigm of religion and health in tension to religion as an active ally to global health. why is it not sufficient? because, religious entities offer more than tangible health assets to be leveraged for greater effectiveness or aligned for increased efficiency, and they offer more than intangible health assets such as hope and trust to be operationalized in various public health programs. religious entities provide institutional space in which persons and communities think together theologically about the limits of existing practices and programs of global health as well as the theoretical justifications for the programs. that is, religious entities cultivate theoethical reflection on what it means to flourish as human beings in the context of real-world constraints. for christian theologians and ethicists to acquiesce either to accounts of health and human flourishing or to the value of christian participation in global health that do not sufficiently account for the place of theo-ethical reflection is, it would seem, to jettison the very dynamic that has sustained the reform impulse of socially engaged theological work. from a public health perspective, i can understand the risk of engaging in theo-ethical reflection with religious leaders and members of faith communities. the discussion of stigma illustrates how theo-ethical reflection in religious entities has been done both formally and informally in ways that can have a negative impact on health outcomes and limit human flourishing. here, the contribution of theology to further stigmatization is recognized, if not always understood, by global health leaders. this is certainly one way in which religious entities have offered something distinctive to the conversation about hiv, but such distinctive contributions offer a strong argument against any turning to religion as an ally. but, even these negative contributions can be a catalyst for more direct engagement with the processes of theo-ethical reflection taking place among religious entities. for example, countering a religious argument that stigmatizes may require developing an immanent critique of the theology that supports such stigmatization and then offering a constructive theological proposal for inclusivi56 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. ty. 45 stigmatization is clearly not the only response to emerge from theological reflection on the hiv pandemic. religious leaders can be exhorted to invoke the ―prophetic voice of faith‖ on behalf of those affected by hiv, calling on religious entities ―to advocate for appropriate and inclusive hiv and aids responses.‖ 46 minimally, the absence of theologically informed participants in global health conversations should provoke questions — among religious and global health leaders — about the relationship between scientific descriptions of the determinants of human health and normative arguments about what constitutes human flourishing. this is not to suggest that theology or a particular theology provides the ground for global health, rather it is a reminder that definitions of health and conceptions of human flourishing that orient global health priorities and drive flows of resources are arguments about what it means to be human. as such, these arguments require attention to the question why this particular vision of human flourishing? answers to this question are always provisional, revisited by each generation as it seeks to integrate advances in human knowledge (e.g., the virological understanding of hiv) with both shared and contested visions of human being. yet, the encouragement for the prophetic voice of faith rings hollow if religious entities are merely asked to transpose the language of prevention and treatment into a theological key. while it can be a form of confession for denouncing theologies of exclusion, the prophetic voice of faith runs the risk of merely amplifying existing best practices in the global health response to aids. to be sure, this amplification is necessary and welcome, but something of the power religions claim is lost when religious leaders mistake conforming to existing global health practices for the more difficult task of articulating and enacting theo-ethical commitments capable of transforming the practices, themselves. to borrow from christian ethicist james gustafson’s analysis of the varieties of forms of moral discourse in medicine, global health policy, and practices that fail to account for ethical critiques, including theo-ethical critiques, ―easily degenerate into satisfaction with the merely possible, with assumed values and procedures, with the domination of the economic or institutional considerations.‖ 47 religious entities — or, better, the ―right‖ religious entities — have been invited to the global health table, but it remains unclear whether they sit at the table as equals or as subordinates. the evidence offered above suggests that the movement toward religion as an ally in the response to hiv is taking place largely on terms set by the secular global health community. that is, despite the initial development of the religious health assets language by theologians and religion scholars, the global health discourse about religion’s value circumscribes the contributions of religion to global health within an existing set of best practices in the hiv response. in this way, religious health assets, tangible and intangible, become valuable if they can be rendered intelligible and appreciated using the existing lexicon and logic of global health. as a result, the primary activity of religious entities in partnerships with global health institutions is limited to conforming their practices to the best practices of hiv programs. religious entities become valuable, become an asset to be valued, then, not for the processes of critical theological reflection they encourage, but for any outcomes of their theological reflection that can be readily appropriated in the service of existing global health paradigms. health for all is history? for readers familiar with the history of christian participation in global health, the argument for valuing theological reflection as a transformative activity within global health should not be completely new. the history of the christian medical commission’s (cmc) catalytic role in the who’s primary health care framework in the 1970s has been well documented in recent years. and, more recently, it has been argued that the new ecclesiological vision of the ―healing church‖ that emerged from theological reflection on the crisis in medical missions throughout the 1960s forms an important, though less often noted backstory for making sense of the prophetic idealism 57 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. and eschatological hope that animated christian participation within the early primary health care movement. 48 yet, in spite of the international (and ecumenical) consensus on the concept of primary health care, it never really got off the ground, or, rather, it never got on the ground after the alma ata declaration, at least not in formal global health policy, priorities, and programs. in 2008, a decade after the cmc dissolved and amid global health commemorations of the thirtieth anniversary of alma ata, the world health organization resurrected primary health care, touting it as an urgent priority with particular relevance for the scale-up of access to antiretroviral treatment for persons infected with hiv. 49 but, as who director margaret chan intoned, a renewed interest in primary health care is not meant to invoke the revolutionary spirit (e.g., the popular but much maligned slogan ―health for all!‖) that so captured the original formulation of the concept. rather, the 2008 world health report in which primary health care is the theme is meant to clarify and provide practical, technical guidance on how to integrate primary health care into the who’s ongoing commitment to health systems thinking. 50 by invoking the history of the cmc and the primary health care movement at this late stage in the argument, i am not hoping to re-ground global health in theology. rather, i am attempting to locate the current limited turn to religion in the longer, more robust history of christian participation in global health. the cmc story is suggestive of a particular historical moment in which the value of christian participation in global health can be seen in the capacity of christians to articulate in theologically resonant language an expansive and compelling vision of health and human flourishing, and this vision proved sufficient enough to reorient priorities and mobilize resources. that such a vision was recognized within official, expert-dominated global health discussions suggests that global health leaders today may do well to pay closer attention not only to shared practices of health care but also to the creative and courageous health practices out of which christians generate substantive theological claims about human being and human flourishing. global health after pentecost the current turn to religion as a global health ally presents an opportunity to reimagine the spaces in which complex social phenomena are described, interpreted, and responded to. christians live into the role of co-participants in these spaces when they seek to develop a greater competence for engaging the complex arena of global health policy and programming. this competence emerges from demonstrating understanding of the empirical context in which global health is carried out as well as showing in an imaginative and compelling manner how the theological resources from their own tradition illumine the patterns and processes of human suffering. at the same time, global health leaders live into the role of coparticipants when they recognize, engage, and value the prophetic religious imagination as a distinctive part of what makes religious entities desirable as allies in global health. what emerges in these spaces is a more fully participatory global health that better reflects in its priorities, policies, and programs the actual ways persons experience and make sense of health and human suffering. for christians, it is to move from the presumption of christian medical mission after babel to the hope of a christian participation in global health after pentecost. christians participating in global health after pentecost begin with the presumption that we are all trying to communicate to one another about our sense of the various forces affecting our ability to flourish as human beings and that, in the end, we can understand one another, because we are all in some way responding to and co-constituting the patterns and processes of interdependence that give a particular shape to our world in this moment. in this way, we are all responsible for carrying out the commission archbishop desmond tutu set forth at the world health assembly in 2008: ―god is watching. the people are waiting. you are commissioned to go to wipe the tears away from all faces and bring forth 58 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. lives filled with strength and purpose which will make for peace.‖ 51 the recent (re)turn to religion in global health circles documented throughout this article serves as an invitation to christian leaders to recover within their own traditions a prophetic religious imagination, the deep sensitivity to ―the lure of new possibilities and their embodiment,‖ capable of transforming existing structures, institutions, and practices that constrain human flourishing. 52 in the end, it may be in this practical theological work that christians find the imagination and courage to practice global health after pentecost and in so doing bring into being the most valuable religious health asset: the healing church. references and endnotes 1. world health organization. faith-based groups: vital partners in the battle against aids. geneva: world health organization; 2004. p. 3. 2. see acknowledgements below. 3. for a description of the foot washing and the preconference event, see elca presiding bishop washes feet of hiv-positive women [internet]. chicago: elca news service; [press release august 4, 2008; cited 2012 march). available from http://www.elca.org/news-and-events/6285 4. the turn to religion as an ally in global health can be seen as part of a larger conversation about the role of religious entities in supporting human flourishing more generally, or what has traditionally fallen under the auspices of development studies. for a good representation of the current role of religion in development, see ter har g, editor. religion and development: ways of transforming the world. new york: columbia university press; 2011. 5. world health organization. faith-based groups: vital partners in the battle against aids. geneva: world health organization; 2004. p. 4. 6. for example, by world aids day, december 2005, the who’s 3x5 initiative fell significantly short of its ambitious goal of enrolling three million persons in low and middle-income countries on arvs by 2005. by 2005, approximately one million new patients had been enrolled in arv treatment programs. see unaids. aids epidemic update. [internet]. geneva: unaids; 2006 [cited 2007 october 29]; available from: http://data.unaids.org/pub/epireport/2006/2006_ epiupdate_en.pdf 7. world health organization. faith-based groups: vital partners in the battle against aids. geneva: world health organization; 2004. p. 3. 8. much of the literature reviewed below emerges from research on christian religious entities that fall under the broad umbrella of protestant. while recognizing this as a possible limitation, i believe that there is sufficient evidence in catholic circles to support my general claim regarding the “turn to religion.” see, for example, lebouché b, malherbe j-f, trepo c, lemieux r. religion in the aids crisis: irrelevance, adversary, or ally? the case of the catholic church.” in: applied ethics in a world church: the padua conference, maryknoll: orbis books; 2008. p. 170-9. 9. gustafson jm. an examined faith: the grace of selfdoubt. minneapolis: fortress press; 2004; 83. 10. for one of the most comprehensive listing of works related to religion and hiv, see the bibliography created by the collaborative for hiv and aids, religion and theology (chart). the publicly accessible bibliography includes over 2000 entries contributed by various scholars. collaborative for hiv and aids, religion and theology. pietermaritzburg, south africa; c2013. available from: http://chart.ukzn.ac.za/ 11. i have chosen to limit the literature review to 2006-2010 for two reasons: one, in 2006, global health interest in moving from anecdotal evidence to mapping the role of religious entities in health increased, as evidenced by the reports below as well as the uptick in the number and diversity of studies being published. two, arhap completed a comprehensive review and annotated bibliography of the existing literature prior to 2006. see olivier j, cochrane jr, schmid b. arhap bibliography: working in a bounded field of unknowing. cape town: african religious health assets programme; 2006; olivier j, cochrane jr, schmid b, graham l. arhap literature review: working in a bounded field of unknowing. african religious health assets programme; 2006. http://www.elca.org/news-and-events/6285 http://data.unaids.org/pub/epireport/2006/2006_epiupdate_en.pdf http://data.unaids.org/pub/epireport/2006/2006_epiupdate_en.pdf http://chart.ukzn.ac.za/ 59 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. 12. awoyemi sm. the role of religion in the hiv/aids intervention in africa: a possible model for conservation biology. editorial. conserv biol. 2008;22(4):811-3. http://dx.doi.org/10.1111/j.15231739.2008.01007.x 13. gyimah so, tenkorang ey, takyi bk, adjei j, fosu g. religion, hiv/aids and sexual risk-taking among men in ghana. j biosoc sci. 2010;42(4):53147. http://dx.doi.org/10.1017/s0021932010000027 14. root r. religious participation and hivdisclosure rationales among people living with hiv/aids in rural swaziland. afr j aids res. 2009;8(3):295-309. maman s, cathcart r, burkhardt g, omba s, behets f. the role of religion in hivpositive women's disclosure experiences and coping strategies in kinshasa, democratic republic of congo. soc sci med. 2009;68(5):965-70. http://dx.doi.org/10.1016/j.socscimed.2008.12.028 miller n, rubin dl. factors leading to self-disclosure of a positive hiv diagnosis in nairobi, kenya: people living with hiv/aids in the sub-sahara. qual health res. 2007;17(5):586-98. 15. carpenter st. what perceived benefits do hiv positive patients on anti-retroviral therapy derive from participation in a local church?: the experience of patients at valley trust arv centre, kwazulu-natal [master's thesis]. pretoria: st augustine college of south africa; 2007. 16. otolok-tanga e, atuyambe l, murphy ck, ringheim ke, woldehanna s. examining the actions of faith-based organisations and their influence on hiv/aids-related stigma: a case study of uganda. afr health sci. 2007;7(1):55-60. 17. krakauer m, newbery j. churches' responses to hiv/aids in two south african communities. j int assoc of physicians aids care. 2007;6(1): 27-35. keough l, marshall k. faith communities engage the hiv/aids crisis: lessons learned and paths forward. kessler m, editor. washington dc: georgetown university, berkley centre for religion, peace and world affairs; 2007. vitillo rj. faith-based responses to the global hiv pandemic: exceptional engagement in a major public health emergency. special report. j med person. 2009;7:77-84. bazant es, boulay m. factors associated with religious congregation members' support to people living with hiv/aids in kumasi, ghana. aids behav. 2007;11(6):936-45. agadjanian v, sen s. promises and challenges of faith-based aids care and support in mozambique. am j pub health. 2007;97(2):362-6. 18. wagner gj, holloway i, ghosh-dastidar b, ryan g, kityo c, mugyenyi p. factors associated with condom use among hiv clients in stable relationships with partners at varying risk for hiv in uganda. aids behav. 2010;14(5):1055-65. http://dx.doi.org/10.1007/s10461-010-9673-4 19. gyimah so, tenkorang ey, takyi bk, adjei j, fosu g. religion, hiv/aids and sexual risk-taking among men in ghana. j biosoc sci. 2010;42(4): 53147. http://dx.doi.org/10.1017/s0021932010000027 20. sadgrove j. 'keeping up appearances': sex and religion amongst university students in uganda. j rel afr rel afr. 2007;37(1):116-44. 21. denis p. the church's impact on hiv prevention and mitigation in south africa: reflections of a historian. j theol south afr. 2009;134:66-81. denis notes three main areas in which the churches in south africa have contributed: home-based care, orphan care, and arv treatment. 22. agadjanian v, sen s. promises and challenges of faith-based aids care and support in mozambique. am j pub health. 2007;97(2):362-6. 23. tearfund. faith untapped: why churches can play a crucial role in tackling hiv and aids in africa. teddington, uk: tearfund; 2006. woldehanna s, ringheim k, murphy c, gibson j, odyniec b, clerisme c, et al. faith in action: examining the role of fbos in addressing hiv-aids. washinton, d.c.: global health council; 2005. world health organization. faith-based groups: vital partners in the battle against aids. geneva: world health organization; 2004. 24. eriksson e, lindmark g, axemo p, haddad b, ahlberg bm. ambivalence, silence and gender differences in church leaders' hiv-prevention messages to young people in kwazulu-natal, south africa. cult health sex. 2010;12(1):103-14. http://dx.doi.org/10.1080/13691050903141192 http://dx.doi.org/10.1111/j.1523-1739.2008.01007.x http://dx.doi.org/10.1111/j.1523-1739.2008.01007.x http://dx.doi.org/10.1017/s0021932010000027 http://dx.doi.org/10.1016/j.socscimed.2008.12.028 http://dx.doi.org/10.1016/j.socscimed.2008.12.028 http://dx.doi.org/10.1007/s10461-010-9673-4 http://dx.doi.org/10.1017/s0021932010000027 http://dx.doi.org/10.1080/13691050903141192 60 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. 25. a case study of an “aids-sensitive church” in south africa illustrates this point. the authors conclude that the church as a support network provides an important mechanism in resource-poor communities (i.e., those without sufficient public health infrastructure) for coping with the pandemic. what is not clear from this study is whether the importance of this mechanism is its distinctive religious character or simply its presence in the absence of other alternatives. miller rl. a rock in a weary land: aids, south africa, and the church. soc work pub health. 2009;24(1/2):22-38. http://dx.doi.org/10.1080/19371910802569351 26. boulay m, tweedie i, fiagbey e. the effectiveness of a national communication campaign using religious leaders to reduce hiv-related stigma in ghana. afr j aids res. 2008;7(1):133-41. 27. watt mh, maman s, jacobson m, laiser j, muze j. missed opportunities for religious organizations to support people living with hiv/aids: findings from tanzania. aids patient care stds. 2009;23(5):38994. http://dx.doi.org/10.1089/apc.2008.0195 28. perry te, davis-maye d, onolemhemhen dn. faith, spirituality, fatalism and hope: ghanaian women coping in the face of hiv/aids. j hiv aids social serv. 2007;6(4):37-58. 29. for a fuller account of the theological literature, see bersagel braley m. more than just health: theoethical reflection as a religious health asset [dissertation]. atlanta, ga: emory university; 2012. 30. though robert garner is focused specifically on hiv and pentecostalism in south africa, i find his conceptualization of the terms relevance and ally useful helpful for naming broad themes in the literature. see garner rc. religion in the aids crisis: irrelevance, adversary, or ally? aids anal afr. 1999;10(6-7). garner rc. safe sects? dynamic religion and aids in south africa. journal mod afr st. 2000;38(1):41-69. 31. arhap. appreciating assets: mapping, understanding, translating, and engaging religious health assets in zambia and lesotho. report to the world health organization. 2006; p. 39. 32. irhap, formerly the african religious health assets program (arhap), was renamed in 2011 to reflection of the expanding geographic scope of its work. 33. arhap. appreciating assets: mapping, understanding, translating, and engaging religious health assets in zambia and lesotho. report to the world health organization. 2006; p. 23. 34. olivier j, cochrane jr, schmid b, graham l. arhap literature review: working in a bounded field of unknowing. african religious health assets programme; 2006; p. 8. 35. irhap builds on the longer history of the interfaith health program, a program of the carter center now housed at emory university. supported by the prominent epidemiologist william foege, who served as the centers for disease control director (1977-1983) and the carter center’s first director (1986-1992), the interfaith health program was founded in 1991. the vision of extending public health to all persons can be seen in foege’s work on “closing the gap.” some of the roots of the assets and agency focus of irhap can be seen in foege’s concept of “reverse epidemiology,” a concept that encourages a focus on what gary gunderson and teresa cutts have more recently described as the “leading causes of life” or vitality as opposed to a pathological approach focused on the leading causes of mortality and morbidity. see, respectively, foege wh, amler rw, white cc. closing the gap. jama. 1985;254(10):1355-8. gunderson gr, cutts tf. decent care for life. in: karpf t, ferguson t, swift r, lazarus jv, editors. restoring hope: decent care in the midst of hiv/aids. new york: palgrave macmillan; 2008. 36. arhap. appreciating assets: mapping, understanding, translating, and engaging religious health assets in zambia and lesotho. report to the world health organization; 2006. 37. the distinction between tangible and intangible health assets is a source of considerable debate within irhap. the discussion presented here takes its cue from one of the initial matrices presented by irhap to explore the utility of the distinction. 38. see “tangible assets” in the glossary of arhap. appreciating assets: mapping, understanding, translating, and engaging religious health assets in zamhttp://dx.doi.org/10.1080/19371910802569351 http://dx.doi.org/10.1089/apc.2008.0195 61 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. bia and lesotho. report to the world health organization; 2006. 39. arhap. appreciating assets: mapping, understanding, translating, and engaging religious health assets in zambia and lesotho. report to the world health organization; 2006; p. 40. 40. arhap. appreciating assets: mapping, understanding, translating, and engaging religious health assets in zambia and lesotho. report to the world health organization. 2006; p.25. 41. world health organization. the world health report 2000 health systems: improving performance. geneva: world health organization; 2000. 42. see, for example, parry s. beacons of hope: hiv competent churches: a framework for action. geneva: wcc publications; 2008. 43. this is the definition of health enshrined in the constitution of the world health organization. see world health organization, "constitution," in basic documents. geneva: world health organization; 1986. 44. for discussions about how global health institutions can assist religious entities in accessing global donor resources, see speicher s, editor. final report. global assessment and strategy session on faith communities accessing resources to respond to hiv/aids; 2005 january 18-20; geneva, switzerland: ecumenical institute of bossey. 45. for the use of immanent critique as a strategy for engaging in conversations involving competing comprehensive visions of the good, see stout j. democracy and tradition. princeton: princeton university press; 2003. for a representative theological proposal, see messer de. breaking the conspiracy of silence: christian churches and the global aids crisis. minneapolis: augsburg fortress; 2004. 46. speicher s, editor. final report. global assessment and strategy session on faith communities accessing resources to respond to hiv/aids; 2005 january 18-20; geneva, switzerland: ecumenical institute of bossey. 47. gustafson j. moral discourse about medicine: a variety of forms. j med phil. 1990;15:125-42. [p. 141] 48. for a fuller account of the institutional and theological histories of the christian medical commission, see patterson g. the cmc story: 1968-1998. contact. 1998 june-july and augustseptember(161/162):3-52. bersagel braley m. the christian medical commission and the world health organization. in: idler e, editor. religion as a social determinant of health. new york: oxford university press; 2014. p. 298-318. 49. world health organization. the world health report 2008 primary health care (now more than ever). geneva: world health organization. 2008. 50. world health organization. the world health report 2008 primary health care (now more than ever). geneva: world health organization. 2008. 51. tutu dm. address by reverend desmond mpilo tutu. sixty-first world health assembly. 2008. available from: http://apps.who.int/gb/ebwha/pdf_files/wha61rec2/a61_rec2.pdf 52. gunderson gr, cochrane jr. religion and the health of the public. new york: palgrave macmillan; 2012; p. 21. ____________________________________________________________________________ acknowledgements: i would like to acknowledge my deep gratitude for colleagues in the international religious health assets program (irhap) as well as mentors at emory university who have encouraged scholarship at the intersections of theology, ethics, and global health that informs this current work. also, i am grateful to the editors of the cjgh for their invitation to share this work in a venue that i believe honors the collaborative, transdisciplinary spirit necessary for a fully participative global health. lastly, a word of thanks to the reviewers whose candid and provocative comments have been a catalyst for clarifying the argument and a reminder of the “grace of self-doubt,” to borrow from christian ethicist james gustafson. i hope that any failures to address the concerns raised serve as an invitation to further dialogue. http://apps.who.int/gb/ebwha/pdf_files/wha61-rec2/a61_rec2.pdf http://apps.who.int/gb/ebwha/pdf_files/wha61-rec2/a61_rec2.pdf 62 bersagel braley nov 2014. christian journal for global health, 1(2):48-62. competing interests: the author is an associate of the international religious health assets program discussed in this article. correspondence: dr. bersagel braley, viterbo university, la crosse, wi, usa mtbersagelbraley@viterbo.edu cite this article as: bersagel braley mt. global health after pentecost: toward theological reflections as a religious health asset. christian journal for global health (nov 2014), 1(2):48-62. http://dx.doi.org/10.15566/cjgh.v1i2.34 © bersagel braley mt. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ _______________________________________________________________________________ www.cjgh.org mailto:mtbersagelbraley@viterbo.edu http://dx.doi.org/10.15566/cjgh.v1i2.34 http://creativecommons.org/licenses/by/3.0/ commentary nov 2020. christian journal for global health 7(4) response of a non-governmental organisation to covid-19 sara varughesea a do, frcs(ed): msc public eye health (lshtm), cbm india liaison office and cbm india trust, india abstract: the covid-19 pandemic has had a global impact with local or national lockdowns imposed in 172 countries. morbidity and mortality due to the virus has seriously damaged both the health of populations and the economy. government and nongovernmental agencies (ngos) have been hard pressed to respond meaningfully in the global crisis, the likes of which have not been experienced in recent times. a disability and development organization in india, a branch of a global nongovernmental organization, reflects on the challenges and lessons learnt in responding to the crisis. the need to be alert, responsive, and consultative is highlighted. key words: covid-19, leadership, partnership, expertise, inclusion, response, agility introduction covid-19 has had a global impact on health, with nearly 20 million cases and 732,000 deaths worldwide at the time of writing and equal or greater devastation on economies. the numbers are continuing to rise. in india, currently there are 2.2 million cases and 44,300 deaths in the second week of august. globally, unemployment is expected to rise to the highest level since 1965.1 unemployment rose in india from an average of 6–8% in the months before the pandemic to 24% in may 2020.2 organizations may have learnt lessons from past responses to emergencies, but the scale and breadth of the impact have no precedent in recent history. a hundred years ago, after the 1918 influenza pandemic, the issue of disease prevention in a “mass society . . . connected by new forms of public education, transportation, and amusement”3 was recognized. these issues are exacerbated today, with an even larger “mass society”; international and within country travel, sporting, and cultural events are much more accessible and large numbers participate with the potential to spread infections across continents. along with this, there is easy access to information. information technology and modern communication give access to up-to-date information from remote locations. it also brings the failures of appropriate response, of both government and non-governmental organisations, to the public domain. public expectations of quick, appropriate action from those in authority has also increased. 15 varughese nov 2020. christian journal for global health 7(4) covid-19 came at a time when nongovernmental organizations (ngos) in india were facing other challenges with governance and the economy. the growing indian economy, with a gdp growth rate in 2018 of 6.8%,4 made india a low priority area for donors. for example, the unesco report highlights the decrease in aid to india in the field of education in 2019.5 however, while the gdp was growing, inequality was increasing. india is among the countries with the highest inequality in the world, with the top 1% having 67% of the country’s wealth.6 the gdp growth did not improve the quality of lives of the majority who were poor. india has nearly 120 million people living on less than $1.90 a day.7 india ranks 129 on the un human development index of 2019.8 the need for ngo assistance was great but ngos found their funding curtailed and resources shrinking. another reality confronting voluntary organisations was the shrinking of the space for ngos with increasing government restriction and regulations. this changed a little with the pandemic. when the lockdown crisis started, the government reached out to ngos and asked for their help. most ngos responded positively, some more than others. what made some organizations quicker and more active than others? what helped make a response relevant? the indian branch of an international disability and development organization reflects on its own response and that of its partners. the lessons learned may help us and others to respond better with less disruption in a potential second rural wave of the pandemic or in a new crisis.9 cbm india works in the disability and development sector. with a christian heritage and christian values, we work with a nationwide network of both faith-based and secular partner organizations, including community-based organizations, major christian medical teaching institutions, educational institutions, and specialist hospitals. these partners have different mandates, skills, capacities, and sizes. our challenge was keeping our mandate of inclusion of people with disabilities in mind to respond in a relevant way. we had to work through our networks in very dynamic situations, disparate needs, and geographical locations. insights and lessons alertness and preparedness india went into lockdown on 24 march 2020. cbm in india anticipated this by late february and took measures to safeguard our staff while continuing to work. our medical/public health experts, who were part of the team, helped to disentangle relevant and correct information from the mass of circulating information and make early decisions. in early march, we stopped people with disabilities who were using public transport from attending the office (about 18% of our staff are people with disabilities). staff members whose homes/families were in different cities were supported to travel home before lockdown started. staff were asked to ensure they carried laptops home each day and laptops were configured for remote server access so they could work from home. when the lockdown in india was declared with a four-hour notice, our staff were prepared. financial readiness march 31st is the end of the indian financial year, and a large number of transactions needed to be completed, and books of accounts closed soon after the lockdown. year-end financial transactions were expedited before lockdown occurred. access to online banking was already in place, but the transaction limit had to be increased. good banking relationships and financial standing helped increase banking limits and enabled financial transactions to continue smoothly. controls were set in place. the systems and processes were first documented and 16 varughese nov 2020. christian journal for global health 7(4) then shared with partners. a digital financial competency mapping and improvement plan was made with the support of our financial advisor. this was then documented, and a workshop was held to allow partners to benefit. this is being written up for circulation to others. responsiveness the issues we then needed to respond to were different from those upon which we regularly work. the first issue in india was that of the migrant workers who had come from remote villages of faraway states to large cities in search of work and were engaged usually in low paying manual work like in the construction industry. when the lockdown started, these workers in the informal sector were without work, without wages, and away from home. an estimated 6 million people were trying to return to their homes to distant states. most modes of transport had been suspended. many had to walk all the way. people with disabilities were specially disadvantaged. they could not even access the free food being distributed. the lockdown of schools meant children with disabilities had no access to their usual rehabilitation or the nutritious mid-day meal. it immediately became evident to us that among our partners, the readiness to respond was not related to the size of an organization. some organizations saw the distress around them, managed to get the necessary permissions to move in the lockdown, and responded. while their regular activities were health services, eye care services, or education, we found both faith-based and secular organizations responded from the heart. seeing people walking down the highways drove them to provide food and water and open their premises to those who had no place to shelter. internally too, this was observed among our own team. some staff members immediately began to highlight the needs of our networks and areas for intervention. we learnt to start the work with those who were ready to work, and to push the boundaries of what we and our partners did. fostering engagement frequent discussions and sharing of what was being done internally helped the more remotely located team members engage and participate. sharing of experience between partners working on different mandate areas, such as education and health, inspired other organizations. an example was a virtual meeting in which organizations involved in inclusive education shared their experiences of teaching children during the lockdown. some of this was very practical and down to earth: teachers guiding parents over the phone on the use of household items like lentils and rice to provide sensory stimulation for children with intellectual disability. some appeared less realistic and said that all their children had access to good internet and zoom classrooms, despite being in remote rural locations. such meetings allowed partners to learn from each other about how to provide services to their constituencies in spite of the lockdown. consultation in all this, we were greatly helped by advice from other experts. we did not set ourselves as “the disability experts” but reached out for advice. consulting others helped us make our responses relevant when we faced demands from both donors and implementing partners. discussion with public health experts helped to refine our ideas. our first thought was to provide accessible information and dry rations for people with disabilities during the lockdown. advisors from the field suggested providing accessible hand-wash stations. we were flooded with requests for expensive personal protective equipment for eye hospitals. public health specialists guided us as to the protective equipment needed by different health care providers according to their exposure risks. 17 varughese nov 2020. christian journal for global health 7(4) consultation with experts also enabled us to push our boundaries. we were keen not to bite off more than we could chew. we first declined funding of a corporate donor to set up an intensive care unit. however, later, we identified expertise in our networks to take up this project. leadership it was important to have leaders and managers who cared about the poor and marginalized. they brought information to the organization about needs so that we could assess our potential to respond. managers were passionate about finding resources for their areas of intervention. reading the news reports was often painful, but it was necessary to stay in touch with the situation. as christians we felt it important to feel the pain of others and not distance ourselves from the situation. it was important, though sometimes difficult, not to get hijacked by donor agendas, especially from large corporate organizations. the role of senior management was also to push the teams to do more, align opportunities with our mandate, take up new challenges, find new partners, and strengthen documentation and learning. discussion organizational agility is much valued in the corporate sector because of the need to exploit changes and convert them to opportunities for growth.10 haneberg defined agility as the efficiency with which organizations respond to continuous change by consistently adapting. in order to be agile, an organisation needs to be sensitive, with a heightened perception to minute changes in the environment which is brought to the attention of the leadership.11 we too found that when people at different levels, from program officers to managers, had the opportunity to highlight needs and share information from our partner networks, this led to appropriate decision making and deployment of scarce resources. whatsapp was a useful tool to quickly share ground situations. roundy et al. propose that agility allows some organizations to uncover entrepreneurial opportunities others do not find or do find much later.12 they suggest that seeing change as an opportunity without immediately thinking about resources or capacities, helps in responding to significant disruptions.13 we found that management could be sometimes entrepreneurial, thinking about opportunities to respond to, but at other times underestimated the capacities of the organization and its networks. in a case study of an organization that deliberately set out to become an agile organization, shafer et al. wrote of a three-pronged strategy of “initiate, adapt and deliver”.14 very few organizations consciously decide on developing such strategies. conscious adoption of such policies in non–emergency situations or the chronic crises which ngos are already facing may help in greater agility in emergency situations such as pandemics. even for an organization where the workforce is dedicated and personally accountable for the organization’s success, being “comfortable with change as an essential feature of organizational life” will be a challenge, but essential in order to function effectively in crisis situations. 14 beyond agility, there is also a need for humanity. what helps build an organization with heart? in organizations with soul hope chigudu and rudo chigudu wrote, “seeing and presence are key elements of being human . . . it means that you are conscious of what is going on within you and around you.”15 listening to people helps build an organization with a heart. in smaller organizations, a more junior person may be able to speak up about the realties around; in larger organizations, this voice may need to be nourished and fostered. stability and strong processes are essential attributes for good, quick decision making, a fact 18 varughese nov 2020. christian journal for global health 7(4) that many may not recognize. in addition, team members at levels close to the field situation need to be empowered, not just for communication “upwards” in the hierarchy, but also for field level decision making with a clear mandate.16 financial readiness in some ways contributes to stability. aaron de smet noted that besides the ability to react quickly, a stable foundation in one’s mission is needed.17 having systems and processes in place makes for that stable foundation. cbm is an international christian development organization, committed to improving the quality of life of people with disabilities in the poorest communities of the world. valuing and accepting each person as jesus values and accepts them, cbm seeks to change attitudes, practices, and policies that lead to marginalization, exclusion, and poverty because of disability and to strive for peace, justice, and dignity for each and every person. cbm india has worked in partnership to create an inclusive society for all irrespective of caste, creed, gender, and ethnicity for over 50 years. as the needs of the communities we work with change, we need to remain relevant and responsive in order to continue our witness of service. covid has been the latest and perhaps the greatest of these challenges. conclusion in summary, an organization needs to have heart, mind, and systems to respond in a relevant fashion to a situation such as the covid-19 pandemic. finally, there is also a need for humility. in the face of the huge humanitarian challenge in india, our inability to do more mirrors the helplessness of the most marginalized. we are aware that what we do is a drop in the ocean of need, two copper coins in the words of the biblical parable. we need to play our part but also to acknowledge the contribution of others. we need to be prepared for the impending international economic collapse that is sure to follow, leaving huge swathes of people dependent on our agile humanitarian response. references 1. kose a, sugawara n. world bank: covid-19 recession is expected to be twice as bad as the 2009 financial crisis. world econ forum. 2020 jun 18 [cited on 2020 july 2]. available from: https://www.weforum.org/agenda/2020/06/coronaviru s-covid19-economic-recession-global-compared/ 2. keelery s. impact on unemployment rate due to the coronavirus (covid-19) lockdown in india from january to may 2020. statista. 2020 june 15 [cited 2020 july 2]. available from: https://www.statista.com/statistics/1111487/coronavir us-impact-on-unemployment-rate/ 3. tomes n. “destroyer and teacher”: managing the masses during the 1918–1919 influenza pandemic. pub health rep. 2010;125(3): 48–62. https://doi.org/10.1177/00333549101250s308 4. world bank. world bank open data. gdp growth (annual %) – india 1961 -2019. [cited 2020 july 2]. available from: https://data.worldbank.org/indicator/ny.gdp.mktp. kd.zg?locations=in 5. global education monitoring report team. global education monitoring report, 2019: migration, displacement and education: building bridges, not walls. isbn: 978-92-3-100283-0.unesdoc digital library. 2018 [cited 2020 july 2]. available from: https://unesdoc.unesco.org/ark:/48223/pf0000265866. 6. world bank group. india: systematic country diagnostics. realizing the promise of prosperity. report number: 126284-in. 2018 [cited 2020 july 2]. available from: http://documents.worldbank.org/curated/en/62957152 8745663168/pdf/volumes-1-and-2-india-scdrealising-the-promise-of-prosperity-31may06062018.pdf 7. asian development bank. poverty data: india. 6 adb avenue, mandaluyong city 1550, metro manila, philippines. april 2020 [cited on 2020 july 2]. available from: https://www.adb.org/countries/india/poverty https://www.weforum.org/agenda/2020/06/coronavirus-covid19-economic-recession-global-compared/ https://www.weforum.org/agenda/2020/06/coronavirus-covid19-economic-recession-global-compared/ https://www.statista.com/statistics/1111487/coronavirus-impact-on-unemployment-rate/ https://www.statista.com/statistics/1111487/coronavirus-impact-on-unemployment-rate/ https://doi.org/10.1177/00333549101250s308 https://data.worldbank.org/indicator/ny.gdp.mktp.kd.zg?locations=in https://data.worldbank.org/indicator/ny.gdp.mktp.kd.zg?locations=in https://unesdoc.unesco.org/ark:/48223/pf0000265866 http://documents.worldbank.org/curated/en/629571528745663168/pdf/volumes-1-and-2-india-scd-realising-the-promise-of-prosperity-31may-06062018.pdf http://documents.worldbank.org/curated/en/629571528745663168/pdf/volumes-1-and-2-india-scd-realising-the-promise-of-prosperity-31may-06062018.pdf http://documents.worldbank.org/curated/en/629571528745663168/pdf/volumes-1-and-2-india-scd-realising-the-promise-of-prosperity-31may-06062018.pdf http://documents.worldbank.org/curated/en/629571528745663168/pdf/volumes-1-and-2-india-scd-realising-the-promise-of-prosperity-31may-06062018.pdf https://www.adb.org/countries/india/poverty 19 varughese nov 2020. christian journal for global health 7(4) 8. undp (2019). human development index ranking. human development reports. 2019 [cited on 2020 july 2]. available from: http://hdr.undp.org/en/content/2019-humandevelopment-index-ranking 9. seshadri ms, john tj. rural india: the new viral flash-point. the hindu. 2020 june 17. available from: https://www.thehindu.com/opinion/op-ed/rural-indiathe-new-viral-flash-point/article31845783.ece 10. dülgerler m. making better, more responsive organizations. paper presented at pmi® global congress; 2015 [cited 2020 july 2]. emea, london, england. newtown square, pa: project management institute; 2015. available from: https://www.pmi.org/learning/library/making-bettermore-responsive-organizations-9664 11. nord h, michel l. the performance triangle, a model for corporate agility. leadership & organization development journal, vol. 37 no. 3, pp. 341356. https://doi.org/10.1108/lodj-07-2014-0123 12. roundy p, fayard d. dynamic capabilities and entrepreneurial ecosystems: the micro-foundations of regional entrepreneurship. j entrepr. 2018 july. https://doi.org/10.1177/0971355718810296 13. roundy pt, harrison da, khavul s, pérez-nordtvedt l, mcgee j e. entrepreneurial alertness as a pathway to strategic decisions and organizational performance. strat org. 2018;16(2):192-226. https://doi.org/10.1177/1476127017693970 14. shafer ra, dyer l, kilty j, amos j, ericksen ga. crafting a human resource strategy to foster organizational agility: a case study [cahrs working paper #00-08]. ithaca, ny: cornell university, school of industrial and labor relations, center for advanced human resource studies; 2000 [cited 2020 july 2]. available from: http://digitalcommons.ilr.cornell.edu/cahrswp/87 15. chigudu h, chigudu r. 2015 strategies for building an organisation with a soul. editor jorn j. african institute for integrated responses to vawg & hiv/aids (air); 2015 [cited 2020 july 2]. available from: http://airforafrica.org/wpcontent/uploads/2015/09/strategies-for-building-anorganisation-with-soul-for-web1.pdf 16. aghina w, smet ad, murarka m, collins l. the keys to organizational agility [interview]. mckinsey and company. 2015 dec 1 [cited 2020 july 2]. available from: https://www.mckinsey.com/businessfunctions/organization/our-insights/the-keys-toorganizational-agility# peer reviewed: submitted 9 july 2020, accepted 13 aug 2020, published 9 nov 2020 competing interests: none declared. acknowledgements: support from the cbm india trust correspondence: sara varughese, cbm india liaison office and cbm india trust, india. sara.varughese@gmail.com cite this article as: varughese s. response of a non-governmental organization to covid-19. christ j glob health. november 2020; 7(4):14-19 https://doi.org/10.15566/cjgh.v7i4.421 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://hdr.undp.org/en/content/2019-human-development-index-ranking http://hdr.undp.org/en/content/2019-human-development-index-ranking https://www.thehindu.com/opinion/op-ed/rural-india-the-new-viral-flash-point/article31845783.ece https://www.thehindu.com/opinion/op-ed/rural-india-the-new-viral-flash-point/article31845783.ece https://www.pmi.org/learning/library/making-better-more-responsive-organizations-9664 https://www.pmi.org/learning/library/making-better-more-responsive-organizations-9664 https://doi.org/10.1108/lodj-07-2014-0123 https://doi.org/10.1177/0971355718810296 https://doi.org/10.1177/1476127017693970 http://digitalcommons.ilr.cornell.edu/cahrswp/87 http://airforafrica.org/wp-content/uploads/2015/09/strategies-for-building-an-organisation-with-soul-for-web1.pdf http://airforafrica.org/wp-content/uploads/2015/09/strategies-for-building-an-organisation-with-soul-for-web1.pdf http://airforafrica.org/wp-content/uploads/2015/09/strategies-for-building-an-organisation-with-soul-for-web1.pdf https://www.mckinsey.com/business-functions/organization/our-insights/the-keys-to-organizational-agility https://www.mckinsey.com/business-functions/organization/our-insights/the-keys-to-organizational-agility https://www.mckinsey.com/business-functions/organization/our-insights/the-keys-to-organizational-agility mailto:sara.varughese@gmail.com https://doi.org/10.15566/cjgh.v7i4.421 http://creativecommons.org/licenses/by/4.0/ introduction insights and lessons discussion references commentary april 2020. christian journal for global health 7(1) separated but whole: pursuing health and redefining community amidst covid-19 jordan millhollina a bs, theology, medicine, and culture fellow at duke divinity, durham, nc, usa abstract in his speech "health is wholeness," wendell berry says that when we are healthy, we are unconscious of our bodies—only sickness brings our attention to them. he also says that people’s sense of wholeness is tied to community, and any removal from common life together is a denial of wholeness and a removal of health. as we find ourselves in this strange covid-19 moment, we are wrestling with a sudden awareness and anxiety about our own bodies while also hearing the call for social separation that takes us apart from the communities which provide us meaning. this is precisely the type of issue that berry describes; a closer look at berry’s theological leanings may give us the resources we need to find hope and meaning during this crisis. within covid-19’s clear violation of wholeness, berry’s understanding of health as interconnection and orientation toward one another under god’s divine love is a faithful and loving way to find meaning during this crisis. if we follow berry's assertion that under christ the community is the smallest unit of health, then observing social distancing for the sake of public health is faithfully in line with a theological vision of health as wholeness. key words: wendell berry, covid-19, coronavirus, christian life, health, wholeness. in his speech "health is wholeness," wendell berry says that when we are healthy, we are unconscious of our bodies—only sickness brings our attention to them. he also says that people’s sense of wholeness is tied to community, and any removal from common life together is a denial of wholeness and a removal of health. as we find ourselves in this strange covid-19 moment, we are wrestling with a sudden awareness and anxiety about our own bodies while also hearing the call for social separation that takes us apart from the communities which provide us meaning. this is precisely the type of issue that berry describes; a closer look at berry’s theological leanings may give us the resources we need to find hope and meaning during this crisis. within covid-19’s clear violation of wholeness, berry’s understanding of health as interconnection and orientation toward one another under god’s divine love is a faithful and loving way to find meaning during this crisis. if we follow berry's assertion that under christ the community is the smallest unit of health, then observing social distancing for the sake of public health is faithfully in line with a theological vision of health as wholeness. in the past few weeks, most of us have gone from a blissful unawareness of our bodies to constantly thinking about washing our hands and not touching our faces, as well as gauging the distance we keep from those around us. however, while physically distancing ourselves is necessary to stop the spread of the virus which causes covid-19, such physical division from one another has made us acutely aware of how we need each other and the social systems we inhabit to bring meaning to our lives. without gathering for church, school, or work, we know that there is something off about the world. we no longer feel whole. we no longer feel healthy. according to agrarian essayist and christian 21 millhollin april 2020. christian journal for global health 7(1) thinker wendell berry, to be healthy is to be whole.1 for the most part, our sense of wholeness is difficult to recognize because when our bodies are healthy, nothing readily draws our attention to them — we are unaware of our wholeness. it takes pain, fear, or disease to make us conscious of our bodies, and then we can pay attention to little else. for instance, when we have a stomachache, we can barely think of anything else. similarly, our sense of health as wholeness is also tied to an unconscious need to belong to a community. if together and sharing life in common with one another is an expression of human wholeness, then imagining ourselves as isolated beings is a division of wholeness and a violation of health. this view of what berry labels as “health is membership” certainly describes our life during the current pandemic. how might we find health and wholeness in an age when living under the threat of death has violated the unconscious wholeness of our bodies? perhaps even more obviously for our daily lives, what might health look like in a time when physical distancing is vital to “flattening the curve?”2 in berry’s words, how might we find wholeness in a world in which, “disintegration and division, isolation and suffering seem to have overwhelmed us?”3 given covid-19’s clear violation of wholeness, berry’s understanding of health still gives us the resources to faithfully imagine what it means to be healthy and whole, even during a time of anxious bodily awareness and the need for physical distancing. first, it is important to indicate how berry’s account of health is different from the medicalized definition, which tends to see the body as a machine made up of isolated and occasionally failing components. for example, berry claims, “the human heart . . . is no longer understood as the center of our emotional life or even as an organ that pumps; it is understood as “a pump,” having somewhat the same function as a fuel pump in an automobile.”4 when the pump is broken, it can be fixed with “mechanical tinkering” that does not need to acknowledge the habits, narrative, or commitments of the patient. if there is ever an instance in which the pump cannot be fixed, the patient is doomed never to be considered “healthy” again. however, such an account of health misidentifies our nature. bodies cannot be machines because without fuel a machine is still a machine, but without “air, food, drink, clothing, shelter, and companionship,” a body is not a body but a cadaver.5 our bodies cannot be machines because they are not self-contained; rather, they extend outward through how we interact with the world and others around us. our mind even more obviously exceeds itself, as our contribution to culture and relationships cannot be pinpointed to a physical location within our body. because our bodies exceed themselves, wholeness is not something that mere individuals can possess. our reliance on and interconnection with others makes “a place and all its creatures . . . the smallest unit of health and . . . to speak of the health of an isolated individual is a contradiction in terms.”6 of course, focusing on one part does not always necessarily happen at the exclusion of the whole. for instance, when a cardiologist places a stent, it is good that they focus on the heart to prevent myocardial death and resulting death of the entire body. when a family physician pays attention to examining the body of the patient in front of them, they are not elevating that patient’s particular body over bodies of the patients in the waiting room or those outside the clinic. in fact, compassionate and undivided attention toward to the patient’s body in that moment is a caring affirmation that the patient is made in god’s image. violating wholeness does not come when attending to, particularity if it is proper to do so, but in doing so when it comes at the expense of others. an account of health that focuses on components of the body by ignoring others or emphasizes the value of certain individuals within a larger community doesn’t properly understand the embodied and interconnected nature of humanity — something that saint paul underscores in his presentation of the church as one body in 1 corinthians 12:12-27. like berry, paul recognizes our fundamental interconnectedness, for “[i]f one member suffers, all suffer together with it; if one member is honored, all rejoice together with it.” each of us is held together to one another not just by our own effort, but by the sustaining love that christ has for us as interconnected people. all things are held together by love (colossians 3:14). god’s love does not pass over the sparrows (matthew 6:26), the one lost sheep (matthew 18:1214, luke 15:3-7), or the poor (luke 1:53-53). god is attentive, paradoxically, to all, as they form a whole, 22 millhollin april 2020. christian journal for global health 7(1) but also to each, in his or her particularity. thus, when we learn that a new therapy or medication will save most of those who are sick, we are called to remember the global marginalized “least of these” who may otherwise be denied treatment. recognizing that each person is irreplaceable and valued within the health of the community, the world of love cannot accept marginalization of the elderly or any other life.7-8 in the age of the covid-19 pandemic, we cannot afford to think of ourselves as isolated individuals even if we are being told to self-isolate. yes, it is abundantly clear from epidemiological estimates that reducing the impact of covid-19 depends on our ability to remain physically distant from one another, but we do so for the greater health of all — something we also see when we as individuals are inoculated for, say, measles, as the immunity of each of us contributes to the immunity of the “herd.”9 in that respect, we are profoundly interconnected, even as we are called to be apart. during this pandemic, we cannot rightly think of our health as our ability to survive as individuals. knowing that we rely on one another for health and wholeness, we cannot afford to selfishly or fearfully hoard resources like hand sanitizer, toilet paper, or n95 masks.10-12 similarly, even if someone does not fall within the “atrisk” category, acting with love for the wholeness and health of the community requires that they follow the cdc and who recommendations to remain at home. if berry’s account of health and the world of love is to be taken seriously, any loss of life within our global community would be a tragic loss to the communal body. unfortunately, tragedy like this is bound to happen. we have already seen hundreds of thousands of lives lost due to the pandemic, and it is projected that we will continue down this path. how might we still have hope? what will keep us moving forward? a turn to berry reminds us that the world of divine love that sustains and interconnects us is not blind to tragedy or death. we can be assured through jesus as the incarnate and embodied god that divine love recognizes the brokenness of this world, yet still chooses to involve itself “inescapably in the limits, sufferings, and sorrows of mortality.”13 jesus does not turn his face away from suffering and death but leans into it alongside us. even now, in the face of covid-19, “ . . . the threat of death, and death itself, [love] insists unabashedly on its own presence, understanding by its persistence through defeat that it is superior to whatever happens.”14 the question for those of us living in the covid-19 moment, then, is how we might better love each other despite the ongoing crisis. love looks like the frontline medical response where nurses, and doctors, and others refuse to ignore the needs of the sick despite personal risk. love looks like adhering to physical distancing guidelines while still checking in on those around us as an affirmation that their lives matter deeply. love in accordance with jesus’s teaching and a vision of shared wholeness also requires ongoing witness and action, even in the months after physical distancing ends. side effects of mitigating the covid-19 spread will spill into the global economy, and those who already live in impoverished communities around the world will be significantly afflicted.15 recognizing this, love for global wholeness will not accept the marginalization of any individual or elevation of one community over another, because doing so directly damages our shared health. as we think about faithfully working for global health in the months to come, we must think in terms of moving toward wholeness and acting out of love to ensure that the entire global body is cared for. by continuing to love one another and advocating for wholeness even in the midst of physical separation, we serve as reminders to one another that despite worldly brokenness, bodily fear, and societal anxiety, we recognize a greater light that “shines in the darkness, and the darkness did not overcome it” (john 1:5). references 1. berry w. health is membership [internet]. presented at the conference on spirituality and healing, louisville, ky; 1994 oct 17. available from: https://scienceandsociety.duke.edu/wordpress/wpcontent/uploads/berry-health-is-membership.pdf. 2. fineberg hv. ten weeks to crush the curve. n engl j med [internet]. 2020 apr 1 [cited 2020 apr 13]. https://www.nejm.org/doi/full/10.1056/nejme20072 63. 3. berry w. health is membership. 1. 4. berry w. health is membership. 4. 5. berry w. health is membership. 4. 6. berry w. health is membership. 2. 7. aronson l. ‘covid-19 kills only old people.’ only? [internet]. the new york times opinion. 2020 mar https://scienceandsociety.duke.edu/wordpress/wp-content/uploads/berry-health-is-membership.pdf https://scienceandsociety.duke.edu/wordpress/wp-content/uploads/berry-health-is-membership.pdf https://www.nejm.org/doi/full/10.1056/nejme2007263 https://www.nejm.org/doi/full/10.1056/nejme2007263 23 millhollin april 2020. christian journal for global health 7(1) 22 [cited 2020 apr 13]. available from: https://www.nytimes.com/2020/03/22/opinion/corona virus-elderly.html. 8. moore r. god doesn’t want us to sacrifice the old [internet]. the new york times opinion [internet]. 2020 mar 26 [cited 2020 apr 14]. available from: https://www.nytimes.com/2020/03/26/opinion/corona virus-elderly-vulnerable-religion.html?smid=fb-share 9. ferguson nm, laydon d, nedjati-gilani g, imai n, ainslie k, baguelin m, et al. impact of nonpharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand. imperial college covid-19 response team. 2020 march 16 [cited 2020 apr 13]. available from: https://www.imperial.ac.uk/media/imperialcollege/medicine/sph/ide/gida-fellowships/imperialcollege-covid19-npi-modelling-16-03-2020.pdf. 10. nicas j. he has 17,700 bottles of hand sanitizer and nowhere to sell them [internet]. the new york times. 2020 mar 14 [cited 2020 apr 13]. available from: https://www.nytimes.com/2020/03/14/technology/cor onavirus-purell-wipes-amazon-sellers.html. 11. kavilanz p. toilet paper makers: ‘what we are dealing with here is uncharted’ [internet]. cnn business. 2020 mar 19 [cited 2020 apr 13]. available from: https://www.cnn.com/2020/03/17/business/toiletpaper-supply-chain-coronavirus/index.html 12. thorbecke c. americans hoarding hand sanitizer, face masks and oat milk amid coronavirus fears [internet]. abc news. 2020 mar 4 [cited 2020 apr 13]. available from: https://abcnews.go.com/business/americanshoarding-hand-sanitizer-face-masksamid%20coronavirus/story?id=69385946 13. berry w. health is membership. 8. 14. berry w. health is membership. 8. 15. grills n. covid-19: containment, poverty and population health [internet]. 2020 mar 23 [cited 2020 april 13]. in: ama insight+. available from: https://insightplus.mja.com.au/2020/11/covid-19containment-poverty-and-population-health/ competing interests: none declared. correspondence: jordan millhollin, durham, nc, usa. jordan.millhollin@gmail.com cite this article as: millhollin j. separated but whole: pursuing health and redefining community amidst covid-19. christian journal for global health. april 2020; 7(1):20-23. https://doi.org/10.15566/cjgh.v7i1.367 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.nytimes.com/2020/03/22/opinion/coronavirus-elderly.html https://www.nytimes.com/2020/03/22/opinion/coronavirus-elderly.html https://www.nytimes.com/2020/03/26/opinion/coronavirus-elderly-vulnerable-religion.html?smid=fb-share https://www.nytimes.com/2020/03/26/opinion/coronavirus-elderly-vulnerable-religion.html?smid=fb-share https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/imperial-college-covid19-npi-modelling-16-03-2020.pdf https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/imperial-college-covid19-npi-modelling-16-03-2020.pdf https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/imperial-college-covid19-npi-modelling-16-03-2020.pdf https://www.nytimes.com/2020/03/14/technology/coronavirus-purell-wipes-amazon-sellers.html https://www.nytimes.com/2020/03/14/technology/coronavirus-purell-wipes-amazon-sellers.html https://www.cnn.com/2020/03/17/business/toilet-paper-supply-chain-coronavirus/index.html https://www.cnn.com/2020/03/17/business/toilet-paper-supply-chain-coronavirus/index.html https://abcnews.go.com/business/americans-hoarding-hand-sanitizer-face-masks-amid%20coronavirus/story?id=69385946 https://abcnews.go.com/business/americans-hoarding-hand-sanitizer-face-masks-amid%20coronavirus/story?id=69385946 https://abcnews.go.com/business/americans-hoarding-hand-sanitizer-face-masks-amid%20coronavirus/story?id=69385946 https://insightplus.mja.com.au/2020/11/covid-19-containment-poverty-and-population-health/ https://insightplus.mja.com.au/2020/11/covid-19-containment-poverty-and-population-health/ mailto:jordan.millhollin@gmail.com https://doi.org/10.15566/cjgh.v7i1.367 http://creativecommons.org/licenses/by/4.0/ references editorial june 2020. christian journal for global health 7(2) the future of health in mission starts with reading the story together bruce dahlmana a md, mshpe, faafp, christian academy of african physicians, former head, department of family medicine and community care, school of medicine and health sciences, kabarak university, kenya, this christian journal for global health issue (june 2020) focuses on the “changing landscape of faith-based hospitals.” but the broader context is the future of how healthcare and mission intersect. the tübingen conference of 1964 began the conversation of the need for greater integration of health within mission.1 certainly the context of our current covid-19 pandemic gives us significant impetus to reflect further on the roles and places of christian healthcare service and healing. i believe this reflection needs to begin with a focus on how our lord modeled a servant heart. as healthcare providers who desire to emulate jesus, the great physician, we need to more thoroughly engage and influence mainstream, mission strategy. without greater dialogue, healthcare mission can too easily be relegated to the “compassion corner.” instead, all mission endeavors need to come together to embrace an integral mission approach as the way things need to be. parallel mission universes two well-known, us-based, mission groups held their annual gatherings of several hundred persons each this past september 2019. missio nexus held its "leadership conference"2 for evangelical protestant church and mission agencybased organizations. samaritan’s purse held its annual "prescription for renewal"3 retreat for medical and other healthcare missionaries. both conferences were held on the same weekend and in the same city. yet, from my inquiry to the organizational leadership of both, neither conference-planning group seemed to be aware of the others’ plans and the opportunity for crosspollinating collaboration. church and mission agency leaders didn’t hear about the work of health and healing in mission. physician attendees of the second meeting didn’t hear about the breadth of church engagement that is not healthcare-related. both organizations do their respective jobs well. doesn’t it seem unusual that groups that profess the same goal continue to plan and strategize in parallel tracks? in the larger context, isn’t there something terribly amiss when “health for all nations” becomes one of the last of the more than thirty groups of the "issue networks of the lausanne movement?"4 how would jesus want to see mission? the essence of the answer to this question is given by rev. john stott, the deeply loved 20th century evangelical pastor and scholar, in his exploration of the theology of missions entitled christian mission in the modern world.5 stott explained his “conversion” from the dualism of the great commandment and the great commission categories when he encountered the apostle john’s version of jesus’ sending of the disciples from his gospel: “again, jesus said, ‘peace be with you! as the father has sent me, i am sending you.’ and with that he breathed on them and said, ‘receive the holy spirit.’” (john 20: 21 – 22). 148 dahhlman june 2020. christian journal for global health 7(2) western theological culture has inherited systematic theologies that create the categories within which we order our theological understandings. the richness of african and eastern cultures is their dependence on narrative — the story. the four gospels and acts are the new testament’s narrative story. and in his version of jesus’ commission to christians, the apostle john reveals how jesus ministered. absorbed in the story, we cannot help but see that there was no separation of love into proclamation and compassion. jesus moved seamlessly between teaching, discipling, healing, and confronting anything and anyone that stood between a person’s need and their ultimate need for his father: money, past relationships, sickness, demons, death. and to whatever hindrance might be standing in the way of relationship with the divine, in john’s poetic rendering, jesus offered himself as the “i am:” the bread, the light, the gate, the way, the vine, the resurrection: the life. and to make no mistake of the only source of that life, juxtaposed to the near final “i am,” is the delineator: “no one comes to the father except through me [jesus]” (john 14:6). how does all this matter to the global christian church, missions, and global health as we enter the 2020s? and what does it mean to the goal of jesus’ name being known among the ethne [peoples] that have not yet heard? simply put — by not being intentional in following the clear example of how christ reached out to all whom he met, we risk not being able to complete that defined, and eternally important, task. in this wholistic understanding, medical ministry, ministry among orphans, ministry among disabled, agricultural ministry, fill-in-the-blank ______ “compassion” ministry does not exist to “open the door” to the “real thing.” there is no dichotomizing in the gospel narratives of jesus’ ministry. the categories are not there — we put them there. must we name jesus as god’s answer to reconciliation with the father? yes. but when reaching out to a remote people group, what is communicated to them when there is no response to the wailing after a woman has died in childbirth? wouldn’t following christ’s injunction to go “as the father has sent me” mean attempting to bring a higher healthcare standard to bear? can our defense really be, as keith green poignantly put it in his song the sheep and the goats,6 “lord, that [caring for her “social gospel” need] just wasn’t our ministry?” no, there is no “good news” in a needless death. good news in word cannot help the soul of a person that has died. is it possible today to make the same modernist mistake of the 1920s and sideline orthodoxy? of course. but in erecting defenses to this error over the last century, does the church, especially its evangelical stream, fall into the equally erroneous proposition that we can proclaim the gospel without following the clear example of jesus and the consistent teaching of the scripture? i hope not. i do not believe that those who are yet to hear can be expected to respond without us risking what it means to be and to make disciples by incorporating the radical, allinclusive, non-categorized love that is lived out in an “as jesus was sent” way. can we westerners listen to our latin american, african, and asian brothers and sisters who don’t see such cleanly erected, culturallybound categories? can we critically read john stott and others who provocatively speak to the hang-ups of our modern, strategically planned programs? can we hear scripture and the spirit to be intentional in our love to come alongside compelling needs? is jesus christ’s love compelling without our total life witness? not if we accept the either/or mentality of our cultural history of the modernist/ fundamentalist debates that fed this dualism. and not even in a both/and mode to thereby accept these two categories as legitimate. but we must embrace the shalom that is found only in our lord and savior, the one way, jesus. 149 dahhlman june 2020. christian journal for global health 7(2) why two parallel, non-communicating conferences in the same city at the same time? i believe the greater responsibility rests on healthrelated ministries to seek out opportunities to inform the conversation within legacy mission networks. the church/mission hospital cannot work in isolation to the church next door. the western mission agency cannot afford to relegate healthcare mission to a “department” to meet its goals. short-term medical missionaries can be more aware of how their contribution connects to the larger mission of the church. healthcare missions and the mission of the church can no longer afford to be siloed because it is one and the same life of loving as jesus loved. what would jesus do? as christopher grundman has eloquently explained in his explication of the christus medicus trope: therefore, christian medical missions cannot sufficiently be justified by personal devotion and commitment to the task nor with strategic considerations. considerations like these fail to notice that exploiting human suffering as opportunity for evangelization and church growth compromises the integrity of both, medicine and the gospel. working under false pretense is neither reconcilable with professional ethos nor with christian standards, one of which is refusing “to practice cunning” (2 cor 4:2).”7 as prof. grundman explains, i believe it is imperative that we in the west humbly shed our centuries old cultural dualism between medical vs. proclamation missions and agree that we serve medically because we love as christ loved. we can and must learn from our african and other majority world colleagues in order to work as a unified church and mission enterprise to proclaim and demonstrate word and deed; oh, the deep, deep love of jesus. the story of the gospels: “jesus went throughout galilee, teaching in their synagogues, preaching the good news of the kingdom, and healing every disease and sickness among the people” (matt. 4:23). education, proclamation, healing. all in one verse, all in one person, throughout his ministry on earth. we are sent as the father sent jesus. jesus has called his church to, “do greater works than these.” may even greater dialogue begin to see healthcare and mainstream mission find their synergy as integral mission. soli deo gloria references 1. grundmann ch. the legacy of tübingen i: on the occasion of its fiftieth anniversary. int rev mission. 2005 apr;104(1):118-33. available from: https://missionexus.org/future-mission/ 2. missio nexus leadership conference [internet]. 2019 [cited 2020 june 22]. available from: https://missionexus.org/future-mission/ 3. prescription for renewal [internet]. 2019 [cited 2020 june 22]. available from: https://video.samaritanspurse.org/prescriptionfor-renewal-2019/ 4. the lausanne movement issue networks [internet]. [cited 2020 june 21]. available from: https://www.lausanne.org/networks 5. stott j, wright jh. christian mission in the modern world. westmont, il: iv press; 2016. 6. green k. the sheep and the goats [internet]. 1981 [cited 2020 june 10]. available from: https://songs-tube.net/200432-keith%20greenthe%20sheep%20and%20the%20goats.html 7. grundmann ch. christ as physician: the ancient christus medicus trope and christian medical missions as imitation of christ. christ j global health. 2018 nov;5(3):3-11. https://doi.org/10.15566/cjgh.v5i3.236 https://missionexus.org/future-mission/ https://missionexus.org/future-mission/ https://video.samaritanspurse.org/prescription-for-renewal-2019/ https://video.samaritanspurse.org/prescription-for-renewal-2019/ https://www.lausanne.org/networks about:blank about:blank https://songs-tube.net/200432-keith%20green-the%20sheep%20and%20the%20goats.html https://songs-tube.net/200432-keith%20green-the%20sheep%20and%20the%20goats.html https://doi.org/10.15566/cjgh.v5i3.236 150 dahhlman june 2020. christian journal for global health 7(2) submitted 20 june 2020, accepted 23 june 2020, published 29 june 2020 competing interests: none declared. correspondence: bruce dahlman, minnesota, usa bruce.dahlman@aimint.org cite this article as: dahlman b. the future of health in mission starts with reading the story together. christ j global health. june 2020; 7(2):147-150. https://doi.org/10.15566/cjgh.v7i2.411 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:bruce.dahlman@aimint.org https://doi.org/10.15566/cjgh.v7i2.411 about:blank case report may 2019. christian journal for global health 6(1) understanding treatment-resistant depression: a missionary’s autobiographical case report hunter yorka a cross-cultural development worker, philippines abstract as a career cross-cultural missionary in southeast asia, the author has seen first-hand and has personally experienced the devastating effects of colleagues, families, leaders, clinicians, and the sufferers themselves misunderstanding the symptoms and the reality of major depressive disorder, an increasing global health problem. this autobiographical case report reflects on twenty years of treatment-resistant depression and a journey through pharmacological approaches, psychotherapy treatment, christian prayer counselling, and electro convulsive therapy without improvement in this condition. the primary concern is how to remain faithful and effective with this condition in a service-oriented occupation that requires regular emotional expenditure. in lieu of effective conventional and non-conventional therapies, the remaining option is to find a way to manage chronic depression; identify personal trends, weaknesses, and triggers; and find a personalized way to live that minimizes the effects of the condition. in any chronic, incurable disorder, the sufferer must inevitably come to terms with his or her reality and find peace in the acceptance of that reality. by expressing the journey through treatment-resistant depression, the author encourages readers to persevere in ministry and to respond more appropriately to the afflicted with clearer understanding and empathy. a companion article on mitigating depression symptoms through the spiritual discipline of identifying with christ and his experience of human emotional pain during his passion is available. key words: treatment resistant depression, suffering, missionary retention, empathy, transcendence introduction according to a world health organization estimate, unipolar depression is the leading cause of ill health and disability worldwide, affecting 300 million people.1 worldwide, irrespective of cultures, there has been a steady increase in the reported cases of depression, considered an epidemic of modernization. there has been some association 44 york may 2019. christian journal for global health 6(1) with global increases in obesity, poor diet, sleep deprivation, sedentariness, social inequality, and social isolation, but a specific cause of the increase has not been determined.2 the increased incidence has particularly affected younger age groups in diverse global contexts. loss of family stability, increases in individualism, reduced religious observance, and industrial environmental factors have been implicated.3 trivedi and greer conclude that although antidepressant treatment may offer some improvement, symptoms can also persist residually for the life span.4 though there is no universally accepted definition, treatment-resistant depression (trd) is commonly defined as no response to two or more antidepressant trials of adequate dose and duration.5 al-harbi identifies that depressive illness-related factors, personal characteristics, medication variables, and psychosocial stresses collectively contribute to the development of trd and are associated with a considerable disease burden. he notes that 10-30% of cases of depression are refractory to pharmacologic treatment, and 30% of those with trd do not respond to any treatment.6 gish identified 19 stressors that contributed to a possible build up to depression among crosscultural workers that, if unrelieved, lead to health issues, relational problems, and cognitive impairment.7 a study in the united states concluded that 35% of pastors battle depression, fear, and anxiety, and that only one out of ten pastors will retire as a pastor.8 depression is a major cause of attrition among cross-cultural workers, with an incidence of 27-32% among missionary healthcare workers.9 burnout does not equate with depression but is often a precursor to depression if left unmanaged. hodges posits that the remedy for ministerial burnout may be found partially in transcendence of purpose combined with intrinsic values and community. the transcendence of which she speaks does not mean the eradication of all symptoms, but it allows the sufferer the ability to function and contribute while minimizing the constant negative influences and subconscious suggestions of depression through a faith focusing on the positive aspects of god and his promises.10 there is little in the literature on the nexus between persistent ministerial depression, crosscultural stress, and missionary retention. my contribution is an autobiographical case report from which i hope to offer an understanding of the depths of misery of one suffering this affliction and a way of approaching transcendence for ministerial endurance. depression is a visceral, irrational, and stupefying state that may persist despite sincere efforts of the faith community, member care of faithbased organizations, and psychotherapeutic approaches by professional mental health practitioners. depression, even if treatment resistant in nature, does not need to be a disqualifying condition for effective cross-cultural or ministerial service, but can be redeemed by perseverance and endured through faith and a consistently-dependent relationship with god. charles spurgeon, hudson taylor, william carey, and saint teresa of calcutta are all good examples of this, but contemporary examples and analysis are needed. experience with treatment-resistant depression as a cross-cultural missionary to southern philippines for the past 30 years, i have experienced significant treatment-resistant depression, a disease of the brain, and if you will allow, the soul. it is an affliction, disability, “personal demon” (figurative), a form of insanity, profound and inexplicable sadness, debilitating listlessness, white-hot electric anxiety (symptoms which can accompany depression), near-complete emotional disassociation, debilitating fear, irrational guilt, untethered moral and spiritual confusion, and unabating assaults on self-worth and all things good. my contribution to the problem is a more visceral and intuitive understanding of the experience of 45 york may 2019. christian journal for global health 6(1) depression, and how, despite its persistence, it has been managed by the grace of god through faith and spiritual disciplines. solutions without empathetic personal understanding often are not effective treatment options for mental illness conditions where people are in need of emotional connection. family and phyco-social history there is a long family history of depression and brokenness in my family. i was raised in the united states. shortly after my birth, in the early 1960s, my mother had what she called a nervous breakdown, which included hallucinations of demons crawling on the walls. unfortunately, she never recovered and never admitted she had a problem and, therefore, was never diagnosed or treated. she would regularly and for no apparent reason go into fits of violent rage at the speed of flicking a light switch. she would often beat me until she got tired or hurt herself, whichever came first. when i got older, bigger, and stronger, she resorted to weapons. but worse than this was the relentless emotionally emasculating ways she verbally destroyed every ounce of self-esteem i would ever have. this rage was expressed physically and verbally until i was old enough to leave home. my father never talked about being a virtual orphan during his up-bringing, but he made it clear to us that two of the most clearly understood rules as i was growing up were, “no complaining,” and “no excuses.” he was a quiet man until he lost his temper. i remember him giving me advice only twice in my life. he was not prone to compliments or affirmation. personal transformation when i found faith and embraced jesus with all my heart at the age of twenty, in 1982, i was bursting with unadulterated joy and zeal. i felt a compelling desire to serve as a missionary among the poor overseas. i began my career when i was twenty-two. for years i had felt a spiritual energy that helped me push through insurmountable obstacles and helped me accomplish more solid missionary goals in my first few years of cross-cultural work than one could reasonably expect after a lifetime of service. i felt unstoppable in my faith. i worked hard, slept little, and grew accustomed to working in life-threatening environments in relief and development projects in impoverished conflict zones. my biggest fear was not kidnapping, bullets or bombs, but rather, not measuring up to other people’s expectations. much of my early ministry was probably motivated by the need to prove my worth. about thirteen or fourteen years into my missionary career, i started to feel different. by this time, my amazing wife and partner in ministry had borne me four beautiful daughters, i had founded a mission, published a book, earned the respect of most of my peers, and had significantly invested in the lives of thousands. we lived simply, without much money, but we were content. since we were not a member of a recognized mission organization, we were often painfully rejected by our peers who were members of larger organizations. essentially, we were isolated with small children in a war zone for ten years. affective decline the first signs were subtle and confusing. i remember during a break at one of my missionary training courses in 1999, i was in my room and feeling completely devastated. people from all over the country had traveled to our remote location to be trained by me, but i, irrationally, felt like a complete failure and fraud. it took every fiber of will to force myself to walk back to the classroom and teach. something had changed. i am no stranger to spiritual warfare, but i honestly was not able to understand what weaknesses were being exploited by spiritual powers and what weaknesses were the results of overwork or possibly biological imbalance. i did not know what i was experiencing, but it was about to get worse. the successive years led to our team planting the first church among a previously 46 york may 2019. christian journal for global health 6(1) unreached tribe in 2003. i had reached my goal of building our local organization up to national sustainability and was in the process of passing the leadership of the mission over to my protégés. at this stage, i still was unaware that i was trying to regain my sense of self-worth through my accomplishments and working harder than everyone else. at the pinnacle of missionary success, i felt indescribably miserable. it was baffling. i had doubts of my legitimacy. i had doubts about my accomplishments. i had doubts about some aspects of my faith. i began to long for an existence untethered to spiritual obligation. i felt brutalized by irrational guilt and daily assaults of neurotic selfloathing. my confusion was extreme, and i began to lose my connection to all things dear. i wanted to escape, but i had no idea of where to escape. burnout? maybe. for a couple of years i had brushed off the possibility of depression because i thought it was the invention of lazy people who wanted to justify their weaknesses. “no complaining. no excuses,” was the way i was raised as a child, and i carried that attitude into adulthood; so i did not see the need to seek help. the years progressed, and life got lower, darker, more confusing, and more hopeless. i remember the first time my mind wandered off to a fantasy state sometime around 2007, where the thought of not being alive was so much more appealing than being alive in my condition. by this time, i had already passed leadership of our mission over to my filipino protégé and had taken my family to the united states to experience my side of their cultural heritage. i realized that it was the first time i had consciously thought of suicide as a possible answer to the deep pain i constantly felt. two years before that, in 2005, we were hit with hurricane katrina and our house, as well as most of the mississippi gulf coast, experienced catastrophic damages. the floods rose so fast that i had to swim out of a bedroom window with my two youngest children on my back amidst debris and 200 kph winds. by this time, i had started a fledgling construction company to support my family. the work demands were high, and the days were long. i began to slip deeper and deeper into a level of stress overload for which i had no vocabulary. then, while we still did not have internet, phone, electricity, or water, my filipino mission leader protégé died from a brain tumor at age 38. i was not aware that he had passed for nearly two weeks, which was misinterpreted by some of my staff that i did not care. it took me more than two years to unburden myself from debts and commitments in the united states, raise support, and move back to the philippines to rebuild my life’s work. my sense of responsibility to people for whom i had moral obligations was all that was keeping me in the ministry. in 2009, i moved my family back to the philippines. joy was often a distant concept after the initial sense of “coming home” to my calling had receded. my visits to the province and my recruiting and training of new staff became a heavier and heavier burden for me. it is not possible to describe the black, oppressive weight that crushed the life out of me twenty-four hours each day. thoughts like the non-existence of god were intruding into my mind and managed to stay around regardless of how hard i tried to drive them out. all the mornings were hard. though i had insomnia, sleep was the closest thing to oblivion and the only time i was not in constant, savage agony. diagnostic and treatment approaches a diagnosis of major depressive disorder was suggested, in 2002, by a retired american psychologist i consulted first through email while in the philippines and then in person while visiting the united states, but only psychological tests and an assessment were offered. in 2004, i returned to the united states for five years, and in 2006, i tried to explain to my american family doctor about the white-hot panic and fear, the dark oppression that eclipsed all positive emotions, and the intense, 47 york may 2019. christian journal for global health 6(1) constant misery i felt. i showed him the uncontrollable trembling in my hands. he listened but did not seem to take my complaints seriously, nor accept the previous diagnosis of depression until i told him about some anti-depression medication commercials that i had seen. after that, he basically gave me what medications i asked for. if i revisited him weeks later with more depression symptom complaints, he would take me off the medicine i was currently on, without tapering, and prescribe another. in 2007, i sought help from a psychologist who confirmed the diagnosis of major depressive disorder and began a very cursory form of psychotherapy. i also consulted a psychiatry professor at a major university who seemed extremely qualified, but he was an hour’s drive away in another state, because i did not want anyone in my small town to see me walking into a psychiatrist’s office. he hardly ever made eye-contact during our ten-minute monthly sessions in 2007-2008, as he focused on writing prescriptions of different kinds at each visit, often filling my arms with free sample packs. this did not provide any relief. upon my return to the philippines in 2009, and in 2011, i consulted a filipino psychiatrist who made a better effort, and i spent six months with him in weekly freudian psychoanalysis while continuing adjustments in anti-depressant medications. at the end of this time, he diagnosed treatment-resistant depression, basically admitting that there was nothing more he could do for me, but would prescribe any available medication of which i had researched and for which i asked. over the period from 2006 to 2017, i was prescribed at least nine different anti-depressant medications starting with fluoxetine followed by extended trials of venlafaxine and duloxetine in addition to tranquilizers, anti-psychotics like quetiapine, anti-anxiety medications like clonazepam, and sleep aid sedative-hypnotics like zolpidem. none seemed to make any difference in my depression but produced uncomfortable sideeffects, like tremors, numbness or tingling sensations, listlessness, cognitive impairment, sexual dysfunction, incoordination, and feeling like a zombie. ultimately, the prescription of different medications was a well-intentioned, but unsuccessful, search for something that could provide relief. my teeth chattered uncontrollably for several years. i learned to mask it well in public. i could not experience enjoyment of food, sex, family, money, hobbies, adventure, faith, or fellowship. i was not just numb. i felt like i had lost my soul and was walking around without it. sometimes changing medicine was not well supervised by my doctors, and i would go into full-blown withdrawals that included convulsions, hallucinations, insomnia, vomiting, fainting, and incoherence. due to little guidance, i had to learn by trial and error how to taper off medicines. there was no collaboration between doctors. none of my doctors were available by phone, so geographical distance often made the treatment sporadic. during my time in the united states from 2004 to 2009, i still had work and church responsibilities that required me to literally drag myself out of the house and engage with the world seven days a week. i had a mortgage, a construction company, clients, and six mouths to feed. my wife was very compassionate, but scared during this time, and things were generally good with the children. i was determined not to drag anyone else down with me, so i pressed on. after fourteen years of various medications, different forms of psychotherapy, and christian counselling, my condition became so severe in 2016 that i sought out what i considered extreme therapy and requested six bi-lateral electroconvulsive therapy (ect) sessions in january 2017. during my convulsions, i fractured a molar and tore my rectus abdominus muscle so severely that it took me seven months to be able to sit up without significant difficulty. after the treatment, i suffered confusing side effects and spent the next two months in bed. there were significant gaps in my memory that still remain empty. for nearly two months, full body spasms came without warning about a dozen times a 48 york may 2019. christian journal for global health 6(1) day, and new tactile, verbal, and auditory hallucinations were common, tremors were constant, and incoherence came and went. this lasted a few months. after this disappointing attempt at a cure, i experienced a deep slide back into my depression which eventually eroded hope that i could ever be cured. adaption to my current condition my depression symptoms persist to this day. i have come to accept my condition while neither surrendering to it nor being completely disabled by it. in a way, my weakness forces me to look to god in faith because my sight is so diminished. i have lost the ability to enjoy legitimate pleasures, but somehow, after so long, i still hope that this capacity will someday, in some form, be restored. in the meantime, i have found ways to live a productive life and remain in my cross-cultural service context as i realistically manage my capacity by operating within my known limits. for example, i know that most social interactions bring me to a critical breaking point after two and a half hours. i know that i will usually have four significantly productive days in a week. one or two days i often crash completely and do not get much of anything done, like a forced sabbath rest. and usually i have one neutral day where i am able to function at a basic survival level doing chores, errands, etc. i have learned to coordinate my schedule according to my limits and to identify the feelings that indicate the need for rest and withdrawal which suggest an imminent crash. though it seems divergent to the victorious life in christ i am supposed to experience, i often feel like a cold, lifeless being that tries to project normalcy for the benefit of others. i do not pretend to understand this seeming contradiction except perhaps that it forces me to look to god more intentionally and more frequently. fortunately, my feelings do not define my relationship with god. most of what remains of my ability to feel is the capacity to experience the negative emotions of guilt, perceived rejection, self-loathing, fear, and loss. without this pain, i would have little sensation at all, and i have to daily remind myself of the promises of god that contradict my negative emotions. this, and my intentional recognition and thanksgiving for the good god has allowed in my life, even when i can not feel it, daily constitute a form of cognitive behavioral therapy for me. many saints before me have gone through longer and more difficult trials that have almost certainly resulted in depressive periods. our conventional concept of joy has to do with things like happiness, fulfilment, exuberance, prosperity, lack of problems, and good health. is it possible to find a different, more subtle, and possibly even a deeper form of joy without these qualities through a settled faith and surrender to god in the midst of our uncomfortable situations? attempts at integration the soul is sometimes defined as a combination of one’s mind, will, and emotions. in my case it seems that there is a disintegrating, and at times, contradictory relationship between these three components. it feels like i have mostly my mind to get me through this life for now. my will is feeble and anemic at times, and my heart, my passion, which used to be the strength that defined my personality, has all but faded away. yet despite this disintegration, there is the occasional synapsis between the three. these occasions remind me that there is hope for recovery... someday. outwardly, i look normal. no one would guess that i almost always feel like a hollow man without a normal, free-functioning soul—a frankenstein’s monster, an outcast, a misfit, an invalid—breathing, walking, and speaking in a weary, middle-aged body. most of the time, the darkness within me is stronger than the light, but occasionally i get a glimpse of the sun, and my hope is renewed that god is with me, watching me, remembering me. it was not until i was in my mid-20s, after talking with peers about their childhoods, that i began to realize that my 49 york may 2019. christian journal for global health 6(1) childhood was not normal or nurturing. there are many who fall into this category. my mind tells me that the bible is true, that god is real, and that he loves me. my heart feels almost nothing emotionally supportive of this most of the time. duty has eclipsed delight. the complexity of etiology the cause of my condition remains elusive. perhaps my insecurity-driven motivation to prove myself has contributed to my condition, or perhaps it has been my abusive childhood, genetic predisposition, independent-mindedness, or the stresses of cross-cultural service. i am not a legalist, but i have been an individualist most of my life, which may have led to isolation. my pursuit of care and treatment were not optimal, due to limited resources, travel schedules, and no collaboration between mental health providers. my independentmindedness isolated me from potentially healing contexts. long-term misery had a negative impact on important relationships that would otherwise have been supportive among family and ministry colleagues. each time i come back “home,” i find that time, distance, and other interests and seasons of life have reduced the closeness with friends that used to bring me such encouragement. sometimes, i regret the single-hearted devotion with which i have served as a missionary for thirty plus years. when one focuses almost exclusively on one’s calling, it is unbalanced and, in the end, fails the ideals of the body of christ which values people more than productivity. the loss of intimacy and comradery is one of the things i hope to have restored. the necessity of transcendence i have managed to remain relevant by a conscious and consistent focus on jesus and his presence with me by faith despite the inability to feel connected to him. the bible describes faith as, “... being sure of what we hope for and certain of what we cannot see.” (heb 11:1 [niv]). faith is what tethers us to a god we cannot see when all our senses tell us he is not there. in the end, when all other reasonable options have failed for the sufferer of depression, this case report and my companion article biblical reflection on the passion of jesus christ as it relates to 20 years of treatment-resistant depression11 suggests that faith can help those who suffer trd transcend the debilitating symptoms of depression and provide the hope necessary to remain productive, seek healthy relationships, and contribute to society and transformational development. conclusion with the global burden of disease from depression increasing, the limitations in access to good mental health services, and as many as 30% of depressed persons not being able to fully recover from their illness regardless of responsible treatment, the global medical, psychological, and religious community is faced with a significant challenge. empathy, understanding, perseverance, and patience seem to be a key to effective support for depressed persons. building global capacity for better availability, collaboration, and competency of mental health services is vital. reducing isolation through systems of caring and supportive relationships within family, organization, and community is critical. faith is essential for hope, and hope is essential to cope with the heavy darkness of treatment-resistant depression. for those who follow the christian faith, remembering that christ is not aloof and far away, but has experienced our humanity and pain and lives in us by his spirit helps us to connect with him in a unique way when we are in emotional pain and seeking to connect and minister to others (2 cor 1:4). an intentional focus on the example, promises, and the presence of christ in our life combined with our assurance of complete relief after this body is fully transformed might be the most effective approach by which to transcend 50 york may 2019. christian journal for global health 6(1) the debilitating symptoms of major depression disorder and continue to persevere in effective ministry to others. references 1. world health organization [internet]. depression: let’s talk. 2017 april 7. available from: https://www.who.int/mental_health/management/depr ession/en/ 2. hidaka bh. depression as a disease of modernity: explanations for increasing prevalence. j affect disord. 2012;140(3):205-14. https://doi.org/10.1016/j.jad.2011.12.036 3. goleman d. a rising cost of modernity: depression. new york times. 1992 dec 8. available from: https://www.nytimes.com/1992/12/08/science/arising-cost-of-modernity-depression.html 4. trivedi mh, greer tl. cognitive dysfunction in unipolar depression: implications for treatment. j affect disord. 2014 jan;152-154:19-27. https://doi.org/10.1016/j.jad.2013.09.012 5. trevino k, mcclintock sm, mcdonald fischer n, vora a, husain mm. defining treatment-resistant depression: a comprehensive review of the literature. ann clin psych. 2014 aug;26(3):222-32. available from: https://www.ncbi.nlm.nih.gov/pubmed/25166485 6. al-harbi ks. treatment-resistant depression: therapeutic trends, challenges, and future directions. patient prefer adher. 2012 may;6:369-88. https://doi.org/10.2147/ppa.s29716 7. gish dj. sources of missionary stress. j psychol theol. 1983;11(3):231-6. https://doi.org/10.1177/009164718301100309 8. strand ma, pinkston lm, chen ai, richardson jw. mental health of cross-cultural healthcare missionaries. j psychol theol. 2015 dec 1;43(4):28393. https://doi.org/10.1177/009164711504300406 9. pastoral care inc [internet]. statistics in the ministry. statistics provided by the fuller institute, george barna, lifeway, schaeffer institute of leadership development, and pastoral care inc. [cited 2019 feb 15]. available from: https://www.pastoralcareinc.com/statistics/ 10. hodges s. mental health, depression, and dimensions of spirituality and religion. j adult dev. 2002 april;9(2):109-15. https://doi.org/10.1023/a:1015733329006 11. york h. biblical reflection on the passion of jesus christ as it relates to 20 years of treatment resistant depression. christ j global health. 2019;6(1):51-58. https://doi.org/10.15566/cjgh.v6i1.279 peer reviewed: submitted 27 jan, revised 1 april, accepted 13 april, published 31 may 2019 competing interests: none declared. correspondence: hunter york, philippines. hunteryork68@yahoo.com. note that for reasons of patient privacy and security, a pseudonym was used for the author. cite this article as: hunter york. understanding treatment-resistant depression: a missionary’s autobiographical case report. christ j global health. may 2019; 6(1):43-50. https://doi.org/10.15566/cjgh.v6i1.275 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.who.int/mental_health/management/depression/en/ https://www.who.int/mental_health/management/depression/en/ https://doi.org/10.1016/j.jad.2011.12.036 https://www.nytimes.com/1992/12/08/science/a-rising-cost-of-modernity-depression.html https://www.nytimes.com/1992/12/08/science/a-rising-cost-of-modernity-depression.html https://doi.org/10.1016/j.jad.2013.09.012 https://www.ncbi.nlm.nih.gov/pubmed/25166485 https://doi.org/10.2147/ppa.s29716 https://doi.org/10.1177/009164718301100309 https://doi.org/10.1177/009164711504300406 https://www.pastoralcareinc.com/statistics/ https://doi.org/10.1023/a:1015733329006 https://doi.org/10.15566/cjgh.v6i1.279 mailto:hunteryork68@yahoo.com https://doi.org/10.15566/cjgh.v6i1.275 http://creativecommons.org/licenses/by/4.0/ field report may 2019. christian journal for global health 6(1) jacob’s pharmacy jacob d. blaira a pharmd, christian urban development association, arequipa, peru now he had to go through samaria. so he came to a town in samaria called sychar, near the plot of ground jacob had given to his son joseph. jacob’s pharmacy was there, and jesus, tired as he was from the journey, sat down by the pharmacy. it was about noon. when a samaritan woman came to fill her prescription, jesus said to her, “will you give me some medicine?” (his disciples had gone into the town to buy food.) the samaritan woman said to him, “you are a jew and i am a samaritan woman. how can you ask me for medicine?” (for jews do not associate with samaritans.) jesus answered her, “if you knew the gift of god and who it is that asks you for medicine, you would have asked him and he would have given you living medicine.” “sir,” the woman said, “you have no prescription and the medicine is controlled. where can you get this living medicine? are you greater than our father jacob who gave us the pharmacy and filled his prescriptions here himself as did also his sons and his livestock?” jesus answered, “everyone who takes this medicine will be sick again, but whoever takes the medicine i give them will never get sick. indeed, the medicine i give them will become in them a miracle cure leading to eternal life.” the woman said to him, “sir, give me this medicine so that i won’t get sick and have to keep coming here to fill my prescriptions.” adapted from john 4:4-15 (niv) submitted 16 nov 2018, accepted 20 dec 2018, published 31 may 2019 competing interests: none declared. correspondence: jacob d blair, arequipa, peru. jblair@harding.edu cite this article as: blair jd. jacob’s pharmacy. christian journal for global health. may 2019; 6(1):90. https://doi.org/10.15566/cjgh.v6i1.263 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ original article dec 2020. christian journal for global health 7(5) preparing christian health workers for international work: evaluating a short global health course sneha kirubakarana, doug shawb, lawrie mcarthurc, angus millerd, anthony radforde a bcomp, bappsc (hons), bmbs, graddip (clined), fracgp, chair, intermed sa, australia b mbbs, ma, mth, fracgp, fafphm, course coordinator, intermed sa, australia c mbbs, dracog, fracgp, facrrm, phd, associate professor, immediate past chair, intermed sa, australia d bhsc, md, researcher, intermed sa, australia e sm, frcp (edin), ffcm, fracp, fracgp, fafphm, dtm&h, emeritus professor, founder, intermed sa, australia abstract improving global health education to ensure health professionals are prepared and competent in the world’s increasingly interconnected health-scape is a vital need. for many health professionals, global health education is facilitated through short, pre-departure courses in cross-cultural health and development work. there is currently limited literature on both the availability and the effectiveness of such courses. our research aim was to explore the impact of a short course in global health education, designed and delivered by an australian not-for-profit organisation, intermed sa (intermed). we conducted a short online survey of intermed graduates, followed by semi-structured interviews with selected participants. the results indicate that intermed’s international health and development course was effective in achieving the course objectives as assessed by graduates, whilst also having a positive practical impact on the graduates’ professional development. key words: global health education, preparatory short courses, international health and development, cross-cultural health care introduction current global health concepts are descended from older streams of public health, international health, and tropical medicine.1-3 molyneaux & o’hare explain the differences: whereas public health is largely focused on preventive care and is usually within a country or a community, and international health is mainly about the health problems of low income or middleincome countries and the binational assistance given to them. global health deals with those health issues that may affect many countries, irrespective of their level of development. it includes both clinical and preventive health care and goes beyond the traditional health specialties to include a wider range of disciplines such as economics, biomedical engineering, city planning, social science and policy making. it addresses problems such as epidemics (e.g., hiv, influenza) and also health 22 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) issues resulting from urbanisation, climate change, tobacco use, micronutrient deficiencies, and other challenges to well-being.2 a burgeoning interest in global health (gh) has also brought into focus global health education (ghe).4-10 governments and educational institutions alike are promoting ghe as imperative in health professional education.3,4,9,10 however, there is yet no consensus on how gh education should best be delivered.1,3,5 johnson et al. note that undergraduate gh curricula could be divided into three categories: compulsory components for all students addressing gh issues in their local contexts, optional components for students with a special interest in gh, and targeted training prior to elective studies undertaken internationally.6 many post-graduate medical specialty programs are also incorporating gh curricula into their training.2,4,7,9 health professionals engaged in international health frequently need to work beyond the scope of their basic training in situations of cross-cultural differences, language barriers, and a lack of medical resources. thus, health workers preparing to practice internationally need both professional and cross-cultural training.5,7,9,11,12 traditionally, lengthy, degree courses in public health, tropical medicine, international health, and community development have been offered by many universities around the world.1,3 shorter courses have also been offered—the most common of which is an international elective undertaken by many health professional students.1,3,8 literature on the effectiveness of short courses to equip health professionals for global or international health is limited. interdisciplinary approaches and interprofessional collaboration have been recommended for ghe.3 we wanted to address this gap in the literature by evaluating an interdisciplinary international health education initiative developed by intermed sa (intermed). intermed is a non-profit educational organization based in adelaide, south australia, whose primary remit is to run a 3 to 4-week intensive interdisciplinary course for christian health professionals, entitled international health and development, along with an optional 2-week extension—the overseas practicum. the international health and development course (ihdc) is probably the only course of its kind in the world as it is based on a christian understanding of health and development and brings together aspects of public health, community development, and clinical care important for international health work. the aim of the ihdc is to prepare christian health professionals for effective practice in crosscultural health and development work with knowledge, skills, and attitudes to better approach the diverse circumstances and challenges they might face. the curriculum of the ihdc is organized around five educational streams: biblical perspectives on medical mission, healthcare service delivery with a primary healthcare focus, issues in public health, issues in clinical care (specifically infection and nutrition), and applicable elective components. students also gain basic practical clinical skills in the areas of obstetrics, dentistry, community development, and musculoskeletal health. the course has now been run in some form on five continents over the past two decades. the overseas practicum (practicum) has been conducted in timor leste, indonesia, and vanuatu. our research poses a vital question: can a short course in international health and development have a positive impact in preparing healthcare workers who intend to work shortor long-term in less resourced communities of the world? by evaluating the impact of intermed’s ihdc, we aim to address this question and better understand the methods that effectively prepare christian health professionals for such work. this will contribute to existing literature and practice, and also guide future research and education. materials and methods to answer our research question, we evaluated intermed’s ihdc by surveying and interviewing graduates of the course. ethics approval was obtained from the flinders university social and behavioural research ethics committee (project number 7214). we conducted our research from mid-2016 to mid-2018 on graduates who had undertaken the 23 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) ihdc between 2008 and 2014 (7 cohorts). this time bracket marked a period of consistent leadership by the same course coordinator. prior to 2008, the same course was coordinated by a different academic, and in 2015, the course underwent a major restructure and became the basis of a larger accredited post-graduate program on international health and development at a tertiary institution. we constructed the on-line survey using survey monkey® software. it contained 29 questions covering six areas: (1) demographic information, (2) motivations, (3) achievement of course objectives, (4) practical preparatory impact, (5) more and less effective elements, and (6) participant-specific practical experiences preand post-completion of the course. the required responses included five-point likert scales and comment boxes allowing the collection of quantitative and qualitative data. the on-line survey was pilot tested on a group of eight graduates from the 2015 and 2016 ihdc cohorts excluded from the final study. following modifications based on the pilot survey, the final survey was sent by email to 130 graduates from the 2008 to 2014 cohorts. a total of 139 people completed the ihdc during this period, however nine did not have valid email addresses and were, thus, lost to follow-up. of the 130 people contacted, 68 participated in the survey (52% response rate). of these 68 participants, 31 agreed to be interviewed. of the 31 only 20 were eligible for interview as they had engaged in international health and development work both before and after completing the ihdc. this criterion of “both before and after” was important to gauge how the course changed participants’ practices within international health and development. of the 20 eligible participants, seven were interviewed via telephone or skype®. further interviews were planned but were unable to be completed within the research project’s time frame. the semistructured interviews explored participants’ perceptions of their involvement in cross-cultural health and development work relative to the ihdc. interviews were audio recorded and “clean” transcribed. the transcriptions were thematically analysed using nvivo® 11 software. results demographics figure 1 depicts the age and gender spread of the study participants, which was dominated by females (88%), with 30% of all participants in the 30–49-year age group. two-thirds (67%) of the participants had a bachelor degree educational level prior to commencing the ihdc, 21% a postgraduate qualification, 6% had a hospital-trained nursing certificate, 3% a diploma (not specified), 1.5% had a post-graduate fellowship, and 1.5% a masters level degree. figure 2 shows the professional backgrounds of the respondents with nursing as the most prevalent profession (51.5%), followed by medical doctor (20.6%). the “other” professions category included a public health professional, developmental educator, musician, social worker, pharmacist, radiographer, and a nutritionist. 24 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) figure 1. participant age distribution by gender figure 2. participants’ professional backgrounds participants’ motivations from the responses to the question, “what were your motivations for enrolling in intermed’s international health and development course?”, eight thematic motivations were identified. the chief motivation expressed by 46 of the 68 (67.1%) responders was a perceived need to increase their international health and development skill set. nearly half (32, 47.1%) the participants noted their interest in christian health and development work as a motivating factor. a further six participants (8.8%) noted that prior experiences in a crosscultural health and development role prompted the need for further training. how effectively the ihdc achieved its stated objectives five-point likert scales with explanatory comments evaluated how effectively the ihdc achieved each of its five course objectives (table 1). 0 5 10 15 20 25 30 35 20 29 30 39 40 49 50 59 60 69 n o. o f p ar tic ip an ts age (years) male female 7 14 8 5 2 2 30 0 5 10 15 20 25 30 35 other medical doctor midwife occupational therapist dentist physiotherapist nurse 25 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) table 1. achievement of course objectives objective strongly agreed/agreed % (n) neutral % (n) disagreed/ strongly disagreed % (n) developed knowledge of key healthcare issues in less-resourced settings 96.9 (62) 1.6 (1) 1.6 (1) ability to formulate theology and philosophy of community health and development 77.8 (49) 19.1 (12) 3.2 (2) facilitated critical reflection on personal and professional experiences 75.0 (48) 21.9 (14) 3.1 (2) developed communication and problem-solving skills for less-resourced settings 82.5 (52) 12.7 (8) 4.8 (3) developed ability to assess, manage, and control health problems in less-resourced settings 87.3 (55) 7.9 (5) 4.8(3) almost all (62, 96.9%) either strongly agreed (26, 40.6%) or agreed (36, 56.3%) with the statement, “intermed’s international health and development course developed my knowledge relating to key healthcare issues facing underresourced or disadvantaged communities,” with the most common reasons being that the lecturers were experienced in health and development work and that the participants gained significant new knowledge. most participants (49, 77.8%) either strongly agreed (7, 11.1%) or agreed (42, 66.7%) with the statement, “intermed’s international health and development course developed my ability to formulate a theology and philosophy of community health and development approaches in less resourced and more disadvantaged contexts,” reporting their development of a new appreciation for community development in healthcare and the helpfulness of the practical group sessions in developing theological and philosophical values. however, 12 participants (19.1%) indicated a neutral opinion on this statement, explaining that the course only touched superficially on theology and philosophy and that personal philosophical and theological viewpoints had already been established prior to the course. the one participant who disagreed with the statement said that the course focused too much on the reward gained from engaging in cross cultural health and development work. most participants (48, 75%) either strongly agreed (19, 29.7%) or agreed (29, 45.3%) with the statement, “intermed’s international health and development course facilitated my own critical reflection upon significant personal and professional experiences and challenges related to the delivery of health and development programs in more disadvantaged contexts,” reporting that personal reflection was facilitated by the course structure, the group sessions, and the stories shared by others. of the 14 participants (21.9%) who expressed neutrality toward the statement, three did so because they had not engaged in any crosscultural work prior to nor following the course and, therefore, found it difficult to self-reflect. most participants (52, 82.5%) either strongly agreed (8, 12.7%) or agreed (44, 69.8%) with the statement, “intermed’s international health and development course developed my skills in communication and problem solving in a crosscultural setting,” citing the case scenarios, the stories of personal experiences, and the group work as particularly beneficial. five participants specifically noted the helpfulness of the overseas practicum for this objective. of the eight participants (12.7%) neutral to this statement, two had not yet had an opportunity to practice these skills in a cross-cultural setting. the participant who strongly disagreed stated that the western approach offered by intermed was not helpful. most (55, 87.3%) either strongly agreed (13, 20.6%) or agreed (42, 66.7%) with the statement, “intermed’s international health and development course developed my ability to assess, manage, and control health problems 26 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) related to infectious diseases and chronic, noncommunicable diseases in less resourced and more disadvantaged settings,” noting the importance of the practical group work. four participants reported their knowledge had improved but had not since been put to specific use. two of the neutral participants also similarly reported their knowledge had improved but had not since been put to specific use. of the three participants who either disagreed or strongly disagreed, two reported a lack of confidence in their abilities following course completion, while the remaining one reported significant prior experience in the area and could not identify any specific improvement after the course. practical preparatory impact of the course almost all (62, 96.8%) either strongly agreed (23, 35.9%) or agreed (39, 60.9%) with the statement, “intermed’s international health and development course had a practical impact in preparing me for cross cultural health and development work,” reporting the importance of the practical skills taught, the supervised overseas practicum, the experienced lecturers, the philosophical and theological teaching, and the fostering of a cross-cultural focus for healthcare delivery. the one participant who expressed neutrality commented that the skills learned were not yet used in their health and development work, while the one participant who strongly disagreed did so because of significant prior knowledge and experience. in the semi-structured interviews, participants were asked how the course impacted their cross-cultural health and development work compared with their experiences prior to the course. interviewees highlighted the role the course played in understanding the complex relationships between social/economic factors and health. one respondent, a general practitioner by profession, stated: i think the intermed course probably broadened [my view of health] even further. so it highlighted aspects relating to health you don’t probably always think of. you know you’re always aware that environment and upbringing and education impact on health but access to clean water and all that that entails and the difficulties of getting that into some areas and transport, and i guess the extent that education influences health and all of those sorts of things. i guess it broadened my knowledge of how all of those things impact on health more so than before. one interviewee who had spent extensive time in remote australian indigenous communities before the course spoke at length about their increased confidence: it probably gave me more confidence. you can’t compare me going to an australian aboriginal community and working compared to going to remote vanuatu. another interviewee commented that the ihdc provided a good introduction to public and community health principles, creating a positive mindset shift going forward into future health and development work: having done the intermed course gave me a much better understanding that having highly trained people is not necessarily the best solution in the resourcepoor setting. two of the interviewees had completed the ihdc for credit towards other studies and, thus, had to undertake an additional essay on an aspect of community health in developing settings. both these interviewees noted that the process of writing the essay assisted them to develop stronger philosophies of community health and development that they then carried with them during subsequent placements in cross-cultural health and development work. specifically, one stated the research paper was an “opportunity to crystallise some of my thinking on development topics in central australia.” when asked if there were specific examples of times when the ihdc impacted the way they operated in cross-cultural health and development settings, many of the interviewees struggled to think of specific examples. those that commented discussed specific scenarios managing patients in 27 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) cross-cultural or disadvantaged settings and all the problem solving and resourcefulness this often entailed. many of these interviewees credited the ihdc with providing a lot of these skills in communication and problem solving. in particular, one interviewee said: i found i was able to work within the resource capability of the country, and i was able to culturally adapt my own knowledge and practices to the culture that i was working in so i found that really beneficial and really useful. the participant who expressed strong disagreement in the on-line survey with the course’s practical impact because of significant prior experience elaborated during the interview: how did it impact me? it confirmed that i had a lot of experience . . . i didn’t actually learn much at all . . . impact? not really. whether or not i did intermed wouldn’t have changed the course of much i don’t think. in response to the follow-on question of whether or not this reflected poorly on the course, this participant said: . . . not at all . . . the fact that i didn’t learn anything does not reflect badly on intermed at all, it just shows that i have been extremely privileged in what i have been able to experience personally and professionally . . . so, it made me reflect and be grateful for the experiences i’ve had, and i suppose it also made me realise that intermed is a very good program because it covers all of these things. more and less effective elements of the course survey responses regarding why the course was so effective were thematically collated into the experience of the lecturers, the practical teaching, the optional overseas practicum, the emphasis on community empowerment, christian-based leadership and teaching offered by the lecturers, and the medical coursework. less effective aspects of the course were noted as being the excessive content for the short length of the course and the inclusion of outdated information on some issues. details of participants’ specific practical experiences survey questions regarding the participants’ practical experiences with international health and development work both before and after the ihdc were asked. specific information including geographic locations where this work was undertaken and the time spent in such roles was sought. of the 68 survey respondents, only 48 completed this section. thirty-six (75%) participants had cross-cultural health and development experiences prior to doing the course, with 27 of these involved in international work, four in domestic work, and five in both international and domestic locations. forty participants had cross-cultural health and development experiences after the ihdc with 31 (77.5%) doing international work, four in domestic locations, and five in both international and domestic locations. of the 48 respondents, 22 had participated in the optional overseas practicum. they noted this was useful in implementing the skills learned during the course in a real cross-cultural health and development setting. discussion it was important to elucidate the motivations of ihdc graduates during data collection as a person’s motivation may significantly influence their subjective experience of the course. for example, if enrolment motivation was for course credits, there is potential that the graduate would have a different opinion of the course’s impact, compared with someone whose motivation was to spend a lengthy period working in a cross-cultural health and development setting. the majority of participants stated their main motivation for enrolling in intermed’s ihdc was a perceived need to increase their knowledge and skill set. this study did not elucidate the nature of these perceptions for most of the participants. however, a smaller group stated that this perceived need was 28 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) based on prior experiences in health and development roles that suggested a need for upskilling. this means these participants were actively seeking professional development specifically relating to cross-cultural health and development work; thus, it could be assumed that they were hoping the ihdc would positively impact their ability to operate in future global health settings. due to the relative infancy of global health education as a domain, the current literature has little discussion on the assessment of global health course objectives, in particular for short courses such as the ihdc. attempts have been made to establish core competencies in ghe.13,14 arthur et al. outline seven core areas of global health teaching that should be included in a ghe course: (1) the global burden of disease, (2) health implications of travel, (3) migration and displacement, (4) social and economic determinants of health (including population, resources, and the environment), (5) globalisation of healthcare, (6) healthcare in low-resource settings, and (7) human rights in global health.14 the ihdc covered most of these core areas in varying degrees. the global burden of disease, the social and economic determinants of health, and healthcare in low-resourced settings were covered in depth, while human rights in global health was the area least covered. ablah et al. discuss seven core domains of ghe and assert these are applicable to varied global health practice regardless of context, location, or scale of work: (1) teaching as capacity strengthening, (2) collaborating and partnering, (3) ethical reasoning and professional practice, (4) health equity and social justice, (5) program management, (6) social-cultural and political awareness, and (7) strategic analysis.13 the ihdc addressed each of these domains to varying degrees, with strategic analysis being the least covered domain. ordinarily, a course that prepares people for specific scenarios (in this case, cross-cultural health and development work) could also be assessed through outcomes in the given scenario; however, this approach to assessment of effectiveness is complicated by the unique setting of cross-cultural health and development work.15 factors such as communication and problem solving skills, cultural sensitivity, and healthcare proficiency are difficult to objectively assess in under-resourced settings.16 a further complication for this research is that following completion of intermed’s ihdc, not all graduates engaged in cross cultural health and development work, and among those who did so, there were a diverse range of locations and settings, all with different challenges. for these reasons, the method chosen to assess the objectives of the ihdc in this study, through the participant’s perceptions of the ability of the course to achieve its objectives, was both practical and reasonable. the term “impact” was chosen as the measurable dependent variable in the research question. what does “impact” mean, and why was it chosen? kerry et al. write about measuring the impact of a global health course.4 they suggest that programs should be evaluated on their progress towards reducing the global burden of disease.4 however this was not the intent of the study reported here; in any case, such an evaluation would need to be conducted some years later and using a quite different methodology. impact can be interpreted in multiple ways, and to some extent this was the intention in this study. for this study, impact was interpreted as a positive or negative change brought about directly or indirectly as a result of intermed’s ihdc within the domain of cross-cultural health and development. a course such as the ihdc may have an impact on those who complete the course or on those members of the communities in which graduates work, or both. in addition, the impact may be small or large in scale, and it may be a short-term impact or a longer lasting impact. kerry et al. suggest that programs need to be evaluated in leadership development, healthcare system strengthening, and scientific advancement, and also measured by new knowledge, research, treatments, technologies, or strategies to deliver care.4 whilst this applies to larger scale global health courses, it can still be applied to the assessment of the ihdc’s impact. according to participants’ feedback, the course successfully developed leadership, strengthening of knowledge 29 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) of the global healthcare system, and new knowledge and skill development among graduates. many participants spoke of various ways in which the course improved their own professional capacity, including new knowledge attainment, increased confidence, improvement in communication and problem-solving, and increased appreciation for social and community factors in health. many participants spoke of the importance of the community development teaching but did not comment on how this teaching might directly impact the communities they served. realistically, the only way to truly measure the impact of the course on communities would be to conduct field studies during the various crosscultural work placements in which the graduates were involved after completion of the course. this is both impractical and difficult due to the heterogeneous nature of cross-cultural health and development work, the geographical dispersion of the intermed graduates, and the related costs and difficulties that would arise. there is also the potential for negative impacts resulting from the course. the data did not identify any such negative impacts, but instead noted scenarios where impact was lacking; for example participants not being able to put the knowledge and skills obtained in the course to use. this is a genuine limiting factor in the course’s impact on both the participants and potential communities. if graduates do not enter into crosscultural health and development work following completion of the course, then while there may be some positive impact in terms of professional development for the participants, there will be no impact on any potential communities where they might otherwise have worked. limitations of this study include the relatively low response rate (52%) to the online survey and that participants did not always complete the survey in full as all questions were optional and could be skipped. additionally, the completion of only seven of the eligible 20 interviews reduced our ability to clarify survey comments and interpret the qualitative data. conclusions global health education is a relatively new component of mainstream undergraduate and postgraduate education and is steadily growing in response to the need for healthcare and community development in less resourced settings. intermed’s international health and development course is a short course in global health that effectively achieved the course objectives and was deemed to be very effective and valuable for gh preparation. our study suggests that short courses in crosscultural health and development work can have a positive impact on the level of knowledge, skills, attitudes, and holistic preparation of participants. it was also reported to have had a positive impact on the majority of graduates’ professional development as global health ambassadors. this is likely to positively impact on their individual adjustment and resilience and the communities these graduates serve. however, measuring effectiveness and impact long-term, in individuals and on communities, from a global health educational intervention, is a difficult task. this study contributes to the current paucity of literature on this topic. further research is indicated to more effectively measure the effectiveness of global health courses. references 1. macfarlane sb, jacobs m, kaaya ee. in the name of global health: trends in academic institutions. j public health pol. 2008;29(4):383-401. http://dx.doi.org/10.1057/jphp.2008.25 2. molyneux e, o’hare b. the value of including global health in the training of health professionals. arch dis child. 2013;98(11):840-2. http://dx.doi.org/10.1136/archdischild-2013304815 3. liu y, zhang y, liu z, wang j. gaps in studies of global health education: an empirical literature review. global health action. 2015;8(25709). http://dx.doi.org/10.3402/gha.v8.25709 4. kerry vb, ndung'u t, walensky rp, lee pt, kayanja vfib, bangsberg dr. managing the demand for global health education. plos medicine. 2011;8(11). http://dx.doi.org/10.1371/journal.pmed.1001118 about:blank about:blank about:blank about:blank 30 kirubakaran, shaw, mcarthur, miller & radford dec 2020. christian journal for global health 7(5) 5. battat r, seidman g, chadi n, chanda my, nehme j, hulme j, et al. global health competencies and approaches in medical education: a literature review. bmc med educ. 2010;10(94):1-7. http://dx.doi.org/10.1186/1472-6920-10-94 6. johnson o, bailey sl, willott c, crocker-buque t, jessop v, birch m, et al. global health learning outcomes for medical students in the uk. lancet. 2012;379:2033-5. http://dx.doi.org/10.1016/s01406736(11)61582-1 7. haq c, rothenberg d, gjerde cb, bobula j., wilson c, bickley l, et al. new world views: preparing physicians in training for global health work. fam med. 2000;32(8):566-72. 8. panosian c, coates tj. the new medical "missionaries" — grooming the next generation of global health workers. new engl j med. 2006;354(17):1771-3. 9. brown c, martineau f, spry e, yudkin js. postgraduate training in global health: ensuring uk doctors can contribute to health in resource-poor countries. clin med. 2011;11(5):456-60. 10. crump ja, sugarman j. ethics and best practice guidelines for training experiences in global health. am j trop med. 2010;83(6):1178-82. http://dx.doi.org/10.4269/ajtmh.2010.10-0527 11. strand ma, chen ai, pinkston lm. developing cross-cultural healthcare workers: content, process and mentoring. christ j global health. 2016;3(1):57-72. http://dx.doi.org/10.15566/cjgh.v3i1.102 12. smith jd, holland r, phillips jd, falkenheimer sa. mobilizing and training academic faculty for medical mission: current status and future directions. christ j global health. 2016;3(2):16875. https://doi.org/10.15566/cjgh.v3i2.134 13. ablah e, biberman da, weist em, buekens p, bentley me, burke d, et al. improving global health education: development of a global health competency model. am j trop med. 2014 [cited 2015 march 5];90(3):560-5. https://doi.org/10.4269/ajtmh.13-0537 14. arthur ma, battat r, brewer tf. teaching the basics: core competencies in global health. infect dis clin n am. 2011;25(2):347-58. pubmed pmid: 21628050. https://doi.org/10.1016/j.idc.2011.02.013 15. eichbaum q. the problem with competencies in global health education. acad med. 2015;90(4):414-7. pubmed pmid: 25692558. https://doi.org/10.1097/acm.0000000000000665 16. lingard l. rethinking competence in the context of teamwork. in: hodges b, lingard l, eds. the question of competence: reconsidering medical education in the twenty-first century. 1st ed. ithaca: cornell university press; 2012. peer reviewed: submitted 28 june 2020, accepted 13 oct 2020, published 21 december 2020 competing interests: none declared. correspondence: sneha kirubakaran, intermed sa, australia. sneha.kirubakaran@gmail.com cite this article as: kirubakaran s, shaw d, mcarthur l, miller a, radford a. preparing christian health workers for international work: evaluating a short global health course. christ j global health. december 2020; 7(5):21-30. https://doi.org/10.15566/cjgh.v7i5.415 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v7i5.415 https://doi.org/10.15566/cjgh.v7i5.415 about:blank abstract introduction materials and methods results practical preparatory impact of the course more and less effective elements of the course discussion conclusions references more and less effective elements of the course discussion book review june 2020. christian journal for global health 7(2) why religion and spirituality matter for public health — evidence, implications, and resources, ed. doug oman, springer, 2018 matthew t bersagel braleya a ma, phd, associate professor and director, honors program, ethics, culture, and society, college of business and leadership, viterbo university, usa a little over a decade ago, i found myself sitting in a lecture hall as part of a course simply called aids: public health implications. i had enrolled in it as a part of an interdisciplinary fellowship year during my doctoral studies in religion. for two semesters, i had the opportunity to sit in on the global health conversation as conducted within the professional education of future public health practitioners. the course covered the virology, epidemiology, and history of the aids epidemic and was co-taught by one of the foremost medical researchers in the field and a respected social epidemiologist, both of whom had significant field experience in sub-saharan africa. this particular night, however, featured a guest speaker, an atlanta community member who was hiv positive. he had contracted the virus as a young, gay man in rural georgia. raised in a devout christian community, he experienced hiv as a punishment for his sins as a homosexual. already marginalized by his identity as a gay man, his status as hiv positive made reconciliation with his faith community and his family impossible. his story of alienation and pain has become for many in the public health community the conventional wisdom about the relationship between christianity and aids in america. christianity, according to this line of thinking, served as a cultural barrier to effective aids education, prevention, and treatment. no effort was made that night or any other night during the course to offer a counternarrative about the involvement of christian communities in aids hospice care or the efforts of global christian communions to combat stigma and discrimination against persons living with hiv and aids. as he spoke to the lecture hall full of aspiring public health professionals, i was cognizant that this may be the most personal story they will hear about christianity and aids — in effect, a testimonial. a decade later, i can’t help but wonder how that evening, that whole course, might have been different if doug oman’s edited volume had been available. the volume is, arguably, the most comprehensive effort to date to provide public health students, faculty, and professionals with the empirical tools to understand religion and spirituality (r/s) as an underappreciated but essential dimension of not only individual health behavior and outcomes, but also population health dynamics. the volume reads, to borrow from the language of theology, as a kind of empirical apologetic. part one covers exhaustively the evidence base for religion and spirituality as a causative and not merely correlative factor for many group-level phenomena affecting population health. individually, many of the chapters in part one marshal evidence for established subfields within public health such as environmental health, infectious disease, and nutrition. taken together with the broader state-of-the-field reviews that bookend part one, these chapters attempt both to firmly establish and to move beyond what is often 160 bersagel braley june 2020. christian journal for global health 7(2) referred to as the “generic model” of causal effects of religion and spirituality on individual health. the generic model conceptualizes religious beliefs, practices, etc. as primary inputs that are then mediated by the more conventional determinants of health including health behaviors, social connections, and mental health. for example, the generic model suggests that to understand (and ultimately work with) what determines the physical health of a seventh day adventist who abstains from alcohol and meat consumption (health behaviors), one needs to acknowledge and account for the role of religious beliefs in shaping those particular health behaviors. to establish and expand the generic model, oman relies on a remarkable range of empirical evidence, much of which has emerged in the past two decades. many of the chapters in part one are authored or co-authored by oman, though the later parts of the book draw on a wider variety of voices. part one is essentially a report out of the findings from two large templeton funded research studies oman directed as a faculty at the university of california-berkeley. oman is also upfront about his indebtedness to the seminal work done by harold koenig in the handbook of religion and health1 as a well as the complementarity of works such as ellen idler’s recent edited volume, religion as a social determinant of health.2 the latter is the culmination of much of the work profiled in the chapter on emory university’s religion and public health initiatives, many of which i had the privilege of participating while a graduate student. this range and, importantly for oman, the credibility of religion as a causal factor, are made possible by the growing number of meta-analysis and meta-synthesis articles that place the burden of proof on the skeptics. in the chapter, “weighing the evidence: what is revealed by 100+ meta-analyses and systematic reviews,” a title indicative of both part one’s primary methodology and, perhaps, suggestive of his empirical apologetic, oman asks “can anyone sincerely maintain that religion and spirituality are entirely non-causal epiphenomenal byproducts of other variables”? (p. 278) the need for a volume like this arises precisely from the persistence of sincerely held doubts (or, at minimum, unexamined biases) among public health professionals and faculty about the relevance of religion and spirituality to their work. whether we employ sweeping language like the (re)turn to religion or the more subdued frame of a heightened sensitivity to interdiscplinary academic discourse, professional practice, and participation in a democracy defined by pluralism requires in the early 21st century a basic level of religious literacy. public health, according to oman, has been late to the party, and this volume serves as a way to catch public health folks up. the logic reads something like this: (1) religion remains an important aspect of how individuals and groups make sense of the threats to and potential for human flourishing and (2) religious entities (e.g., churches) persist as potential and actualized assets in communities — especially vulnerable communities — that affect health behaviors, access to health resources, etc. of members and non-members (e.g., through health screenings hosted at a church). therefore, public health professionals cannot ignore religion in their efforts to improve health at the population level. this message is reinforced at the end of each chapter in the “ideas for application to public health practice.” most of the ideas are introduced by the general exhortation “be aware.” “be aware and acknowledge that religious communities are often among the most important respondents to disasters.” or, “be aware that religious communities are perhaps the largest source of ‘social capital’ in the us.” the body of the chapters serves, then, as the reference point one can reach for to confirm that, “yes, in fact, i am now aware,” and as the starting point for helping others (read: public health students) become aware. i must admit these exhortations fell flat in most cases, adding little value to the chapters and, ironically, reinforcing an overly simplistic, yet 161 bersagel braley june 2020. christian journal for global health 7(2) persistent trope in public health campaigns: knowledge equals behavior change. the second half of the book (parts two, three, and four) show what this awareness can lead to in terms of both professional practice (part two) and academic public health education (part three). the examples from part three are drawn from curricular and co-curricular initiatives at highly respected universities. they read largely as report outs, documenting the uniqueness of their respective programming. as such, they are likely to prove most useful for universities looking for, on the one hand, ideas of how to begin integrating religion and spirituality into their curriculum, and, on the other hand, a barometer to gauge the degree to which this integration makes sense in their particular context. the take away from these seems to be that more could be done to integrate r/s more thoroughly, even in settings where, historically, institutional support for religion and public health dialogue is strong. part four includes two brief chapters, the first of which may be of particular interest here given its global perspective. co-authored by liz grant and oman, it is the only chapter to set the religion and health conversation explicitly within this wider frame, a limitation oman identifies upfront in the introduction. this limitation is articulated as largely the result of insufficient empirical data on religion and health outside the u.s. the evidence in this chapter is offered as snapshots of religion and public health in low income settings, with sub-saharan africa as the primary point of reference. the chapter’s concluding remark is a fitting reminder of the volume’s primary aim, even as it gave me pause to consider what gets lost when working so hard to translate r/s value into particular type evidence recognized by contemporary public health: “the shared trajectory of religion and public health is as old as their co-presence on the planet, although this collaborative trajectory is increasingly available in new modern forms, and is increasingly informed by empirical evidence.” (p. 460) the global chapter and two chapters in part two offer a more compelling answer to the question in the book’s title: why religion and spirituality matter for public health. as someone whose introduction to global health came through primary training in christian ethics and the work of a global religion and public health collaborative that included grant and the co-authors of a chapter in part two, i am not the audience for part one; i am already convinced that r/s matters for public health (as i suspect are many readers of this journal). but the reason i am convinced is due only in part to empirical evidence generated by the various methodological tools favored increasingly in the social sciences. in part two, we see more clearly that the real value of r/s to public health emerges in transdisciplinary spaces made possible when the phenomenon of human being and flourishing are conceptualized in holistic terms like healthworlds rather than as the aggregation of relationships between independent and dependent variables. for example, nancy epstein’s chapter in part two takes as its orienting frame socio-ecology, emphasizing the “dynamic interrelations of individual, social, and environmental factors.” epstein makes clear that “public health and religious communities share a number of important prevailing values and commitments, particularly with regard to promoting peace, health, and well-being, social justice, and addressing social determinants of health.” (p. 308) this claim is rooted in the practical wisdom she has gained from years as a rabbi and community health worker, labels that one suspects are not so neatly delineated in her sense of self and vocation. and this last point is what likely accounts for my concerns about the evidence base privileged in part one. to be sure, the emphasis on empirical evidence in charting pathways for both perceiving and partnering with the health assets of r/s entities remains critical, a point underscored in the chapter by teresa cutts and gary gunderson, “implications for public health systems and clinical practitioners: 162 bersagel braley june 2020. christian journal for global health 7(2) strengths of congregations, religious health assets, and leading causes of life.” the three frameworks signaled in the chapter subtitle reflect gunderson’s primary areas of research (and practice) over the past several decades. but as with epstein, the case studies gunderson and cutts highlight suggest that practical, salutogenic efforts to respond to the complex, dynamic relationships between public health and r/s often emerge in places where empirical evidence, practical wisdom, and the religious imagination are all valued as informing, and even transforming, one another. one suspects, if the part two chapters are representative, that these are all places where the insights are made possible by the relationships not only among these three ways of knowing, but more importantly the relationships cultivated among the knowers, that is, the people working together to address community health. the volume trades, for the most part, on the assumption that religion and spirituality are best understood as one among many factors that contribute to population health in ways we can isolate and measure to determine the strength of correlation and the direction, if any, of causation. but is r/s just another type of information that can be shoehorned into an existing framework for understanding health? or can religion and conceptual frameworks within religion help public health understand (and act in) the world in which it finds its meaning, purpose, and authority? perhaps, it is unfair to expect these questions to be addressed in a volume so explicitly focused on marshalling an empirical evidence base from within the epistemological and discursive structures of public health. a strategy of immanent critique, or critique from within, that i am sympathetic to and which, in the end, may prove to be more effective in convincing skeptics of why r/s should be included in public health curricula. but i am left to wonder whether the value of r/s, that is, why it matters, can really be assessed confidently if public health encounters r/s as an object of study rather than as a co-participant in conceptualizing and actualizing the conditions necessary for human flourishing? there are moments throughout the volume in which this conspicuous absence makes itself known, though often more by implication. in part three, for example, the report out from harvard on their “initiative on health, religion, and spirituality,” includes a recognition that “[w]hile the initiative has brought many faculty together from harvard’s school of public health, medical school, and affiliated hospitals, further work is needed to integrate with ongoing research and teaching carried out by faculty at the divinity school, the school of arts and sciences, and elsewhere at harvard.” (pp. 380-81) how would this work look different if faculty with deep knowledge of and experience in the formative education of religious leaders (i.e., the divinity school faculty) were more fully integrated into the conversation about why r/s matters? a decade after sitting in that lecture hall listening to the testimonial about how religious communities can amplify the devastating effects of hiv/aids — no less a part of the story of why religion matters to public health than its salutogenic effects — i am left to wonder how the follow-up classes might have looked had perspectives from religious practitioners and the faculty of theology been included. the absence of any follow-up conversations, let alone the voices of those whose commitments to public health stem from their religious commitments, left the hundred or so aspiring public health professionals in that lecture hall with few, if any, resources for developing a nuanced understanding of r/s and public health. (as the chapter “religion and public health at emory” points out, there did exist and continues to exist a course on faith and health at that time, though enrollment for this course has historically been driven by theology students. since that time, a course on hiv/aids and religion has been developed as well a dual degree mph/mdiv program.) but, it did imply the type of causal relationship oman’s volume is intent on 163 bersagel braley june 2020. christian journal for global health 7(2) demonstrating through empirical research, and therein lies the danger. it may very well be that mph faculty cognizant of a more sophisticated model of r/s as a causal factor in public health would have been in a better position to offer their students additional context for understanding this one man’s testimonial. it is important to note that these students’ own religious beliefs are not simply checked at the door to the lecture hall. and oman’s surveys of mph deans and students suggest a willingness, albeit variable, to consider options for integrating r/s more intentionally in their curricula. there is no question that the empirical evidence for the impact of r/s has expanded, even as oman dutifully shows it to be mixed and not always grounded appropriately in the methodological standards demanded in the empirical sciences. as such, the volume serves notice to public health faculty and professionals that r/s can no longer be dismissed as beyond the scope of practice or as insubstantial as a body of research relevant to professional formation in public health or as too fraught to engage or . . . the list of potential reasons for excluding is likely long. the publication of this volume refutes the de facto exclusion of r/s among many of those responsible for creating the policies and implementing the practices for protecting the health of the public. i just hope that in the quest for demonstrating theoretical cogency and empirical causality, we do not lose sight of the myriad ways in which the complexity of the religious mind and the capacity of the religious imagination persistently call into question existing paradigms and the dominant epistemologies that sustain them.3 references 1. koenig hg, mccullough me, larson db. a handbook of religion and health. new york: oxford; 2001. 2. idler el. religion as a social determinant of public health. new york: oxford; 2014. 3. for more on the religious mind and religious imagination in relation to public health, see gunderson gr, cochrane jr. religion and the health of the public. new york: palgrave macmillan; 2012. submitted 1 june 2020, accepted 11 june 2020, published 29 june 2020 competing interests: none declared. correspondence: matthew t bersagel braley mtbersagelbraley@viterbo.edu cite this article as: bersagel braley mt. why religion and spirituality matter for public health — evidence, implications, and resources, ed. doug oman, springer, 2018. christ j for global health. june 2020; 7(2):159-163. https://doi.org/10.15566/cjgh.v7i2.399 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:mtbersagelbraley@viterbo.edu https://doi.org/10.15566/cjgh.v7i2.399 http://creativecommons.org/licenses/by/4.0/ review article june 2020. christian journal for global health 7(2) a review of faith-based holistic health models: mapping similarities and differences ruth dykstra a, jason paltzer b a student, grand canyon university, united sates of america b phd, mph, assistant professor of epidemiology, department of public health, baylor university, united states of america abstract this review identified and determined core aspects of holistic health models often used in faith-based global development to integrate the spiritual determinant of health into a multiple determinants framework. understanding the similarities and differences of such models is essential when planning development opportunities. seven holistic health models were identified for review. a similar feature among the models was the importance of the community’s worldview and health beliefs on discussing the spiritual aspects of health and behavior change. community engagement and cultivating relationships were two common themes motivating the models. a primary difference among the models was the direction of engagement. some models intentionally focus on individual-level relationships and move toward larger community-level impact while others start at the community-level and move toward individual-level engagement. both approaches are helpful depending on the context, community readiness, and available local leadership. based on the review, two diagrams or maps were created to help organizations determine which models or model components may be applicable to their situation. introduction the relationship between faith-based organizations and community health and development has been the topic of much discussion within the past twenty years with focus on how a holistic model can lead to a more successful and sustainable outcome.1,2,3 holistic health can be difficult to define and even more difficult to apply in practice.4 public health and religion have at times been at odds with each other resulting in distrust and limited collaboration for the benefit of the community.5 given this history, communities of faith and public health agencies have successfully worked together to improve health in faith-based partnerships.6 this history provides the significance for reviewing existing approaches not only to work together but to authentically combine faith with public health. faith-based health organizations often 121 dykstra & paltzer june 2020. christian journal for global health 7(2) describe an integrated approach combining the physical and spiritual determinants of health in various community health programs. however, this integration can range from staff with spiritual beliefs implementing health services, to a brief devotion or prayer prior to delivering services, to embedding scripture lessons into the service delivery. faithbased holistic health models have been developed to assist organizations looking to emphasize the spiritual determinant of health alongside and within the physical, social, and emotional determinants when it comes to improving quality of life. such models contain several assumptions: 1) faith and beliefs drive behavior; 2) faith and beliefs determine the strength of relationships; and 3) faith and beliefs influence priorities. from these assumptions, holistic health models start from a place of faith to inform the other health determinants. in order to further understand what a holistic model is, it is necessary to explore the definition of poverty. a typical explanation of poverty is simply a lack of resources, but when examined with a different lens, it is possible to see how authentic holistic community health and development can lead to communities that thrive. a biblical view of poverty can be defined in terms of relationships.7 when sin entered the world, it broke mankind’s relationship with god, each other, and the environment, creating a fractured system. holism has at its core a focus on the restoration of these relationships. a holistic health model, therefore, seeks to complement existing health services by improving the relationships and addressing the conflicts hindering the living conditions and environment. it also promotes health and works toward removing obstacles to freedom, while keeping a relationship with god at the center. this differs from a secular multidimensional approach to community health and development, which takes into account various aspects of life such as genetics, environment, culture, or health beliefs but not necessarily on a foundation of faith and spirituality.8 it is important to understand this difference between a faith-based holistic model and a more secular multidimensional approach to development. within the world of multiple determinants of health, models exist that include components impacting a person’s health like the physical environment, genetics, and the social environment, but spirituality is minimally addressed or absent from discussions of “holistic” interventions. the health field framework,9 the social-ecological model,10 and the one health model11 are three examples of multiple determinant models that imply spirituality as a determinant but do not consider it as an integral aspect of health. for the purpose of this review, a holistic health model was defined as one that integrated faith and a belief system in other dimensions of health. this integration is important and is what sets holistic health and development models apart from secular models. within the current literature, there exists some gaps in knowledge regarding how holistic health models are implemented, where they are implemented, and whether models of holistic community development vary or are similar.1 a common criticism of faith-specific holistic health models is that they are not always sensitive to or inclusive of traditional or local beliefs and how these beliefs interact with the overall health of the community. it can be easy for organizations to go into a community with a heavy focus on their definition of what faith is or should be and not address the existing belief structures. given this real possibility, it is important to explore various health models and determine strengths and limitations of each model to minimize division given the existing faith and belief system of each community. a successful holistic model will be able to address the community’s existing spiritual beliefs and either use them as motivators for health or introduce the community to a new way of thinking to promote health and development through reframing, reprioritizing, and reforming beliefs.12 122 dykstra & paltzer june 2020. christian journal for global health 7(2) while a holistic methodology can be undertaken by a faith-based organization from any religion,13,14 the majority of the literature reviewed for this paper involved christian faith-based organizations integrating a christian worldview and beliefs. although much literature exists describing examples of faith-based community health and development endeavors, the majority are focused on efforts in africa15,16,17 and southeast asia.13,14 individual models are identified, such as community health evangelism18 and umoja,19 but little to no comparison of the models exists. this lack of sideby-side evaluation leads to a need to examine the various components and driving factors behind the models. such components include how the model engages the community, how it incorporates and measures spirituality (both the community’s existing spirituality and that of the faith-based organization) and health, and its view of holism as a primary approach to the development mission or as a secondary priority. evaluating the strategies behind holistic health models is an important factor that should be undertaken before implementation of any project. currently, no decision matrix is available to help choose what holistic model may be appropriate for the community. this paper will focus on providing a comparison of the components of various holistic models of community health and development and identify tools used to evaluate the community throughout the development process. the goal is to provide a starting point for developing a resource with which to determine how to select a holistic model that fits the community of interest or pull together components of multiple models. this will also help in measuring effectiveness of the models by identifying unique components important for the change process. methods a review of the existing literature on transformational or holistic community health and development was conducted from september 2018 to january 2019 to identify existing frameworks or models being used within the community development field. the following databases were used: scielo, directory of open access journals, atla religion database with atlaserials, social sciences citation index, academic search complete, sciencedirect, cinahl complete, and jstor journals. key words and search terms used to identify articles focused on combinations of community or transformational development, faithbased development, wholistic framework for development, integral mission, holistic mission, and model of community development. search results yielded almost 2,000 articles. from these results, special attention was given to those articles with a more holistic community development focus which could include addressing issues like clean water and agriculture which impact health rather than on those that dealt with individual diseases. approximately 250 abstracts were read, and of these, 120 were chosen for in depth review. evaluation of whether the model presented was truly holistic or simply multidimensional further refined the study. articles discussing other helpful processes and methods and one-off programs that demonstrated integration and discipleship like the salvation army diffusion model15 and missao integral20 were excluded from discussion in this paper due to their lack of an organized developmental focus. resources pertaining to these methods are included in the annotated bibliography available upon request. the review focused mainly on international development as this was a trend in the majority of the literature; however, some models were discussed within the context of the united states. users of the models were contacted by email to provide input into the categorization of their models. input from those that responded were taken into consideration during the categorization process. 123 dykstra & paltzer june 2020. christian journal for global health 7(2) results the existing literature and resources that were reviewed contained many different models of holistic development. figure 1 provides a list of the selected models reviewed and key components identified from the literature. some models did not have extensive support in the literature and may have components or characteristics not described in this review. during the review, it was helpful to group the frameworks, tools, and networks according to their similarities and differences alongside their specific strengths. tools like the wholistic worldview analysis with the ten seed technique21 as well as ccmumoja with the light wheel22 allow for the community to categorize and measure their concerns, evaluate the agents that are causing the concerns, and then, as a whole, determine their priorities. these tools can serve to measure the community’s starting point and create a baseline against which to evaluate future community growth throughout the development process. other models like the holistic health and community transformation model and community health evangelism (che) utilize health flip books as a method of explaining health ideas in an easy to grasp way.15,23 community guidebooks and modules for the community to work through on specific topics also exist and are used by multiple models including truth centered transformation. for example, a module may focus on women and children’s issues, economic development, or agricultural skills. assessment tools that can be used before, during, and after the community transformation also exist for the majority of the models reviewed. figure 1. comparison table of predominant holistic models name organization or group primary initiator of change (can be adjusted to meet the situation) spheres of strength benefits assessment tools available training tools exist community health evangelism (che) global che network individual environmental social clinical easily adaptable has multiple learning tools and modules for specific populations yes churchcommunity mobilization (umoja) tearfund community environmental social clinical multiple tools and instructions on how to facilitate discussions; includes five stages of empowering the church. yes yes transformational development frame world vision individual social economic focuses on children and families, making them agents of change. yes wholistic worldview analysis model/tool developed by ravi jayakaran community environmental social clinical economic aides the community in identifying who they are and what their vision is yes 124 dykstra & paltzer june 2020. christian journal for global health 7(2) holistic health and community transformation model salvation army community social environmental clinical economic political strengthens community cohesion and addresses community needs yes transformational development opportunity international individual economic but strives to address social, political, spiritual, and behavioral aspects using micro-finance programs to raise quality of life and teach empowerment, character, and service yes yes truth centered transformation reconciled world community economic social clinical spiritual environmental strengthens the community and places focus on god empowering/helping them and not relying on organizations yes although spiritual measures were identified as being important to measure, these specific measurements were not clearly defined and is an area for continued improvement. after implementation, the impact of holistic development was measured in three core areas: physical health, spiritual life, and community cohesion (figure 2). a community going through holistic development will also have spiritual change. holistic models emphasize the soul and foster a relationship with god as foundational for understanding purpose and identity. spiritual life can be measured through local church activity or the influence of faith in daily decision-making and behavior. for a truly holistic model, restoring a relationship with god is central7,20 ,24 as it determines the motivation for serving the larger community beyond the individual, a necessary component of development. improved community health can also be measured by direct interventions like vaccines, improved water/sanitation, and adequate nutrition. decreases in disease incidence, morbidity, and premature mortality are indicators of improved physical health.25 community cohesion and the extent to which the holistic approach brought the community closer together is a third type of measurement used by models to measure growth. sharing of resources and skills, social trust, and a greater sense of service can be measures of community cohesion.25 reviewing the models together emphasizes the importance of measuring impact across these three areas throughout the development process and be used to determine how closely the community is staying accountable to its set priorities. 125 dykstra & paltzer june 2020. christian journal for global health 7(2) figure 2. measurement indicators similarities the holistic models discovered during the review are similar in a few key ways. first, community “ownership” is an essential part of all successful development and is no exception when it comes to holistic health models.23,26 ownership typically starts with the community defining what strengths, assets, issues, or needs exist and deciding on possible solutions. holistic models may differ in the approach, processes, or tools used to get to the decision because they start with the community’s worldview. this leads to a focus on motivation and purpose for addressing change. basing ownership on this deeper sense of purpose rather than general input or advice takes more time but is also more sustainable as it switches the typical decisionmaking paradigm. the facilitating organization provides input but the community members have ultimate decision-making ability regarding development and use of their existing skills and resources used alongside any requested training or resources. maintaining the dignity of the community members is central in a self-sustainable community. holistic health models differ regarding community ownership by emphasizing a deeper sense of purpose through faith in god and this manifests itself in communal unity through service and volunteerism. as change happens in the individual, there is a desire to help others find the same freedom. this is achieved in part through service. a model’s sphere of strength can be used to help identify an appropriate model depending on the community’s worldview, assets, and needs. a second similarity between the models is the practice of multiplicative capacity building or a training-the-trainer approach to learning. in many communities, this is used to strengthen community cohesion by building trust.18,23,26 often times, an organization is embraced if a trusting relationship between members of the community and the development organization exists. an example of this concept is seen in the work of dr. regi george and dr. lalitha regi who created the tribal health initiative in the remote villages of india. as doctors, they were able to train community members to be community health workers who could then provide maternal and child care.14 building trust took a while, but eventually the whole community came to embrace the new health workers. community and health development training can take many forms, from medical training conferences27 to agricultural skills.16 differences a key difference among the models is in the flow or direction in transforming a community. some start with individual change and then spread to 126 dykstra & paltzer june 2020. christian journal for global health 7(2) community as seen in che and world vision models23,28 while others start with the community and then trickle down to individuals as seen in tearfund’s ccm-umoja model.19,29 each approach has its strengths based on the existing community politics, attitudes toward religion, and issues facing the community. whether a model starts with individual change or community level change can depend on the context of each site in which they are working. some of the models are adaptable and can operate at both levels simultaneously. for the purpose of this paper, we assessed them on the approach most often represented in the literature. some models, like opportunity international’s transformational development, touch on specific determinants of health such as agriculture or economic development;25 others are more diverse and have manuals or resources that address a wide range of determinants including women’s health, sanitation, and education. another difference is how faith and worldview are integrated into the development process. some models specifically integrate scripture lessons into the training or lessons such as the che model, while others rely on the tool connected with the skill of the facilitator to integrate faith into the community discussions such as the wholistic worldview analysis. model map the goal of this review was to evaluate the current models of holistic health and create a model map that would help communities and organizations determine which model might be best to use based on the specific needs of the community. during this research, several large models were identified and a summary of each is included in figure 3. figure 3. table of model summaries name organizati on or group brief description community health evangelism (che) global che network community health evangelism, or che, is a strategy being used by hundreds of christian churches and organizations across the globe. che integrates evangelism and discipleship with community health and development. through che, communities learn to identify issues and mobilize resources to build up their own community. community health evangelists, or ches, make home visits to share christ and to share with families what they have learned about areas of local concern, such as health promotion, women’s issues, agriculture, economic development, working with children, and working with people with disabilities. it also has multiple tools and handouts to use with the community in various languages. che is adaptable to various situations and communities. it has a well-defined process and track record. churchcommunity mobilization (umoja) tearfund the organization’s mission is to give the church a vision for their community by enthusing and empowering the church to go into the community and help identify and address needs with their own resources. church community transformation also has multiple tools to help identify needs and evaluate along the way such as the light wheel. uses facilitator guides that stress importance of community empowerment (as well as five stages of empowering the church) and offer solutions to potential disagreements or discord. transformational development frame world vision this framework is the preferred model of transformational development for world vision partnerships. a process and set of actions through which children, families and communities move toward wholeness of life with dignity, justice, peace, and hope as the bible describes the kingdom of god. the process emphasizes community ownership, sustainability, holism, and mutual transformation. there is a high focus on children and improving communities by improving the future of the children. 127 dykstra & paltzer june 2020. christian journal for global health 7(2) wholistic worldview analysis tool/model developed by ravi javakaran this model aides the community in identifying who they are and what their vision is for the future. it identifies 3 spheres of control wherein items of life fall: 1) outside control of the community or outsiders, 2) controlled by outsiders, and 3) controlled by community. the model uses tools like the 10 seed technique to identify items of importance for the community and focus of interventions, and can be used throughout development to identify new or changing priorities as well as provide baseline for community. holistic health and community transformation model salvation army this model uses church members help develop skills for communities. it is not just health focused but also development focused and is useful in difficult to access areas and very poor areas. it can be used in conjunction with the community reach model. transformational development opportunity internationa l this model uses microfinance as a way to improve employment and income opportunities. it seeks to holistically transform lives not just financially and has a set of indicators in 4 areas of life: abundance, empowerment, character, and service. as financial means improve, freedom should come in many various forms. truth centered transformation reconciled world this organization works with churches in poor, rural communities to help empower, grow, and strengthen the community. it has 10 modules that the community works through. a module is taught and then the community begins to put the lessons learned into practice. once they are successfully practicing the first module they move onto the next. seeks to dispel lies and fatalistic beliefs and replace them with hope and a value through god. success is seen not only in bettering of economic status, but also in spiritual growth and service. discussion each community comes with its own challenges and pre-existing foundational resources. among the literature identifying holistic community health models, there are a few overarching themes that need to be addressed when looking to adapt the model to future communities. two themes guide the start of the process: individual versus the community and the availability of churches or spiritual leaders in the community. the various models generally fall into two categories: those that start with change in the individual and then builds up to the community and those that start with the larger community and works down to the individual. moving in both directions is possible and the categorization in this review does not imply only one direction but the one commonly identified in the literature or mentioned by users that responded via email. the presence or absence of a local church will influence the type of facilitation required in order to guide and integrate the values and faith of the holistic model into the community discussions and decision-making process. figure 4 shows how these two themes create four quadrants where models can be placed based on their characteristics found in the literature. these themes can be seen within a few of the larger holistic models like che, ccm-umoja, and the wholistic worldview analysis. as an organization approaches a community project, it can place itself on this matrix based on whether or not they will be primarily engaging a community that has a church in place (partnering with the church) or if there is no existing church and the organization will be taking on more of a church planting role. also, depending on the situation, they can consider focusing on implementing individual change first and then spreading to the community or starting at the community level and working down to individual impact. this focus on either individual or community can be seen in several prominent public health theories. for example, the health belief model, diffusion of innovation, and trans128 dykstra & paltzer june 2020. christian journal for global health 7(2) theoretical model place emphasis on individual beliefs. the theory of planned behavior, social cognitive theory, and social norms theory seem to place an emphasis on the environment and community influences.30 each direction of focus uses different tactics and approaches in interventions depending on the site and situation where one direction may be more appropriate to start with than the other. figure 4. map of holistic health models based on the level of initiation and the presence of a local church. while reviewing the current literature, two dominant trends appear about who the initial focus of change is. the first is the individual as the focus of change and the second is the community as the initial focus of change. models that follow the individual first approach focus on developing the individual’s skills, opportunities, and environment as well as their faith. as the individual grows, they then reach out to others in the community and share what they have learned, hopefully serving as an example that motivates others in the community to change as well. the second trend works the other way. change starts on a larger scale initiating community-level development projects through social consensus such as a well health education campaign or a school-based nutrition program, and then using facilitators to follow-up with families on an individual level. although most of the frameworks tended to fall into one or the other category, a few moved back and forth between the two depending on the context. an example of this would be world vision.28 known for their child sponsorships, they manage to help improve an individual’s life in many ways and, through them, the life of their family and then, ultimately, the community. they also work the opposite way, 129 dykstra & paltzer june 2020. christian journal for global health 7(2) starting at the communal level with health care, access to churches, and schooling, which in turn touches the individual. both approaches can be effective depending on the community context, available resources, and the community’s readiness to change. another theme identified during the review of the literature is the use of existing churches or community spiritual leaders in the development process. spirituality and worldview play a large part in how people behave and why they do what they do. understanding this motivation is important in implementing change, therefore identifying current beliefs is essential. utilizing existing churches or leaders can be beneficial because they already have a relationship with the people and have their trust. church buildings and resources can also be used for house training sessions or informational meetings while creating a natural environment to discuss issues related to faith, worldview, and god. the church is often seen as a source of help and this belief can be utilized and reinforced during the transformational development process.31 true holistic development integrates the beliefs of the churches with the change and is not merely faithplaced as many secular multidimensional health models. there may not always be an existing church in the community, and it is within these environments that many holistic health models work to plant churches. one of the benefits of this, especially for those that move from an individual to community focus, is that the community’s faith can be strengthened as individuals now have a safe place to go for spiritual growth. a church can also serve as a place of education for health and skills training. faith-based organizations use holistic health models to come alongside the community and serve as a facilitator for change. the facilitator helps to guide the community in recognizing where growth can occur through the model. the che model identifies members of the community as community health evangelists and trains them about disease prevention and healthy living and the biblical motivation for changing behavior. this integration of the spiritual and the physical can be traced throughout the whole development process. the che is tasked with meeting 10–15 households within the community and sharing what they learned with their neighbors.23 by working in small groups like this, not only do the trainers develop trust but, many times, small churches grow out of this. ccm-umoja follows a similar process, but the facilitator works with small community groups to train community members and develop a plan for change. other models like opportunity international’s transformational development utilize one-on-one relationships between the facilitator and the community member.25 facilitation not only means training the community, but it also means encouraging discussion, managing conflict, and allowing community members to feel like their voices are being heard and are important. this facilitation often involves helping communities define their worldview and assess their current situation to measure change. for example, the light wheel tool used in ccm-umoja or the ten seed technique used by various groups help the community identify who they are and measure where they want to go based on recognition of their worldview. in order to reach the community on certain issues, worldviews may need to be reframed, reprioritized, or reformed. the 3r model explains what this may look like as beliefs can be reframed to provide alternatives without negating the belief, reprioritized to introduce a new belief that corresponds with the behavior wanted, or reformed (directly confronting a belief about its flaws).12 this revision of world view is also seen in the truth centered transformation model.24 beliefs like “we were born poor, we will always be poor” and other fatalistic views are addressed head on and communities are presented with god’s vision 130 dykstra & paltzer june 2020. christian journal for global health 7(2) of the community and the value that god places on people. limitations and strengths although there is much value from the existing literature, some limitations must be acknowledged. attempts were made to gather as many resources as possible from non-christian faith-based organizations as possible; however, there is still significantly less non-christian representation among the articles reviewed. future consideration could be given to how non-christian models differ in scope and practice. multiple databases were used for this review, and some models may have been misinterpreted, missed, or reported in languages other than english, which were not included in the search. there was also a lack of interviews with multiple key leadership within the faith-based organizations regarding the use of the models. this seems to be the case with much of the existing literature as well. although informal discussions were conducted with a couple of leaders, future research may benefit from in-depth discussion with developers of holistic health models. providing research support to faith-based organizations using these models will increase the available evidence of holistic health models and allow for a more accurate and thorough review of the models. in reviewing the literature, it was also noticed that not much was written about advocacy or policy in holistic development. more emphasis was placed on personal relationships and work among the community than on taking on larger changes at a local or national level. this gap presents an opportunity for future developers and researchers to evaluate how faith-based organizations can act as advocates for the population that they serve and encourage participation from the community to fight for change. this review identified and gathered many of the models that exist into a concise compilation, which can be found in the annotated bibliography available upon request. the annotated bibliography also contains information about networks and resources available to faith-based organizations. conclusion within the scope of holistic community health and development, many models exist. by reviewing and discussing the similarities, differences, and important themes among them, a model map was created, pointing to several important decision points in selecting a model or components that would best fit the community. several of the larger models were identified and examples given. the goal of creating communities 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2017;4(1):34-5. 28. byworth j. world vision’s approach to transformational development: frame, policy and indicators. transformation. 2003;20(2). 29. gaw h. church and community mobilization in africa. 2017. available from https://learn.tearfund.org/~/media/files/tilz/churches/ ccm/2017-tearfund-ccm-in-africa-en.pdf?la=en 30. baylor university. behavioral change models. n.d. available from http://sphweb.bumc.bu.edu/otlt/mphmodules/sb/behavioralchangetheories/behavioral changetheories_print.html 31. bryan g, choi j, karlan d. randomizing religion: the impact of protestant evangelism on economic outcomes. nber working paper series. 2018. available from http://www.nber.org/papers/w24278 peer reviewed: submitted 19 june 2019, accepted 18 dec 2019, published june 2020 competing interests: none declared. correspondence: ruth dykstra, grand canyon university, united states of america. ruth.dykstra@gmail.com cite this article as: dykstra a, paltzer j. a review of faith-based holistic health models: mapping similarities and differences. christian journal for global health. june 2020; 7(2):120-132. https://doi.org/10.15566/cjgh.v7i2.311 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank mailto:ruth.dykstra@gmail.com https://doi.org/10.15566/cjgh.v7i2.311 about:blank editorial april 2020. christian journal for global health 7(1) special issue: covid-19 as a challenge on many fronts this special edition of the christian journal for global health takes a multidimensional view of the covid-19 global pandemic. the articles consider its effects on the individual (seshadri), healthcare institutions (seshadri), the community (millhollin), and the wider economic system (grills). as christians, how do we balance our response to account for the various levels at which it affects the world? as christian leaders how can we lead in the face of such an overwhelming situation? matthew santhosh thomas, training coordinator and regional secretary of the international christian medical and dental association, starts by offering 12 important trans-cultural aspects of an effective, god-honoring, leadership response to the pandemic. indeed, covid-19 is a wicked and pervasive global health problem as its causes and impacts reach across various sectors, most countries, all organ systems, and all parts of society. the solutions, therefore, need to be multisectoral and to balance the competing interests of the economy, trade, education, social cohesion, religion, and health. we all need to consider that solutions taken to defeat this disease have significant risks to social determinants of health and have the capacity to cause increased mortality and morbidity in themselves as nathan grills from university of melbourne cautions. an indian proverb comes to mind: a man is fighting a long battle against a rat infestation in his house. in desperation he pours kerosene over the house, lights a match and very effectively defeats the rat problem. likewise, in the covid-19 response, do our strategies to fight covid-19 involve burning down the house? is this the only disease with which we have to contend? likewise, we could respond to the 600,000 seasonal flu deaths using similar approaches as being implemented to prevent covid-19, but we do not as the cost is too great. we must act decisively to limit the impact of covid-19, but it is important that we take a broad view of the response taken as individuals, hospitals, and countries. the necessary social distancing has threatened traditional community, which is in itself so important for health. when the response to covid-19 requires us to be physically apart, how do we maintain the wholeness which jordan millhollin, from duke divinity school, argues is dependent on ongoing interdependence and community? this concept is central to the christian idea of the interdependence within the body of christ (1 cor 12). we are profoundly interconnected, even as we are called to be apart, and he suggests ways we need to explore how we can better love each other despite the disruption to community. apolos landa from the sociedad lucas in peru then offers a similar reflection on the poison of materialist individualism and the need for interdependence and coresponsibility which reflects the character of god, the healer. a number of articles outline practical responses on the global front-lines: the article by seshadri and john from christian medical college (cmc), vellore, india provides a model for hospitals to take the lead in managing the infection and the risk to their staff. this is very practical and much needed but begs the question as to whether smaller hospitals and health systems lacking the expertise, size, and capability of cmc vellore would have the personnel, resources, and systems to implement this approach. these same authors present another paper on the importance of presumptive diagnosis based on https://journal.cjgh.org/index.php/cjgh/article/view/365 https://journal.cjgh.org/index.php/cjgh/article/view/375 https://journal.cjgh.org/index.php/cjgh/article/view/367 https://journal.cjgh.org/index.php/cjgh/article/view/377 https://journal.cjgh.org/index.php/cjgh/article/view/381 https://journal.cjgh.org/index.php/cjgh/article/view/377 https://journal.cjgh.org/index.php/cjgh/article/view/367 https://journal.cjgh.org/index.php/cjgh/article/view/383 https://journal.cjgh.org/index.php/cjgh/article/view/375 https://journal.cjgh.org/index.php/cjgh/article/view/365 2 april 2020. christian journal for global health 7(1) the clinical syndrome in low-resource settings, when pcr testing is less available, and action that must be taken for containment. then they offer preliminary clinical guidelines for empiric therapies, anticipating the results of clinical trials, in order to mitigate the threat which could overwhelm fragile health systems and deeply affect already vulnerable communities around the world. while keeping watch for results of emerging clinical trials, other lowand middleincome countries would be well advised to cautiously consider the approach outlined by these leaders in the field of virology from one of india’s premiere medical colleges. the response to covid-19 raises various ethical issues about resource allocation and who is given access to life saving care when resources are overwhelmed. james haslam and melody redman from the uk argue that triage is not a new concept. they critique, from a christian perspective, the existing ethical frameworks and guidelines and how they apply to management of covid-19 “surges.” we might think that this pandemic is unprecedented, but we are reminded by bryan just from the center for bioethics & human dignity that there is, indeed, precedence in history. he explores the role of christians and the church in responding to previous plagues and pandemics and outlines what we can learn from those responses. he challenges us to follow those who have gone before us and show a radical christian love — albeit in different ways given the very different contexts we live in today. vijay anand ismayel’s article further explores some biblical principles from the story of nehemiah that can be applied in any context to our radical, measured, and effective response to this pandemic. it is our hope and prayer that this special issue offers a compelling christian perspective on the challenges and, yes, opportunities of this unanticipated and vexing pandemic in order to engage the problem with collective strength, wisdom, courage, grace, love, and hope. our call for papers, responding to epidemics and pandemics, remains open for submissions for the months ahead as the world is challenged to deal with the global crisis, and results of further research on creative and effective responses emerges, as well as deeper theological reflection on what this means for us as humans in a broken but redeemable world. key resources: • ccih resources & forum: https://www.ccih.org/cpt_resources/covid-19/ • ccih survey: https://www.ccih.org/covid-19-response-survey-of-fbos/ • leadership consultations (hfan): https://www.healthforallnations.com/ • book & mission blogs: https://www.medicalmissions.com/coronavirus • icmda resource links: https://mailchi.mp/a46dcc104406/covid01? • joint learning initiative for faith and local communities: https://jliflc.com/covid/ • cugh resources for educators and researchers: https://myemail.constantcontact.com/covid-19-newsletter-vol-5.html?soid=1112846108446&aid=aubgak-oi_u • fbo resources from cdc: https://www.cdc.gov/coronavirus/2019ncov/community/organizations/index.htm • community health fact sheet (in 25 languages): https://protectau.mimecast.com/s/8jexcp7yblsk0mxppuzk3iv?domain=r20.rs6.net https://journal.cjgh.org/index.php/cjgh/article/view/369 https://journal.cjgh.org/index.php/cjgh/article/view/373 https://journal.cjgh.org/index.php/cjgh/article/view/371 https://journal.cjgh.org/index.php/cjgh/cfp/pandemics https://journal.cjgh.org/index.php/cjgh/cfp/pandemics https://www.ccih.org/cpt_resources/covid-19/ https://www.ccih.org/covid-19-response-survey-of-fbos/ https://www.healthforallnations.com/ https://www.medicalmissions.com/coronavirus https://mailchi.mp/a46dcc104406/covid01 https://jliflc.com/covid/ https://myemail.constantcontact.com/covid-19-newsletter-vol--5.html?soid=1112846108446&aid=aubgak-oi_u https://myemail.constantcontact.com/covid-19-newsletter-vol--5.html?soid=1112846108446&aid=aubgak-oi_u https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/index.htm https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/index.htm https://nam10.safelinks.protection.outlook.com/?url=http%3a%2f%2fr20.rs6.net%2ftn.jsp%3ff%3d001qpuomqytpbyuhxmywdubhwpbqr2_r19tagtwpmzyfte88mk_0zcmna5xv-lypd6nsmfwav2ztiiyka-sxxfhzmdwb1ijmswnutbrrfumq0sfa1clj8awgxbjkeacfcx_s91uoft1oolm27pnlzqanrkswfx3bcic0agajyrc6sc0cke8ud5qieolmgs6yhyvsdwkn11fenhzkrqqiqst6oidu9bc19d0csmrhmmy6gf5tdgdifkf-f8xcv1frut6u8pd4afylkkq382blxlhquztl6oxwkfhdtiafp5iwmtkvutla-owj0rme-3lusejunzc7enhj4a%3d%26c%3dut2yuavxsr-hqktaakno0o7ndm1dold-st-dmwad5loludm-_on3bq%3d%3d%26ch%3d09yj12lnhtcmogbfqs5trgr6wdbbu5qsod_-gwaca17bgxhfquzxkg%3d%3d&data=02%7c01%7c%7c7d0f746962f44f6a1e5d08d7e6b7a01c%7c84df9e7fe9f640afb435aaaaaaaaaaaa%7c1%7c0%7c637231548657156198&sdata=hfelrbqpm9fijlmggvligeii8xiiheskzu6qj4jqr6w%3d&reserved=0 https://nam10.safelinks.protection.outlook.com/?url=http%3a%2f%2fr20.rs6.net%2ftn.jsp%3ff%3d001qpuomqytpbyuhxmywdubhwpbqr2_r19tagtwpmzyfte88mk_0zcmna5xv-lypd6nsmfwav2ztiiyka-sxxfhzmdwb1ijmswnutbrrfumq0sfa1clj8awgxbjkeacfcx_s91uoft1oolm27pnlzqanrkswfx3bcic0agajyrc6sc0cke8ud5qieolmgs6yhyvsdwkn11fenhzkrqqiqst6oidu9bc19d0csmrhmmy6gf5tdgdifkf-f8xcv1frut6u8pd4afylkkq382blxlhquztl6oxwkfhdtiafp5iwmtkvutla-owj0rme-3lusejunzc7enhj4a%3d%26c%3dut2yuavxsr-hqktaakno0o7ndm1dold-st-dmwad5loludm-_on3bq%3d%3d%26ch%3d09yj12lnhtcmogbfqs5trgr6wdbbu5qsod_-gwaca17bgxhfquzxkg%3d%3d&data=02%7c01%7c%7c7d0f746962f44f6a1e5d08d7e6b7a01c%7c84df9e7fe9f640afb435aaaaaaaaaaaa%7c1%7c0%7c637231548657156198&sdata=hfelrbqpm9fijlmggvligeii8xiiheskzu6qj4jqr6w%3d&reserved=0 god in a cup poetry may 2019. christian journal for global health 6(1) my mother weakens sarah larkina a ba (religious studies), ma (pastoral theology), poet, works for integral alliance, london, uk the world turns and bodies burn and fall many call for help and justice as the sun rises and the summer breeze lifts beauty’s veil sailing boats glide effortlessly through many-shaded blue tones birds fly to their homes and grief, like a lock, snaps into place and many of the poor and weak enraged at their imprisonment lift their eyes to look the rich and powerful in the face my mother weakens and waits hating her powerlessness as evening falls and the night within deepens into prayer and peace dreaming now of a life lived outside many-shaded and defiant to become again a child reliant on the light shining from a parent’s eyes now a prisoner of a body, locked in strength torn from his body stripped whipped and defenceless played upon death’s instrument until silence fell and darkness covered the day the ripped veil moving in sorrow’s breeze beckoning us to move through tears within to the other side of sickness and sin satan’s curse shattered as the lock turned and god’s son died hide or make a break for freedom the enraged raise their fists my mother weakens and waits as evening falls and the night deepens into prayer and peace 118 larkin may 2019. christian journal for global health 6(1) competing interests: none declared. correspondence: sarah larkin (née fordham), london, uk. sarahlarkin68@gmail.com. http://scfordham.blogspot.com. integral alliance (www.integralalliance.org) cite this article as: larkin s. my mother weakens. christian journal for global health. nov 2018; 6(1):117-118. https://doi.org/10.15566/cjgh.v6i1.291 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:sarahlarkin68@gmail.com http://www.integralalliance.org/ http://creativecommons.org/licenses/by/4.0/ editorial april 2020. christian journal for global health, 7(1) leadership in pandemics mathew santhosh thomasa a mbbs, md, training coordinator and regional secretary (south asia), international christian medical and dental association, india the covid-19 pandemic has thrown nations into chaos. fear and panic have gripped the world. many nations are struggling with the impact of large numbers of people falling ill and increasing numbers of new infections. many nations are preparing for such an eventuality, but struggling, not knowing what they should be doing since the current generation of world leaders has not faced such a pandemic before. health care institutions and organizations are struggling with questions of their own responses, and the safety of their staff. christian institutions in the developing world, challenged with their resource constraints but with a desire to make a difference in such a context, are considering what they should do at this unprecedented time in the history of the world. how should leaders respond at such a time as this? if we listen to the media reports, we hear stories of leaders denying the problem, other leaders giving into panic, yet others using the unfolding events for their personal and political positioning. some others have been taking decisions that have no scientific validity. as leaders of organizations and institutions, how will we respond? what will guide our responses? given below are twelve thoughts to guide us as each of us are challenged to respond in such a time as this. 1. do not give into panic there is an overload of information going around in the news and social media, and there is fear and panic among the public. institutions and even some states are not immune to this and are taking reactive decisions. they are fearful for their own health and life and the impact of such an unprecedented event on their institutions, economy and daily lives. we have been given a spirit of courage and wisdom. we are not to give into panic. we cannot be found panicking and taking reactive decisions that will impact the people and community around us adversely. so do not fear, for i am with you; do not be dismayed, for i am your god. i will strengthen you and help you; i will uphold you with my righteous right hand. isaiah 41:101 2. be logical, rational and evidence-based (where there is evidence) panic must be replaced by a sound mind, a mind that considers the emerging and available evidence logically. this involves looking rationally at the numbers, the trends, the emerging evidence of how and what institutions and health care professionals should do to effectively respond. the challenge at this point of time is that the evidence we have is limited, and the evidence that is emerging may not be relevant to the context in some of our locations. 3. innovate if we don’t have resources to follow evidence-based systems. it is in such situations that we need to be creative and innovative. god has given us his nature of creativity. there are many innovative solutions that we can come up with for setting up systems. many are already being tried, as has been done during ebola and sars epidemics. 4 april 2020. christian journal for global health, 7(1) 4. think globally but act locally understand what is happening across the world, but find ways of implementing locally relevant solutions. at the same time, we need to be constantly looking at the emerging context and evidence and be aware of the trends and patterns. this will help us to root our responses in the reality of the global scenario, but the responses will need to be adapted for the local context. we are called to be wise, be rooted in the reality of our context. and be relevant. 5. be compassionate and protect the most vulnerable in our midst we will need to protect ourselves and our colleagues, but our mandate is also to protect the vulnerable in our midst. it is important for us to consider who are the most vulnerable, specifically, the elderly and those with underlying pulmonary, cardiac, and immune diseases, the malnourished, displaced, and the poor. we should ways of protecting them from infection and caring for them if they need to be cared for. 6. understand and help each other to understand that we are called to be channels of hope in “such a time as this” none of us in this generation has faced such a pandemic. but as we look back at the history of pandemics and responses, we would understand that christians pioneered and responded with courage and compassion to care for the afflicted. we are part of such a legacy. we are kept in this generation to be channels of hope like our forebears who left such a legacy for us. for if you remain silent at this time, relief and deliverance for the jews will arise from another place, but you and your father's family will perish. and who knows but that you have come to your royal position for such a time as this? esther 4:14 7. have faith in god and try to reflect and learn what god is teaching us through this. amid this pandemic, hold on to the sovereignty of god. bonhoeffer wrote from prison “of course, not everything that happens is simply gods will; yet in the last resort nothing happens ‘without gods will’ ((matthew 10.29), i.e., through every event, however untoward, there is an access to god.”2 this is the god whom we trust in, one who uses every context for his greater purposes. let us reflect what god is doing through this and what he is teaching us through this unprecedented time in history. 8. review and change things as we learn more, as new evidence emerges. at the same time, cultivate an ongoing learning habit. be willing to review, adapt, and change as evidence and context emerges around us. may god make us such leaders, who understood the times and know what to do like the men of issachar. “. . . from issachar, men who understood the times and knew what israel should do — 200 chiefs, with all their relatives under their command.” 1 chronicles 12:32 9. continue to cultivate a sound mind for god hath not given us the spirit of fear; but of power, and of love, and of a sound mind. 2 timothy 1:73 the original greek word translated “sound mind” here is sophronismos, and it appears in the bible only this one time. in other english bible translations, the word sophronismos is rendered “self-control” (esv), “self-discipline” (niv, nlt), “discipline” (nasb), “good judgment” (gw), and “sound judgment” (csb). the 5 april 2020. christian journal for global health, 7(1) influence of the spirit of god is required to produce a genuinely sound mind. the sound mind paul speaks of is a mind under the control of god’s holy spirit. in the sense of self-discipline, the word sophronismos denotes careful, rational, sensible thinking. having a sound mind requires a thought process based on the wisdom and clarity that god imparts rather than being manipulated by fear. 10. hold on to a hopeful heart in times of uncertainty, where does our hope come from? will it come from the various innovative ways we can respond, a wishful thinking (maybe denial) that the worst will not affect us and our country or a hope that we will be protected come what may — based on our faith in god? instead, our hope in uncertain times should come from certainty of a god who is sovereign, the assurance that the god we believe in is one who will use these circumstances for a greater purpose. though we cannot understand it today, we put our faith in that god who is certainly holding the future in his hands. 11. explore ways of faithful engagement we need to understand what faithful engagement means for each of us. for some of us, it might be being in the forefront of the battle, engaging actively, for others it may mean being in the background, supporting those on the front line. some others might be locked up unable to be out there, homebound. even here, we need to understand how we can contribute, either through prayer, planning, or keeping in touch with those in the forefront. and not to forget the costs the poor and the marginalised bear. 12. encourage and motivate each other to persevere we also need to come alongside people who are fearful and confused and encourage them. we need to be people who motivate the tired and exhausted to persevere. we need to find resources that will provide the strength for these people to continue in their love and good deeds. let us hold unswervingly to the hope we profess, for he who promised is faithful. and let us consider how we may spur one another on toward love and good deeds, not giving up meeting together, [even if online] as some are in the habit of doing but encouraging one another — and all the more as we see the day approaching. hebrews 10: 23-25 conclusion may we be people who encourage each other this season, to faithfully engage, with a hopeful heart and a sound mind. let our foundation be our faith in god and openness to hear what god is teaching us through this season. at the same time, may we be logical, rational, and innovate whenever required, not forgetting that our mandate is to protect and care for the most vulnerable in the communities with which we engage. references: 1. all biblical references except as noted are from the holy bible, new international version. grand rapids, mi: biblea, inc; 1973, 1978, 1984, 2011. 2. boenhoeffer d. letters and papers from prison [1943 dec 18]. croydon, uk: scm classics; 1971. p. 167. 3. the holy bible: king james version. dallas, tx: brown books publishing; 2004. competing interests: none declared. 6 april 2020. christian journal for global health, 7(1) acknowledgement: portions of this paper were published in international christian medical and dental association’s blog 24 march 2020 https://blogs.icmda.net/2020/03/24/leadership-in-pandemics-six-principles-to-guide-us/ and 4 april 2020. https://blogs.icmda.net/2020/04/04/facing-pandemics-four-more-leadership-principles/ published with permission of icmda. correspondence: dr. mathew santhosh thomas, india. santoshmathewpersonal@gmail.com cite this article as: thomas ms. leadership in pandemics. christian journal for global health. april 2020;7(1):2-6. © author this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ https://blogs.icmda.net/2020/03/24/leadership-in-pandemics-six-principles-to-guide-us/ https://blogs.icmda.net/2020/04/04/facing-pandemics-four-more-leadership-principles/ mailto:santoshmathewpersonal@gmail.com http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ references: 1. all biblical references except as noted are from the holy bible, new international version. grand rapids, mi: biblea, inc; 1973, 1978, 1984, 2011. 2. boenhoeffer d. letters and papers from prison [1943 dec 18]. croydon, uk: scm classics; 1971. p. 167. 3. the holy bible: king james version. dallas, tx: brown books publishing; 2004. editorial dec 2019. christian journal for global health 6(2) faith integration and interfaith collaboration this issue of the christian journal for global health features three original articles and a literature review of the influence of hindu beliefs on how people with disabilities are viewed in india. the spiritual aspects of health care1 and the effect of religion on public health2,3 are receiving more attention in public and academic circles, and healthrelated strategies are expanding in global mission endeavors.4 the opportunities to contribute to this bourgeoning area of literature are tremendous. there is a gap between patients’ interest in spiritual care and most professionals’ willingness to address the subject. felisha younkin and her colleagues evaluated the effectiveness of one day of whole-person saline process training for health care students at a christian university. the focus of the evaluation was mainly on their personal spirituality and on participation in christian institution activities, reflecting a more evangelical orientation. the pre-assessment reflected a relatively high level of spirituality which did not change, but the training nine months later was associated with a significantly increased degree of participation in christian or church-based activities or ministries. the authors make some useful observations on how preparation for offering spiritual care may be improved in the future. progress in economic development and in access to adequate health care has been uneven in many lowand middle-income countries, and innovative case studies can provide useful information on how to target left-behind communities. judith opiyo and paul fast describe the implementation of a community-based strategy formerly employed in rural settings, but now in a nairobi urban slum. the slum is characterized by a very dense but transient population lacking adequate water, sanitation, electricity, police, roads, schools, and hospitals. the care group model in this case was implemented by a small, local, church-based organization which lacked large scale administrative, technical, and financial resources. however, its small size offered flexibility in meeting local challenges and encouraged the development of trust. assessed indicators revealed significant improvements in maternal-child health in six of the eight indicators over a period of 24 months in a group of 1950 households. a second case study, undertaken by james pender and his colleagues, reports how an interfaith coalition between christians, buddhists, hindus, and muslims worked together to raise awareness of leprosy in sri lanka, a country noted for an increasing prevalence of the disease as well as sectarian conflict. the increased awareness was accompanied by the identification of new cases, but also by significantly more effective contact tracing. somewhat in contrast, andrew wilson has done a systematic literature review of the influence of hindu beliefs and practices on the approach to people with disabilities. although there are circumstances where these beliefs can be beneficial, the view of karma tends to be a barrier to effective acceptance and support for the disabled. the journal continues to receive valuable short reports and commentaries on various aspects of christian faith and service. in a fascinating account, surgeon david thompson recounts the contrast between an extended period of work in gabon with a more recent initiative in egypt. at the new site, he experienced challenges in communication, in competency of his colleagues, in the willingness of patients to trust him, in the acceptance of scientific medical judgment, and in operating room management and safety. dr. thompson offers some sage suggestions on how one can work for constructive change in such an environment. danielle ellis from duke divinity school explicates https://journal.cjgh.org/index.php/cjgh/article/view/301 https://journal.cjgh.org/index.php/cjgh/article/view/317 https://journal.cjgh.org/index.php/cjgh/article/view/297 https://journal.cjgh.org/index.php/cjgh/article/view/297 https://journal.cjgh.org/index.php/cjgh/article/view/250 https://journal.cjgh.org/index.php/cjgh/article/view/28 https://journal.cjgh.org/index.php/cjgh/article/view/315 2 dec 2019. christian journal for global health 6(2) how the “christ humbling” detailed in philippians chapter two affords a paradigm for all missionary work, consistent with the historical paradigm of the imitatio christi which professor grundman has elaborated.5 this is particularly relevant to medical missions where consideration for power differentials can be very important. finally, lois armstrong offers a meditation on habakkuk and an appreciation of god’s providence in coping with injustice and the need for faithfulness and patience. to round out the issue, neville carr reviews disability in mission: the church’s hidden treasure, coedited by david c deuel and nathan g john. the book is a series of case studies supported by a biblical narrative of how disabilities of various types afford opportunities for mission. dr. carr notes how these accounts can be moving and inspiring, yet there might be contrary accounts that illustrate failure and disillusionment. the book gives practical suggestions and guidelines for agencies that are biblically, if not strategically, called to include people with disability. during this year’s advent season, we share with zechariah the song of the redeemer of israel and all nations, “because he has come to his people and redeemed them . . . to shine on those living in darkness and in the shadow of death, to guide our feet into the path of peace.” (luke 1:68 & 79, niv) references 1. balboni mj, balboni ta. hostility to hospitality: spirituality and professional socialization within medicine. oxford, 2019. 2. morabia a. faith based organizations and public health: another facet of the public health dialogue. am j public health. 6 feb 2019;109(3):341. 3. idler e, levin j, vanderweele tj, khan a. partnerships between public health agencies and faith communities. am j public health. 6 feb 2019;109(3):346–7. [see the whole issue on faith and public health] [available at https://ajph.aphapublications.org/toc/ajph/109/3] 4. ireland jm, editor. for the love of god: principles and practice of compassion in missions. eugene, or: wipf and stock. 2017. 5. grundmann ch. christ as physician: the ancient christus medicus trope and christian medical missions as imitation of christ. christ j global health. nov 2018;5(3):3–11. https://doi.org/10.15566/cjgh.v5i3.236 https://journal.cjgh.org/index.php/cjgh/article/view/331 https://journal.cjgh.org/index.php/cjgh/article/view/313 https://ajph.aphapublications.org/toc/ajph/109/3 https://doi.org/10.15566/cjgh.v5i3.236 case study dec 2019. christian journal for global health 6(2) adapting care groups to urban slums: a case study of a church-based effort to improve maternal and child health outcomes in mathare, nairobi, kenya judith siambe opiyoa, paul shetler fastb a bs in public health nutrition and dietetics, program officer, center for peacebuilding and nationhood (cpn), kenya mennonite church, kenya b mph, ma (international development), global health coordinator, mennonite central committee, haiti abstract progress on maternal and child health has been slow and uneven in africa, with widening geographic and socio-economic disparities despite economic growth and continued investments in health systems. in kenya, modest national-level gains mask wide disparities in progress, with near stagnation among the very poor, those with the least education, and those living in either extremely rural contexts or dense informal urban slums. progress toward kenya’s maternal and child health sustainable development goals will depend on finding new ways to work effectively in dense urban slums where poverty and ill-health are increasingly concentrated. effective approaches require addressing significant knowledge, behavior, and trust gaps, especially with the most vulnerable residents of slum communities like nairobi’s mathare. care groups were designed to address these gaps but have only been effectively tested and scaled in rural and peri-urban environments. the center for peacebuilding and nationhood’s maternal and child health care group project supported by mennonite central committee in mathare, one of the largest informal settlements in kenya, was one of the first to adapt the care group model to an urban slum. adapting the model was necessary in this challenging context characterized by high population density, crowding, extremely transient and unstable populations, low social trust, lack of traditional social structures, high crime, political disruption, and frequent rapid onset disasters. this study shows the pilot’s success and challenges in adapting care groups to the realities of a dense african urban slum, the innovative strategies the project has used, and the unique benefits of doing this work on a small scale rooted in a local church organization. key words: maternal health; child health; social and behavioral change communication; care groups; urban; slum; kenya 33 opiyo & fast dec 2019. christian journal for global health 6(2) introduction while global maternal and child mortalities have declined significantly in recent years (44% and 42%, respectively, between 1990 and 2015), progress has been extremely uneven, resulting in many countries failing to achieve their millennium development goals. an estimated 99% of all maternal deaths remain concentrated in lowand middle-income countries, particularly in africa.1 progress on maternal and child health has been slow and uneven in africa, with widening geographic and socio-economic disparities, despite economic growth and continued investments in health systems.2 kenya exemplifies this trend with a recent systematic review showing only modest gains between 1990–2015 in maternal mortality (26%), neonatal mortality (19%), and stillbirths (7%) despite strong economic growth, relative stability, and continued health system investments. however, even these modest national-level gains mask wide disparities in progress with near stagnation among the very poor, those with the least education, and those living in extremely rural contexts and dense informal urban slums.3 as kenya continues to rapidly urbanize, making progress on maternal and child health, achieving the sustainable development goals (sdgs) will depend on the ability to work effectively in dense urban slums, where poverty and ill-health are increasingly concentrated and older program models have struggled.4,5 kenya’s recent improvements in maternal and child health (accelerating in the early 2000s) have been driven primarily by expanding access to basic health services; improving hiv testing, control, and treatment; and devolving health services to the local level through the ministry of health’s community health strategy.3,6 however, this approach has left significant knowledge and behavior gaps, especially with the poorest and most vulnerable residents of slum communities like nairobi’s mathare. these knowledge and behavior gaps have limited many people’s ability to take advantage of available health services and improve their health and wellbeing. these types of gaps are what the care group model was designed to efficiently address and why this model was selected by the kenya mennonite church’s center for peace and nationhood (cpn) to address the pressing maternal and child health challenges in mathare. the care group model is an innovative cascade-style training and behavior change approach for improving maternal and child health in resource constrained settings. it was first designed by world relief in mozambique in 1995 as a communitybased strategy to facilitate effective and sustained behavior change in a large population at low cost.7 key elements of the care group model include peerto-peer health promotion, cascade training of contextually adapted maternal and child health curriculum, selection of volunteers by participant mothers, no more than 15 households per volunteer leader, no more than 10 volunteers per promoter (often a specially trained community health worker), at least monthly contact between volunteers and targeted mothers, peer support for improved health practices through group meetings, and regular supervision of the volunteers by more highly trained health promoters.8 care groups have since been replicated by at least 23 organizations in 27 lowand middle-income countries. these projects were implemented in rural areas except for one case in cochabamba, bolivia, where care groups were used for promoting behavior change in a peri-urban (nonslum) setting. in kenya, care groups have been implemented by african medical and research foundation (amref), healthright, plan international, and jpegho, all with large multimillion dollar projects based in rural areas.9 with kenya’s rapidly urbanizing population, the growth of dense urban slums, and the growing concentration of poverty and maternal and child ill-health in these slums, it is essential to develop effective maternal and child health programming for these environments. cpn’s maternal and child health care group project in mathare, nairobi, started in 34 opiyo & fast dec 2019. christian journal for global health 6(2) 2017, is one of the first published examples of adapting the care group model to an urban slum environment. mathare is among the largest informal settlements in nairobi, with a population estimated at between 200,000–500,000 people on just three square kilometers of land, giving it one of the highest population densities in africa.10,11 its population is also highly transient, with an estimated 54% of the population having lived in mathare for less than 10 years and 30% for less than 5 years.12 it is characterized by densely packed and poorly constructed housing units built directly on the ground surface. mathare is barely penetrated by basic public facilities such as toilets, water, and sewage systems, electricity, police, roads, schools, and hospitals. there is one functional latrine for every 85 households.13 the few resources available are overcrowded by a constantly increasing population. basic sanitation, hygiene, and health are highly compromised by the crowded environment and lack of basic infrastructure and services. according to the united nations, children in nairobi slums are two and half times more likely to die before their fifth birthday than in other areas of nairobi, and similar statistics exist for most measures of maternal and child health. malnutrition of mothers and children in these areas is high, as most families live below $1 usd per person per day, and 92% pay over half their income in rent. acute child malnutrition and stunting rates are estimated at 39% and 47%, respectively, for these neighborhoods, with malnutrition and diarrheal diseases highest among children of young single mothers (aged 15–19).14,15,16 additionally, as the economic situation has deteriorated in the slums, in order to survive, more women have been forced to choose sex work as a coping strategy, with the percentage of unmarried women who are sexually active increasing 62% from 2000 to 2012, leading to higher rates of hiv, other sexually transmitted diseases, and unplanned pregnancies. among women with little to no education, the average age of first birth is only 15 years, and many of these women lack the social and family support they would have in rural environments.17 this context is one in which care groups appeared to be the most appropriate strategy to help improve health outcomes for vulnerable women and children. while all 14 required criteria8 of the care group approach were respected, the uniquely challenging nature of the slum environment, where care groups had never been tested before, required significant adaptation. to successfully adapt care groups to the urban slum environment of mathare, cpn’s team developed strategies for dealing with key differences between mathare and the more typical rural locations where care groups have been successfully implemented. key challenges of the mathare context that needed to be overcome in adaptation, included: • high population density, crowding, and lack of both private and communal spaces; • extremely transient and unstable populations; • low social trust, lack of traditional communal, familial, and social structures; and • high vulnerability to crime, political disruption, and rapid onset disasters. as a small, local church-based organization, cpn was also very different from the major international ngo actors who have been the primary implementers of care groups. this included a more limited budget of $141,590 over the three-year project cycle, roughly 1/14th of the average budget of care group projects reviewed in the published literature.9 this smaller size and local church grounding meant cpn lacked some of the institutional, technical, and administrative resources to facilitate complex monitoring systems, rapid implementation, and scale-up. however, its small size, rootedness in a local church, and having all local staff allowed cpn to be nimble in quickly adapting programming and strategy to meet local realities and more quickly build trust. cpn was supported in this work through a financial grant and technical accompaniment from mennonite central committee (mcc), a us and canada-based 35 opiyo & fast dec 2019. christian journal for global health 6(2) christian ngo with offices in nairobi that has been a long-time partner of cpn. methods this research study represents a two-year, longitudinal analysis of cpn’s care group adaptation pilot in mathare, nairobi. at the onset of the project, a transect walk was conducted to map mathare 3a, 3b, and 3c villages. these three adjoining areas of mathare were selected because they had the highest levels of maternal and child malnutrition and the lowest rates of antenatal and postnatal care. these areas are considered the most insecure parts of mathare and, for that reason, many other health projects have abandoned or avoided the area. after this transect walk, a survey was done to gather baseline data against which progress toward the project’s outcomes and indicators could be compared. due to the small scale and communityled nature of the project, a smaller set of outcome indicators could be tracked than is typical in multimillion-dollar international ngo projects. all indicators were collected and reported twice yearly through household surveys conducted by project staff and trained volunteers. indicators were selected to provide the most actionable and practical information, be feasible with limited budget and technical staff, and follow internationally recommended indicators whenever possible. a list of the project indicators, indicator definitions, and references in the literature supporting use of these indicators is provided below in figure 1. the project was started slowly in order to build trust and test adaptation strategies more easily. it began with a small pilot of the first care groups in one of the three target villages, mathare 3b. this was done for six months in order to assess the reach, effectiveness, adoption, ability to overcome the unique challenges of working in a slum environment, get new staff up to speed, and ensure the ability to implement and sustain the work successfully. a sixmonth assessment was done, small adjustments were made, and the project was then scaled up to cover all three mathare villages (3a, 3b, and 3c). figure 1. project change indicators indicator and reference indicator definition % of participant pregnant and lactating women who achieve a minimum dietary diversity18 # participant pregnant & lactating mothers who report consuming at least 5 of 10 defined food groups* in the prior 24 hours # participating pregnant and lactating mothers *1) grains, white roots, tubers, plantains; 2) pulses (beans, peas, lentils); 3) nuts, seeds; 4) dairy; 5) meat, poultry, fish; 6) eggs; 7) dark green leafy vegetables; 8) other vitamin a-rich fruits and vegetables; 9) other vegetables; 10) other fruits % of participant pregnant and lactating women receiving recommended daily micronutrient supplements19 # participant pregnant & lactating mothers who received the who minimum recommended daily micronutrient supplements (including iron folate) # participating pregnant and lactating mothers % of children 0–6 months exclusively breastfed19 # participant infants (0–6 months) who received only breast milk during the previous day # participating infants 0–6 months of age % of participant children 6–24 months who are receiving all 3 icyf recommended feeding practices19 # participant children 6–24 months of age meeting all 3 of the following criteria during the previous day (1received breastmilk; 2received solid, semi-solid, or soft food the minimum number of times*; and 3received foods from at least 4 defined food groups**) # participating children 6–24 months of age 36 opiyo & fast dec 2019. christian journal for global health 6(2) *minimum of 2x per day for 6–8 months and 3x per day for 9–24 months. note that there are different guidelines for non-breastfed infants, but these children would not qualify for this indicator. ** 1) grains, roots, tubers; 2) legumes, nuts; 3) dairy products (milk, yogurt, cheese); 4) flesh foods (meat, fish, poultry, liver/organ meats); 5) eggs; 6) vitamin-a rich fruits, vegetables; 7) other fruits & vegetables. % of participant women with live birth who received at least 4 antenatal care visits prior to delivery from a skilled health professional20 # participant women with a live birth during the reporting period who received 4 or more prenatal visits from a skilled health professional (doctor, nurse, or midwife) # participating women with a live birth during the reporting period % of participant children who received at least the recommended 4 postnatal care visits from a trained health professional21 # participant children 6–9 months old, who received 4 or more postnatal care visits from a trained health professional (doctor, nurse, midwife, or trained community health worker) within the first 6 months of life # participating infants 6–9 months of age households practicing good hygiene with a hand washing station in the house22 # participant households with soap and water at a handwashing station within the home that is reported to be commonly used # participant households checked % of participant households that have access to improved sanitation22 # participant households reporting regular use of an improved sanitation facility (flush or pour-flush toilets with sewerage system, septic tanks, or pit latrines and improved pit latrines) # participant households checked the project had three full-time staff as supervisors—the coordinator and two project officers. two of the three full-time staff were nurses, one being a pediatric nurse and the other a nurse midwife. the project coordinator was a public health nutritionist. the project used existing trained community health volunteers as promoters due to their trust and familiarity in the communities and level of health knowledge and experience. the care group volunteers were volunteer women leaders from the neighborhoods. while traditional care groups begin with a complete community census followed by grouping households geographically under community volunteers to ensure saturation coverage, this was not feasible in the mathare context. the transient nature of urban slums and the lack of trust meant that conducting an accurate census was neither feasible (due to low trust and suspicion of political or criminal motives) nor helpful (since people change household locations frequently). instead, cpn took advantage of its experienced and trusted local promoters to build up care groups and household groups organically from existing networks. women were also given the option to stay in the same household group even if they moved geographically within mathare, allowing for more continuity and low dropout rates (less than 10%). while these adaptations are more complicated than the neat geographic boundaries and 100% saturation coverage of the traditional care group methodology, the adaptations were necessary within the context. the promoters organized the household women into groups of 10 and the neighbor women elected their care group volunteers. the care group volunteers were then organized into groups of 10 to form the care groups. context specific behavior change communication curriculum and visual flipcharts were then designed and rolled out. the curriculum was adapted from food for the hungry’s 2013 curriculum from ethiopia, focused around four core modules: 1) orientation, maternal nutrition, and 37 opiyo & fast dec 2019. christian journal for global health 6(2) breastfeeding; 2) growth monitoring, complementary foods, and micronutrients; 3) care of mothers and newborns during pregnancy and postpartum; and 4) water, sanitation, hygiene, and management of diarrhea. messages were communicated in a cascade approach where the project coordinator and supervisor trained promoters, who then trained care group volunteers in the care groups, who then taught the direct participants in the neighbor women groups and through home visits. feedback on the curriculum and rollout of each module as well as basic project monitoring data were relayed back up the cascade through simple monthly reporting forms that captured participant demographics, indicator and output data, participant feedback, challenges being faced, and ideas for improvement. these forms were completed by care group volunteers and shared with promoters who then analyzed and compiled a report to share with their supervisors. both project supervisors visit each care group at least twice per month, and each promoter visits each neighbor women group at least twice per month for supportive supervision. the project currently reaches 1,950 households, organized into 195 neighbor women groups, supported by 12 promoters. results the success of the project can be measured quantitatively against the tracked indicators and qualitatively in its ability to be accepted by the community, adapted to meet the felt needs of participants, and developed a self-sustaining momentum and sense of buy-in that can support the initiative’s long-term prospects. the chart below (figure 2) shows twice-yearly progress on tracked indicators with green highlighted rows showing indicators with statistically significant progress in a positive (desired) direction, not highlighted rows showing no significant change, and red highlighted rows showing statistically significant change in a negative (undesired) direction. since all variables were binary, statistical significance was measured at 24 months using a chi-square test with p-values of less than 0.05 (significant) and 0.01 (highly significant). figure 2. indicator results indicator baseline (may 2017) 6-months (oct 2017) 12-months (may 2018) 18-months (oct 2018) 24-months (may 2019) % of participant pregnant and lactating women who achieve a minimum dietary diversity 13% 21% 29% 63% 70%** (p<0.001) % of participant pregnant and lactating women receiving recommended daily micronutrient supplements 68% 88% 89% 50% 13%** (p<0.001) % of children 0–6 months exclusively breastfed 38% 24% 26% 54% 59%** (p=0.003) % of participant children 6–24 months who are receiving all 3 icyf recommended feeding practices 9% 34% 36% 73% 64%** (p<0.001) % of participant women with live birth who received at least 4 antenatal care visits prior to delivery from a skilled health professional 38% 21% 39% 39% 32% (p=0.374) % of participant children who received at least the recommended 4 postnatal care visits from a trained health professional 41% 23% 30% 45% 34% (p=0.306) 38 opiyo & fast dec 2019. christian journal for global health 6(2) households practicing good hygiene with a hand washing station in the house 42% 67% 70% 52% 77%** (p<0.001) % of participant households that have access to improved sanitation 26% 26% 29% 42% 56%** (p<0.001) households surveyed (n=) 60 385 1392 1671 1950 notes. *statistically significant change at 24 months from baseline, chi-square at p<0.05 **statistically significant change at 24 months from baseline, chi-square at p<0.01 green highlighting of indicators showing positive significant change, orange highlighting showing negative significant change, and not highlighted showing no significant change five of eight indicators show highly significant (p<0.01) positive change (desired direction). these included maternal dietary diversity, exclusive breastfeeding, recommended child feeding practices, hygiene and hand washing, and access to improved sanitation (figure 3). two indicators (antenatal and postnatal care visits) show no significant change and one indicator (receiving appropriate supplements) showed highly significant negative change (nondesired direction). these unchanged and negatively changed indicators are shown in figure 4. figure 3. indicators showing positive statistically significant change 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% may-17 aug-17 nov-17 mar-18 jun-18 sep-18 jan-19 apr-19 % of participant pregnant and lactating women who achieve a minimum dietary diversity % of children 0-6 months of age who are exclusively breastfed % of participant children 6-24 months who are receiving all 3 icyf recommended feeding practices households practicing good hygiene with hand washing station in the house % of participant households have access to improved sanitation 39 opiyo & fast dec 2019. christian journal for global health 6(2) figure 4. indicators showing no change or negative statistically significant change discussion and implications with five of eight indicators showing significant positive change and only one showing significant negative change in such a difficult environment, cpn’s pilot adaptation of the care group model to mathare can be considered successful. despite the many challenges of operating in this context, the project was readily accepted by participants and the wider community and women were able to make significant behavior change in the areas where they have more direct control. success in community acceptance was driven by actively involving the local community (through promoters, care group volunteers, and neighbor women) as key actors in the project from the very beginning, through implementation, monitoring, evaluation, and refinement of the approach. sharing the data from the community with cpn staff and then back to the community was an inspiration to community actors when they could see that their efforts were transforming people’s lives. being a faith-based organization was an added advantage for gaining rapid acceptance and credibility by the community and local authorities. as a small local organization based in a local church meant that community members, staff, volunteers, participants, and local authorities were less likely to think of the project as a source of personal financial gain or possible extortion, compared with projects implemented by large governmental organizations or international ngos. however, the project had significant contextually-driven challenges that it was not able to overcome, which stalled progress on the three project change indicators that are most dependent on interaction with and service availability from the healthcare system (which is largely outside the project’s scope of household behavior change). the three stalled indicators (minimum antenatal care visits, minimum postnatal care visits, and receiving appropriate supplements) struggled because the project depended on (and did not replicate) the public health facilities and services available. however, these services are vastly under-resourced with basic staffing (health care providers) and resources like iron and folic acid supplements. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% may-17 aug-17 nov-17 mar-18 jun-18 sep-18 jan-19 apr-19 % of participant pregnant and lactating women receiving daily micronutrient supplements (at minimum iron folate) % of participant women with live birth who received at least 4 antenatal care visits prior to delivery from a skilled health professional % of participant children who received at least 4 postnatal care visits from a trained health professional within first 6 months of life 40 opiyo & fast dec 2019. christian journal for global health 6(2) mathare was also chronically underserved and under-resourced, resulting in overcrowding of the existing facilities and long costly wait times and reduced quality of care. this makes it even more challenging for women to attend care visits instead of pursuing income generation. other contextual challenges faced by the project included issues of space, time, transience, and crime. the settlement areas of mathare 3a, 3b, and 3c are so tightly clustered together that even finding a safe and free open space where women could meet was difficult. for groups, women had to squeeze in the narrow public aisles between their houses (generally less than three feet wide), meaning they were forced to sit in a line rather than a circle and discuss even delicate matters in relatively public spaces. time was another major constraint for participant women. this was especially true for those who depend on casual day labor and microcommerce to support their families. with razor thin economic margins, women found it difficult to lose productive work time in meetings or waiting for care. the project sought to maximize the little time available to communicate key information during lessons. this meant being extremely focused in what information was conveyed and doing so quickly and efficiently. the economic vulnerability of the women also meant that once organized into groups, one of their top priorities was to improve their economic wellbeing. these groups were supported in forming micro savings programs and, in some cases, even started shared microbusinesses like beadwork. the pilot was also challenged by the extreme transience of many participants. this made goals like 100% saturation or all women staying in the program throughout their pregnancy and lactation difficult to achieve. many of the project participants were not able to stay in the same housing units throughout the project. they were constantly on the move, both voluntarily as they searched for more stability and economic opportunity and involuntarily as the result of disasters like fire, forced evacuations, political violence, conflict, and sociopolitical intolerance. crime is also frequent in these communities, especially petty thievery, which meant many families struggled to establish handwashing stations as the units were frequently stolen if not brought indoors. the results of this study support the broader literature on care groups. the care group approach was designed primarily to improve health knowledge and behaviors at the household and community levels and has been repeatedly demonstrated to be successful in doing that.8,9 this pilot showed similar results with highly significant and positive change in all the indicators over which households had primary control (maternal dietary diversity, exclusive breastfeeding, recommended child feeding practices, hygiene and hand washing, and access to improved sanitation). the three indicators with no significant or negative change (antenatal care visits, postnatal care visits, and receiving appropriate supplements) all depend on government services over which the project and the households have little to no control. during the project, these services were frequently disrupted by strikes, political crisis, and stockouts of essential supplies. these results further support the literature on care groups, which has shown that progress on maternal and child health often faces hard limits by factors outside of household and community levels of control and, therefore, difficult for care groups to impact as significantly as hoped.9 conclusion the cpn-mcc pilot project demonstrated that an adapted care group model can have significant impacts on key indicators of maternal, newborn, and child health in the urban slum environment of mathare, nairobi, kenya. however, the significant struggles in improving indicators dependent on access to government health services (antenatal care, postnatal care, and supplements) is a reminder that household-level behavior change may not be enough by itself to fully achieve the sdgs in maternal and child health in these types of contexts. 41 opiyo & fast dec 2019. christian journal for global health 6(2) the limitations of this study, in interpreting and extrapolating the findings, include the lack of a control group, relatively small sample sizes in the early phases of the project, the lack of time and scope sufficient to see impact on ultimate indicators like maternal and child mortality, and the inability to control for other factors and trends outside of the project’s scope. these limitations are primarily the result of this being a small-scale locally led project, with all data being collected first and foremost for use within the project and for the benefit of the direct participants in improving the quality of programming. to fully understand the potential of care groups and for it to be adapted to dense urban slums across africa, further research is required. however, this pilot project has demonstrated that care groups can be successfully adapted to this type of context and, at least in this case, show significant results on critical behavior change indicators with a very limited budget, small scale local implementation by a faith-based partner, and in a relatively short period of time. this work has been deeply integrated into the already existing community health systems that the government has put in place in mathare and works to support those systems and priorities. however, this approach leaves the project’s success somewhat dependent on the quality and availability of those government services. this pilot supports the literature that care groups can be a highly effective component to fasttracking achievement of the sdgs in maternal and child health, both in kenya and beyond. the experience of cpn and mcc in mathare has demonstrated that this model can be successfully adapted to an urban slum context in africa, where this type of work is urgently needed. references 1. black r, laxminarayan r, temmerman m, walker n, editors. disease control priorities: reproductive, maternal, newborn, and child health [vol 2]. washington, dc: the world bank; 2016. https://doi.org/10.1596/978-1-4648-0348-2 2. cerf m. the sustainable development goals: contextualizing africa's economic and health landscape. global challenges. 2018;2(8):1800014. 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https://aphrc.org/wp-content/uploads/2014/08/ncss2-final-report.pdf https://aphrc.org/wp-content/uploads/2014/08/ncss2-final-report.pdf http://www.fao.org/3/a-i5486e.pdf http://www.fao.org/3/a-i5486e.pdf https://apps.who.int/iris/bitstream/handle/10665/43895/9789241596664_eng.pdf;jsessionid=75865a9916e10b5dfca2e93a67c1b697?sequence=1 https://apps.who.int/iris/bitstream/handle/10665/43895/9789241596664_eng.pdf;jsessionid=75865a9916e10b5dfca2e93a67c1b697?sequence=1 https://apps.who.int/iris/bitstream/handle/10665/43895/9789241596664_eng.pdf;jsessionid=75865a9916e10b5dfca2e93a67c1b697?sequence=1 https://data.unicef.org/wp-content/uploads/2017/04/pregnancy-childbirth-postpartum-and-newborn-care.pdf https://data.unicef.org/wp-content/uploads/2017/04/pregnancy-childbirth-postpartum-and-newborn-care.pdf https://data.unicef.org/wp-content/uploads/2017/04/pregnancy-childbirth-postpartum-and-newborn-care.pdf https://www.who.int/maternal_child_adolescent/publications/who-mca-pnc-2014-briefer_a4.pdf https://www.who.int/maternal_child_adolescent/publications/who-mca-pnc-2014-briefer_a4.pdf https://www.unwater.org/app/uploads/2017/10/g2_targets-and-global-indicators_version-2017-07-14.pdf https://www.unwater.org/app/uploads/2017/10/g2_targets-and-global-indicators_version-2017-07-14.pdf https://www.unwater.org/app/uploads/2017/10/g2_targets-and-global-indicators_version-2017-07-14.pdf 43 opiyo & fast dec 2019. christian journal for global health 6(2) correspondence: paul shetler fast, global health coordinator, mennonite central committee, haiti. paulfast@mcc.org cite this article as: opiyo js, fast ps. adapting care groups to urban slums: a case study of a church-based effort to improve maternal and child health outcomes in mathare, nairobi, kenya. christian journal for global health. dec 2019; 6(2):33-43. https://doi.org/10.15566/cjgh.v6i2.317 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:paulfast@mcc.org https://doi.org/10.15566/cjgh.v6i2.317 http://creativecommons.org/licenses/by/4.0/ introduction methods results discussion and implications conclusion references book review june 2020. christian journal for global health 7(2) setting up community health and development programmes in lowand middle-income settings, 4th edition, by ted lankester and nathan grills. oxford university press, may 2019 sundeep manotha, bethany carrb a mbbs, family medicine, academic fellow, the nossal institute for global health, university of melbourne, australia b ba, dip ed, research assistant, nossal institute for global health, university of melbourne, australia introduction regrettably, universal health coverage is still out of reach for so many, and it is those in rural areas made up of largely poor communities who are the most deprived. setting up community health and development programmes in low and middleincome settings (suchdp) is a classic book that was first published in 1992 and has been utilised throughout the world for almost three decades. this fourth edition has significant updates and revisions with new content covering important issues such as mental health, disability, health information technology, disasters, domestic violence, and noncommunicable diseases. it is a practical tool to guide the process of starting, developing, and maintaining a healthcare programme in these areas. its purpose is to help stakeholders to empower communities to identify and solve their own problems so as to decrease inequality and inequity which remain serious issues in global health. this book also aims to assist academics, policy makers, and planners to understand the realities of field-based development and progress. as an edited compilation, it has a wide range of contributors with expertise in different areas, and they address two main audiences. the first is those working in the field: programme managers and practitioners from government and civil society involved in setting up or developing community health and development programmes, rural and urban. this book is also written for global health and other health care students, academics, policy makers, and planners who wish to anchor their work in fieldbased situations. contributors ted lankester. ma, mb, bchir, mrcgp, fftm, rcpsglasg, founder and co-leader, arukah network and director of interhealth. nathan grills, mbbs, mph, dphil, public health physician, associate professor of global health, nossal institute for global health, university of melbourne section 1 community health principles community-based health care and the health system chapters 1-3 introduce the concept of community-based health care (cbhc) and how it relates to, improves, and strengthens the health care system at a national level. health problems and facts such as poverty and mortality ratios and their effect on populations in different parts of the world are discussed. fifty percent of the world's population has no access to basic health care, and cbhc can contribute to positive change and meet the challenges. the importance of working with communities, developing trust and offering support, 156 manoth & carr june 2020. christian journal for global health 7(2) training, coaching, and connection, when needed, are highlighted. to create genuine partnerships that build confidence and self-belief, it is imperative to listen and learn first and to appreciate the assets, gifts, and different abilities of community members. partnership protects people against exploitation, creates interdependence, and enables communities to identify problems and devise solutions. communities must own their futures. there are a variety of linkages that cbhc needs to establish with different stakeholders such as government, donors, hospitals, doctors and private practitioners, traditional health practitioners, the private sector which includes ngos, communitybased organisations, faith-based organisations, and the voluntary or “third” sector. tools for community participation in setting up programmes chapters 4-7 describe different tools for community participation which include behavioural changes, collaboration among different stakeholders, and using an effective logical framework for better development of the community. the main aim is to create awareness among individuals and the community so they can develop a healthier lifestyle and learn disease preventive measures. for better implementation of measures, good collaboration between community, government, and civil society organisations is vital, since the implementation process involves a series of complex decisions and steps such as developing a team and obtaining funds. moreover, a logical framework analysis is required to make a suitable development plan for the community assuming adequate information has been obtained and strong links with the community either by a participatory appraisal, community survey or both have been formed. community health worker chapter 8 explains that the community health worker (chw) is a core element of communitybased health. the chapter portrays the effectiveness of the chw both from the perspective of government programmes and civil society organisations (csos). with combined forces of government and csos, effective universal health coverage can be achieved. section 2 community health management chapters 9-12 highlight the different aspects of community health management. these chapters outline monitoring and evaluation techniques used to determine the effectiveness of the programmes and their objectives. monitoring refers to an ongoing assessment of the progress, and evaluation refers to the systematic review of the program outcome and impact. this section not only explains how to manage finances and focus on leadership and management skills but also emphasizes the importance of using medicine correctly. this requires community awareness about the correct medicine, dosage, side effects, and risks of selfprescription. in addition, the section describes the sustainability of the programme by focusing on vulnerable groups in the community. the health programme should involve the local community wherever possible, and this will help people to feel that the programme belongs to them which will in turn translate into ownership, an important factor for long-term sustainability. section 3 community health focus areas setting up and improving a community health clinic; maternal, child, and reproductive health chapters 13-18 discuss community health topics such as setting up and improving a community health clinic and maternal, child, and reproductive health. the importance of involving the community in the development of a health clinic so as to ensure 157 manoth & carr june 2020. christian journal for global health 7(2) that their needs are met is emphasised. these chapters also describe different causes and forms of malnutrition in child, mother, family, and community and explain how to measure and prevent them. this section highlights the importance of childhood immunisation. the leading cause of deaths among children are diarrhoea, pneumonia, and malaria, and this section explains how to recognise and prevent these conditions. the need for maternal and newborn health programmes, including antenatal care, postnatal care, and delivery care, is outlined. to improve reproductive health, family planning, and sexual health, these topics are included in community health programmes at an early stage. this section also explains how we can prepare the community through education by training traditional birth attendants and by incorporating proper care plans for both mother and child. communicable and non-communicable diseases: topics hiv and tb chapters 19-20 and 22 outline prevention programmes for communicable, non-communicable, and chronic diseases including tuberculosis (tb) and human immunodeficiency virus (hiv). the seriousness of tb and hiv as global diseases and their life-threatening effects at the community level are discussed. tb usually affects the lungs but can also affect almost any part of the body, and in that case, it is called extra-pulmonary tb. the important signs and symptoms of tb are discussed so that better diagnostic procedures and preventive measures can be implemented. a community approach to hiv care, prevention, and control is extremely important for this deadly disease, and awareness can be promoted by an effective methodology for community appraisal called salt (local story, appreciating assets, listening and learning, and team-building). this section highlights not only the importance of counselling and adherence to antiretroviral (arvs) drugs but also discusses developing resources such as links to a referral hospital and clinics, and partnership with local government, ngos, and local communities. also, the background of non-communicable disease is described, and the main focus is given to early detection of the problem and promoting healthy behaviours such as physical activity, healthy diet, and reduction of alcohol and tobacco. disability, mental health, and end of life care chapter 23-24 and 28 point out the prevalence of both disability and mental illness and emphasises the importance of community-based rehabilitation (cbr) as well as good mental health care. community palliative and home-based care are also discussed. each of these issues requires the involvement of a wide variety of stakeholders and the sharing of resources which will enhance quality of life but also strengthen and empower the community. chws and cbr workers should be trained to identify and assess the health issue, build trust, and relationship with the patient or person with disability and family and promote inclusion and the use of appropriate medication among other things. this will, in turn, promote community development. interestingly, the who definition of palliative care considers the physical, psychological, and spiritual dimensions of the person and the importance of planning for end-of-life care and bereavement is emphasised. social, environmental health chapters 21 and 25-27 discuss the importance of social and environmental health improvements and how these will change the overall health of the community. the importance of the community working together to identify the causes or determinants of ill health, so as to be able to decrease or eliminate the cause altogether, is highlighted. this section concentrates on water, sanitation, and hygiene each of which involves complex programs. the community can be educated about environmental hazards, thus, assisting in developing ways to avoid disasters. furthermore, the introduction of information and communication 158 manoth & carr june 2020. christian journal for global health 7(2) technologies (ict) in community health programmes will improve accessibility. the issues of violence and abuse are addressed and effective responses, which are both long term and short term, discussed. this requires not only community awareness but also the commitment from justice institutions and politicians. conclusion setting up community health and development programmes in low and middleincome settings is invaluable for anyone involved in primary health care: doctors, nurses, and healthcare workers at all levels. the diagrams, graphs, and photos make it extremely accessible. it is ideal for academics, students, programme managers, and health care practitioners in lowand middle-income settings worldwide and is an evidence-based source full of examples from the field. this book can also be recommended to programme managers and practitioners from government and civil society who wish to set up or develop community health and development programmes, rural and urban. it could be further strengthened by, 1. adding suggestions about the different ways stakeholders and responsible authorities could collaborate; 2. dealing with issues like corruption, cronyism, and injustices within governments and policy-makers that favour urban voters and ignore poorer and voiceless ones in decision-making and distributing of resources. the contemporary relevance and value of suchdp cannot be overstated: it both promotes local ownership and has contributions from 16 authors who are current practitioners and researchers with a breadth of experience. motivated by a strong faith, the editors have developed this book with a deep desire for equity and justice. they are committed to seeing poor communities and individuals transformed through access to good health care, and this book is an excellent tool towards achieving that end. peer reviewed: submitted 19 jan 2020, accepted 23 jan 2020, published 22 june 2020 competing interests: none declared. correspondence: sundeep manoth, melbourne, australia. sundeepmanoth@gmail.com bethany carr, melbourne, australia. bethanyloiscarr@gmail.com cite this article as: manoth s, carr b. setting up community health programmes in low and middle income countries, fourth edition, by ted lankester and nathan grills, oxford university press, may 2019. christ j for global health. june 2020; 7(2):155-158. https://doi.org/10.15566/cjgh.v7i2.343 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:sundeepmanoth@gmail.com mailto:bethanyloiscarr@gmail.com https://doi.org/10.15566/cjgh.v7i2.343 http://creativecommons.org/licenses/by/4.0/ conference reports nov 2014. christian journal for global health, 1(2):101-102. 15th world congress of the icmda 2014 rick paul a a md, regional secretary, icmda eurasia, member local organizing committee, vu university hospital, amsterdam, netherlands celebrating 50 years of operations, the international christian medical and dental association chose the title “serve, share and shine” for this year‟s icmda congress: serve jesus, share the gospel and let your light shine in the darkness. http://icmda2014.org speakers from all over the world readily agreed to come, to lecture and/or to give seminars. with the help of the erasmus university congress bureau for the logistic issues, things finally came together: venue ready, program complete and many host-families ready for their guests. over 900 people came from 99 countries, from all continents to rotterdam, netherlands. the venue, the municipal music hall named the doelen, strategically located opposite the main railway station, was buzzing with life: so many people, so many languages, so many contacts. it was great! the first three days were especially for the students and junior doctors. the overall message, not to dichotomize life but to make christ lord over all, was given in bible readings from colossians by lindsay brown (fellowship of evangelists in universities of europe feuer) and in the keynote talks: “differentiating your purpose from your calling” (jan kunene, south africa) „developing competencies spiritually” (pablo martinez, spain) and “growing to full potential” (florence muindi, kenya). after the break, with plenty to eat and plenty to discuss, students would either participate in one of the many seminars or in a parallel program: psychiatry, psychotherapy and counseling, or prime, partnerships in medical education. the entertaining evening programs, worship & music, student presentations often resulted in a „more-than-12-hour-a-day‟ stay, but to everyone‟s joy. at the 50 years celebration ceremony with talks by peter ravenscroft, ed heule, daryl hacklund and icmda ceo vinod shah there was a flag parade by all 64 member-countries. people proudly displayed their national flag while the band played the first lines of their national anthems. a delicious gala-dinner followed. in the 2 nd part of the conference bible readings were led by andrzej turkanik (quo vadis institute, austria, preparing the new generation for christian leadership). the message was taken from the book of titus: we can‟t live „ahistorically‟ but must find our narrative in him. keynote lectures were on “serving jesus as a medical professional” (gisela schneider; germany), “sharing in practice” (john wyatt; uk), and “shining in society at large (issam raad; usa), challenging us to our christian action in society. seminars were many and varied: “whole person medicine”, “prayer, personality and temperament”, “marriage”, “faith in a busy life”, “neuroscience and faith”, “what is a christian physician”, “leadership”, “knowing god‟s path”, “cross-cultural medical mission”, “integrity”, http://icmda2014.org/ 102 paul r nov 2014. christian journal for global health, 1(2):101-102. “career choices”, “growing a student movement” among many other topics. every day started with a prayer session in a separate room. this “chapel room” stayed open all day for people who wanted to pray or who wanted counseling. literature was also available: during the whole conference there was a large well stocked bookstall and over 4000 books went to the 99 countries! the conference ended with a very impressive commissioning service on saturday morning, led by rev. ron van der spoel. together we participated in the lord‟s supper and together we sang. host family members were also invited. finally, led by the choir, adonai, the icmda song, once more filled the auditorium: bring your healing to the nations through our lives and through our hands bring your healing to the nations, dear lord change our lives and change our lands then came the time to say goodbye; the time to go back. filled with memories, thankful for the blessings and longing to serve, to shine and to share. editorial comment: there were many workshops on global health by members of the journal‟s editorial board such as “redefining poverty for mission a „wholistic‟ understanding” by anil cherian and vinod shah;; “scratching where it itches: influencing community health determinants among the impoverished the luke society‟s experience” by apolos landa; and “challenge not to conform in the context of changing values” by mathew santhosh thomas, as well as talks on healthcare in conflict zones such as egypt and south sudan. the managing editor for cjgh, daniel o‟neill, also presented a workshop on research, reflection and publishing during the main congress. there was a time of mourning for the dutch researchers whose plane was shot down over ukraine days before the congress as they were travelling to an innternational aids conference in singapore. the congress was an excellent time of networking and sharpenning, with a view toward the next congress in hyderabad, india in 2018. correspondence: dr. rick paul, vu university hospital, amsterdam, netherlands rickpaul.nl@gmail.com cite this article as: paul r. 15th congress of the icmda 2014. christian journal for global health (nov 2014), 1(2):101-102. © paul r. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.icmda2014.org/content/redefining-poverty-mission-%e2%80%9cwholistic%e2%80%9d-understanding http://www.icmda2014.org/content/redefining-poverty-mission-%e2%80%9cwholistic%e2%80%9d-understanding http://www.icmda2014.org/content/scratching-where-it-itches-influencing-community-health-determinants-among-impoverished-luke http://www.icmda2014.org/content/scratching-where-it-itches-influencing-community-health-determinants-among-impoverished-luke http://www.icmda2014.org/content/scratching-where-it-itches-influencing-community-health-determinants-among-impoverished-luke http://www.icmda2014.org/content/scratching-where-it-itches-influencing-community-health-determinants-among-impoverished-luke http://www.icmda2014.org/content/challenge-not-conform-context-changing-values http://www.icmda2014.org/content/challenge-not-conform-context-changing-values mailto:rickpaul.nl@gmail.com http://creativecommons.org/licenses/by/3.0/ clinical care april 2020. christian journal for global health, 7(1) triage and resource allocation during crisis medical surge conditions (pandemics and mass casualty situations): a position statement of the christian medical and dental associations special task force. paul hoehnera, david h. beydab, william p. cheshirec, robert e. cranstond, john t. dunlope, john e. francisf, c. ben mitchellg, cheyn onareckerh, d. joy rileyi, allen h. roberts, iij, dennis m. sullivank, christine c. toevsl, ferdinand d. yatesm, christopher hookn a md, ma (theological studies), phd, clinical associate, department of anesthesiology and perioperative medicine, dartmouth-hitchcock medical center, lebanon nh, and professor of theology, washington university of virginia, neil t. jones seminary, annandale va, usa b md, chair and professor, bioethics and medical humanism; professor, child health; director, global health program, university of arizona college of medicine phoenix, az, usa c md, ma(bioethics), consultant (neurology), mayo clinic florida, jacksonville, fl, usa d md, ma, msha, faan, associate clinical professor, ci med, neurologist, carle foundation hospital, urbana, il, usa e md, ma (bioethics), geriatrics, yale new haven health, new haven, ct, and adjunct professor of bioethics, trinity international university, deerfield, il, usa f md, facs, assistant professor of surgery, indiana university school of medicine, indianapolis, in and unity surgical center, lafayette, in, usa g mdiv, phd, graves professor of moral philosophy, union university, jackson, tn, usa h md, residency director, family medicine, st. anthony hospital: oklahoma city, ok, usa i md, ma, adjunct professor of bioethics, trinity international university, deerfield, il, usa j md, mdiv, ma (bioethics), fccp, facp, professor of clinical medicine and associate medical director, medstar georgetown university hospital, washington, dc, usa k md, ma (ethics), professor emeritus of pharmacy practice, cedarville university, cedarville, oh, usa l md, ma (bioethics), trauma medical director, terre haute regional hospital, terre haute in, usa m md, ma (bioethics), active associate pediatrician, children's healthcare of atlanta, ga, usa n md, associate professor of medicine, consultant (hematology), mayo clinic, rochester, mn, usa abstract the christian medical and dental associations (cmda) was founded in 1931 and is made up of the christian medical association (cma) and the christian dental association (cda). cmda has a current membership of over 19,000 physicians, dentists, and other allied health professionals. during and in direct response to the pressing urgencies of the covid-19 universal pandemic of 2020 the president of cmda commissioned a special task force to provide current and future christian reflection and 46 heohner, beyda, et al april 2020. christian journal for global health, 7(1) guidance on triage and resource allocation policies during pandemics and other forms of crisis surge medical conditions (e.g., mass casualty situations). this is a condensed version of the cmda special task force position statement. key words: triage, resource allocation, resource reallocation, pandemic, epidemic, mass casualty incident, ethics, stewardship. introduction health care systems and health care professionals (hcps) need to prepare for mass casualty incidents (mci) including disasters, epidemics, and pandemics, as have occurred throughout history and will certainly occur in the future. the purpose of this statement is to provide biblically sound ethical guidance for the triage and allocation of limited life-sustaining and other critical resources (e.g., mechanical ventilators and effective medical therapies) during crisis medical surge conditions when the demand for these resources outstrips the supply. instituting and putting into place broad population-based policies that drastically alter the normal patient-physician relationship should be implemented only if: 1) critical care (life-sustaining) capacity has been, or shortly will be, exceeded despite taking all appropriate steps to increase capacity, and 2) a regional-level and duly-authorized authority has declared an emergency. rationale for advance planning hcps have an ethical duty to provide compassionate and competent care, including making life-and-death decisions with as much forethought and ethical clarity as possible. this clarity must be maintained even during a crisis that creates stress for hcps.1 the only way to make this happen is to carry out advance planning, design decision-making tools, and prepare contingency protocols for dissemination. this will help to alleviate uncertainty and moral distress during a major health care emergency. guiding ethical principles triage in times of medical crisis surge conditions and mass casualty incidents (mci) is directed to the saving of as many lives as possible, seeking to maximize good outcomes for the greatest number of people possible. in shifting the ethical emphasis for pragmatic reasons, it is important not to lose sight of higher moral values. utilitarian goals, while important, must not be absolutized or sought at the expense of respect for the intrinsic value of all human beings as unique bearers of the image of god. • triage policies should only be implemented if: 1) medical and life-saving capacity has been, or shortly will be, exceeded despite taking all appropriate steps to increase capacity, and 2) a regional-level authority has declared an emergency necessitating such policies.2 • all health care facilities should have a formalized emergency operation plan in place under these conditions. • during these periods (e.g., mass casualties, pandemics), there is an imposed shift in a hcp’s duty from providing the most definitive and beneficial treatment to individual patients (standard of care) to the priority of populations or groups of patients who are most at risk and will most likely benefit with an appropriate stewardship of limited resources (sufficient care). triage 47 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) and resource allocation decisions should be objective, formalized, open, and transparent to both hcps and to the public. • as a given medical surge condition mounts and progresses from a conventional to a contingent surge condition, it may be tempting for hcps to begin enacting crisis triage and resource allocation decisions unilaterally or on their own, i.e., moving from patient-oriented medical care and ethics to communityand population-prioritized medical care and ethics. however, until a crisis surge condition or mci has been declared and formal, published protocols have been enacted, standard patient-oriented care and ethics continue to apply to all hcps. • it is important that hcps understand when there is a definitive “all clear” moment when crisis surge conditions have been abated so that standard medical care and ethics become operative once more. this underscores the necessity for advance planning and decisionmaking tools and protocols prior to any foreseen or unforeseen mci. justice • public health decisions should be based on objective factors, rather than on the choice of individual leaders, hcps, or patients. all individuals should receive the highest level of care required for survival or limitation of long-term disability given the resources available at the time. elective, non-essential interventions lack priority in these circumstances. • in accordance with the christian duty to respect all life as sacred, in times of medical crisis surge conditions, triage and resource allocation decisions must be equitable and based on objective and justifiable medical criteria, with the understanding that in unprecedented or unique circumstances these criteria may not have been fully validated for the current situation. they should nevertheless be based on the best medical evidence available as well as informed clinical judgment. all other considerations based on non-medical criteria should be excluded. such decisions must be nondiscriminatory and never based on perceived social worth, social class, ethnicity, age, gender, sexual orientation, religious convictions, political affiliation, economic status, nationality, disability, or any other medically non-relevant trait that does not impact immediate crisis-related prognosis or survivability.3,4 • appropriate stewardship of scarce critical resources requires triage and resource allocation decisions to be prioritized on the basis of medical need and likelihood for survival. survival is defined by examining a patient’s short-term likelihood of surviving the acute medical episode rather than a patient’s long-term prognosis related to chronic medical conditions or disabilities. • devising a just and equitable protocol means more than merely maximizing the absolute number of patients who survive to hospital discharge. other criteria that may be employed include: o prospects for short-term survival. the most straightforward measure of whether a patient will benefit from life-supportive treatment is whether a patient survives to discharge because of this care. o prospects for long-term survival. this measure considers how much benefit treatment produces in terms of survival after discharge. although important, placing too great a priority on this criterion may, in certain circumstances, further disadvantage those who already 48 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) face systemic disadvantages (i.e., this may be discriminatory). o pregnancy. preferences are to be considered for pregnant women. • when objective medical criteria do not clearly favor a particular patient (all things being equal), then “first come, first served” rules of allocation or a lottery system should apply. o “first come, first served” and lottery systems, both based on a theoretically random selection of equally qualified patients, acknowledge that each person is irreducibly valuable and that social value and other subjective factors are irrelevant. it also invokes the concept of justice, in that when a basic human right such as life is at stake, justice requires that all persons be treated equally. “for a right to be called human entails all humans have it equally.”5 o a “first come, first served” rule, as a type of “natural” lottery, has the advantage of reflecting the normal course of the medical system. it also has the advantage of not requiring the time necessary to set up a lottery system in times of public health emergencies. it has the disadvantage of selecting patients who enter the system earlier, possibly discriminating against those populations who have limited physical access to the medical system or limited knowledge of when to enter the medical system (e.g., the economically, physically, and psychosocially disadvantaged). o a lottery system may be more purely “random” but may be impractical based on the logistics of putting one into place in an equitable and fair system in a timely manner during times of public health crises. o both “first come, first served” and lottery systems must be scrutinized to be free from manipulation and to not disfavor disadvantaged and marginalized subgroups. the rationale and procedures for such systems of triage and allocation must be made clear to the public and understandable. • triage and allocation protocols must be established to give guidance to all hcps and to provide for objective standards to ensure fairness and justice during difficult decisions that may be influenced by subjective and personal concerns. it is also important that hcps understand when there is a clear and wellcommunicated moment that a crisis has abated sufficiently to shift focus back to prioritizing individual patient concerns. o in times of limited critical resources, decisions must be made regarding who and who will not receive specific therapies, even life-saving therapies. all patients are still to be afforded the maximal care and comfort that is available, and patient-centered principles of medical ethics still apply. hcps have a paramount duty to care for the individual patient and to seek appropriate and indicated treatment for each patient. this duty persists in a surge crisis. o if resources are available, they should be deployed as indicated regardless of the prognosis of the individual patient. “decision tools should not be used to exclude patients preemptively from use of life-saving resources when these resources are available.”6 49 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) o the capacity and need for treating physicians to reach routine decisions and recommendations regarding the indications for and the appropriateness of treatment are not altered by a surge crisis and not removed by triage and resource allocation restraints. o patients who are no longer eligible for life-saving resources (e.g., mechanical ventilation) are never to be abandoned and should continue to receive intensive symptom management as well as psychosocial and spiritual support. where available, specialist palliative care teams should be involved. o triage and resource allocation decisions that apply to individual patients should be the responsibility of parties other than the treating physician. this is best accomplished through a triage officer or a triage team who are removed from direct patient care and work in close partnership with a facility’s ethics committee. o communicating triage decisions, particularly when a patient is excluded from receiving life-saving resources, should be the responsibility of the deciding triage officer(s) or appointed representatives of a triage committee, along with the treating physician. fairness • fairness concerns require triage and resource allocation to pay particular attention to the needs of at-risk and marginalized persons, including the poor, the aged, and persons with disabilities. • several justifications for pure chronological age-related criteria have been proposed, but each is morally problematic: o strict chronological age criteria can serve as a convenient and objective, albeit hidden, form of social-value criterion.5 the elderly may also be the weakest, marginalized, and least able to resist. age, per se, is not a medically relevant factor in that the elderly can have different medical problems and states of health that make one a better candidate than another, or even a better candidate than younger, less-healthy candidates. age-related medical conditions may be potential reasons for exclusion, but not age itself. age should be seen in the context of overall objective medical predictors of outcome, not as a sole independent criterion itself o an “equal opportunity” justification prioritizes “life-years saved” by giving younger persons an equal opportunity to live a longer number of years. however, persons are more than sums of accumulated life-years. all persons are of equal value and must be treated as such. life is equally precious at any age. o a “life span” justification defends an age criterion by assuming that at a given age everything of significance has been “accomplished” and “achieved.”7 implicit in this argument is that what matters most is “doing” not “being” (a productivity view of human value). o god commands us to honor, respect, and value the elderly. “rise in the presence of the aged, show respect for the elderly and revere your god. i am the lord.” (lev 19:32, niv); “is not 50 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) wisdom found among the aged? does not long-life bring understanding?” (job 12:12, niv). see also deut 32:7; job 32:7; isa 46:4; psa 71:9, 18; prov 16:31; 20:29; 1 tim 5:1.8 transparency and procedural justice • governments and institutions have an ethical obligation to plan allocation of critical scarce resources through a process that is transparent, open, and publicly debated to the extent time permits. • in order to ensure procedural justice, any triage operation should be regularly and repeatedly evaluated to guarantee that the process has been followed fairly, that the need for triage operations still persists, and that current objective criteria continue to be based on the best available evidence.9 • physicians should have a formalized procedure to advocate for their patients with regard to individual triage decisions, including an expedited appeal process. however, decisions authorized by appointed triage officers or teams should generally prevail. • triage decisions for individual patients should be revisited periodically and upon request of the treating physician to consider patients with initial low physiological acuity who may subsequently deteriorate and require more urgent need for critical lifesaving resources. • for patients with very severe illness, an urgent clinical appeal process should be available when a treating physician believes that patient improvement would alter the triage decision.6 categorical exclusion criteria  criteria that are “hard stops” (e.g., age > 85 years) that prevent a patient from even reaching the triage decision-making stage and identify individuals to be excluded from access to critical services under any circumstances during an mci should not be used. categorical exclusions may be interpreted that some groups are “not worth saving.” any triage or allocation system must make clear that all individuals are “worth saving.”  rather than providing categorical exclusion criteria (even some that would seem ethically founded, e.g., hospice care patients, and patients with existing do-notresuscitate (dnr) orders or with advance directives that prohibit intubation or mechanical ventilation),6 hcps should not exclude any patient who would under normal clinical circumstances be eligible (e.g., for mechanical ventilation) and allow the availability of critical resources (ventilators) determine how many eligible patients receive it.2  critical care physicians all recognize that some conditions lead to immediate or near immediate death despite aggressive therapy and that under routine clinical conditions certain critical care services are not warranted or offered (e.g., cardiac arrest unresponsive to appropriate acls, overwhelming traumatic injuries, massive intracranial bleeds, intractable shock, multisystem organ failure, advance states of cancer, etc.). hcps should not be obligated to provide non-recommended, potentially inappropriate interventions that have no reasonable possibility of beneficial effect solely because a patient or surrogate requests them.  during an mci involving a crisis surge condition, physicians should still make clinical judgments about the appropriateness of utilizing critical resources using the same 51 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) criteria they use during normal clinical practice. reallocation of life-supportive resources • during an mci, reallocation is the nonconsensual withdrawal of life-supportive treatment (in the absence of a properly executed advance directive or decision of a properly authorized surrogate) with the direct intent of transferring that same life supportive treatment to another patient who is considered a more worthy candidate for such treatment (by any criteria or bias) when the same or equivalent treatment is currently not available. • non-consensual withdrawal of lifesupportive resources (e.g., mechanical ventilation) involves an active, intentional, and direct taking from a vulnerable person incapable of resisting. except in cases authorized by court order, such withdrawal is recognized as legal in only one jurisdiction in the united states.10 • cmda rejects any form of reallocation as defined above, whether by individual hcps or by triage officers/committees. these utilitarian reallocation decisions tend to be based on notions of quality of life or social value (including age and disabilities not directly contributing to a patient’s short-term prognosis) in which one individual’s “worth” is pitted against another known individual’s. withdrawal of life-supportive resources from a vulnerable patient should never be used as a means to another’s end but should always be decided based on the clinical ends of that individual patient (e.g., reducing the burdens and suffering involved with a given treatment). withdrawal of life-supportive resources should ideally not occur without the patient’s consent (including authorized surrogate consent or through an advance directive). however, if the treatment is deemed non-beneficial to achieving the goal of surviving the medical crisis, urgent circumstances may dictate the necessity of withdrawing lifesustaining therapy according to procedures outlined in this statement. alternative to reallocation: optimal stewardship and care in a time of absolute scarcity  during an mci or officially declared medical crisis surge situation, when the demand for critical life-supportive resources has surpassed the supply and availability of those or equivalent resources, hcps, along with hospital administrators, ethicists, and governing authorities, will be required to make difficult decisions with regards to balancing optimal stewardship of critical scarce resources and the treatment of individual patients who can best benefit from those resources. those decisions must be made recognizing the inherent and irreducible value of each human life.  the difference between reallocation and optimal stewardship is that the former is based on a utilitarian calculus comparing the “worth” or “benefit received” between patients where life-supportive treatment is unilaterally removed from one patient based on their prognosis at the time, and may be given to another. the latter is based on the beneficent/non-maleficent treatment and care of each individual patient irrespective of the immediate needs of other patients. even in an mci, the good of the individual patient remains paramount.  even when life-supportive treatments are readily available, many patients on life supportive treatment may become terminally 52 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) and irreversibly ill with little or no reasonable hope of recovery, from a medical standpoint. all fifty states and the district of columbia recognize advance directives that permit direct withdrawal of lifesupportive treatment under these circumstances. withholding or withdrawal of lifesupport in patients is also ethically permissible when: 1) the medical treatment becomes detrimental or no longer is contributing to the patient’s expected goals and outcomes and 2) the suffering and burdens of a treatment outweigh the intended and foreseen benefits (the intention is to avoid those sufferings and burdens, and even if death is foreseen, it is not intended as a means or as an end, but is accepted as the natural course of the underlying illness).  during worst-case extremes of crisis surge conditions, optimal stewardship of scarce lifesupportive resources, such as mechanical ventilation, may require that a more stringent standard (more so than what would occur under normal circumstances of perceived unlimited resources) apply for what constitutes optimal beneficent and sufficient treatment. the ethical appropriateness of continuing or discontinuing treatment is must be equally applied to all patients. the relative stringency of these clinical standards (e.g., length of a trial of ventilation before a patient improves, percentage estimate of short-term survivability, level of acuity, sofa or apache ii score, and similar markers of survivability and benefit from treatment) will vary depending on the severity and magnitude of the mci or crisis surge condition.  further allocation of available life-supportive resources should be offered only within the bounds of well-communicated time-limited trials appropriate for the patient’s medical condition and the severity and magnitude of the current mci or crisis surge condition.  any decision to apply more stringent standards for what constitutes optimal beneficent and sufficient treatment should be impartial, based only on standard objective medical acuity including short-term prognosis scoring systems (such as sofa and apache ii scores) and not based on long-term survival prospects, age, disability, or social value. these decisions must, whenever possible, be the responsibility of an appointed triage officer or triage committee and not the treating hcp, recognizing the limitations of smaller institutions.  during an mci or crisis surge condition, persons with disabilities possess the same dignity and worth as others and should not be denied treatments based on stereotypes, assessments of quality of life, or judgments about their relative worth. treatment decisions should be based on individualized assessments based on the best available medical evidence. for instance, patients with certain spinal cord injuries or neuromuscular disease who are otherwise stable but require long-term use of ventilators should not have their ventilators removed for the purpose of reallocation. preexisting terminal diagnoses, such as metastatic cancer, end-organ failure (lung, liver, kidneys), or severe dementia11 are not considered a disability, but rather a medical condition.  these situational standards of beneficence should apply to all patients equally. withdrawal of treatment for any patient should be based solely on those objective medical criteria appropriate to the situation and without deference to another patient who may benefit from subsequent resources that would be made available. unless continued treatment is determined to be medically nonbeneficial with no objective reasonable hope of short-term survival, decisions to withdraw treatment should never be unilateral or against 53 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) the patient’s or their family’s wishes but remain a shared decision. unlike many utilitarian reallocation schemes, these standards and criteria are not to be used to stratify or rank one patient against another, but to optimize the stewardship of limited resources by providing the best possible treatment to each and every patient, constrained by the contingencies of an mci.  hcps withdrawing treatment according to these more stringent situational standards should consider consultation with their hospital’s ethics service/triage committee along with the patient’s family/surrogate in order to avoid misunderstandings.  triage teams ideally should have no direct role in the treatment of patients nor in the withdrawal of resources, even when they are in accordance with advance directives, recognizing that this may not be practical in small institutions where those making triage decisions may necessarily also be involved in direct patient care.  it is well established that in trauma mass casualty and resource-limited mission situations, triage and stewardship decisions are based on split-second intake and processing of relative clinical and situational data, but never on any “relative worthiness” criteria. conscience objections during worst-case extremes of crisis surge conditions when an officially declared emergency exists and population-based ethics dominate, nonconsensual withdrawal and reallocation of lifesupporting resources and/or unilateral decisions not to resuscitate (based on either patient condition or health care provider safety) may be dictated by government public health authorities, by designated triage officers/teams, or by published protocols. cmda rejects any form of reallocation. some hcps may experience moral distress based on their professional commitment to be patient advocates. treating hcps should be provided a formal means to appeal and advocate for their patient and/or to conscientiously object to complying with a triage order. at a minimum, hcps should be provided with the option to step aside and allow another hcp to comply with the order when such appeals are denied. for further information and reflections, see cmda’s statement duties of christian health care professionals in the face of pandemics. jesus calls us to love one another, so if differences of opinion about ethical issues arise during mci, christian hcps should work hard to maintain the unity of the spirt through the bond of peace. priority of medical personnel should medical personnel, particularly frontline hcps, receive preferential priority (e.g., subtracting points from their priority score or using it as a tiebreaker criterion) for scarce life saving resources during a medical crisis surge? this is a controversial issue in the ethical and medical literature. three arguments are usually given to advocate for their priority. 1. a policy that prioritizes at-risk front-line hcps will increase their morale and motivation to “show up.” this argument is unwarranted because hcps possess a higher calling and duty than the general public and should not be induced by such preference. 2. front-line hcps deserve preferential treatment “just because” of their valuable contributions in the past, present, and future to the health of society. this argument is also unwarranted because it assumes that the lives of hcps are somehow intrinsically more valuable than any other lives. 54 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) 3. a stronger argument is based on the calculus of medical crisis surge conditions that the increased risk taken by front-line hcps will create a further reduction in important skilled personnel resources thereby contributing to an increased overall loss of life. this cannot be a blanket argument, but must take into account several additional factors such as the absolute necessity and irreplaceable skill a particular hcp possesses, how long they will be removed from the pool of necessary personnel even if given treatment (including mandatory quarantine time), and the projected overall total impact on available personnel resources. while it would be a very extreme and unique situation where such preferential treatment would make a significant impact on overall outcome, there may be some scenarios where this may be a consideration and will depend on the exact nature of the mass casualty incident (mci). aside from the argument for preferential treatment or having an absolute higher priority in triage decisions, it is still imperative for front-line hcps with direct patient contact to receive preferential allocation of scarce personal protective equipment (ppe) resources in order to protect and preserve important personnel resources. physician assisted suicide (pas) and euthanasia cmda opposes the active intervention with the intent to produce death for the relief of suffering, economic considerations, or convenience of patient, family, or society. see cmda’s statement on euthanasia. cmda is equally opposed to all active interventions that intend to hasten or produce death in a patient as part of any population-based ethic during a public health emergency or medical crisis surge. withdrawal of a life-supportive resource may be ethically permissible, however, in some situations where imminent death is foreseeable but not intended. christian hcps, administrators, and legislators should be aware of and oppose any protocols, policies, or legislation put into place or activated during a public health crisis or medical crisis surge that promote or seek to make the acceptance of pas and euthanasia more palatable or more easily accessible either during the crisis or afterwards. conclusions broad population-based policies that drastically alter the normal patient-physician relationship should be implemented only if: 1) critical care (life-sustaining) capacity has been, or shortly will be, exceeded despite taking all appropriate steps to increase capacity, and 2) a regional-level and duly-authorized authority has declared an emergency. as christian physicians, our moral duty in these extreme, distressing, and challenging situations is to use our god-given, spirit-led, and scripture-bounded wisdom to the best of our ability to balance the biblical goals, motives, and directives of the christian life within the complexities of living in a fallen and sinful world, submitting all our limitations to god’s love, mercy, and providence. jesus calls us to love one another, so if differences of opinion about ethical issues arise during these challenging times, christian hcps should work hard to maintain the unity of the spirit through the bond of peace. • public health decisions should be based on objective and transparent factors, rather than on the choice of individual leaders, hcps, or patients. • governments and institutions have an ethical obligation to plan allocation of critical scarce resources through a process that is transparent, 55 hoehner, beyda, et al april 2020. christian journal for global health, 7(1) open, and publicly debated to the extent time permits. cmda opposes the active intervention with the intent to produce death for the relief of suffering, economic considerations, or convenience of patient, family, or society. references 1. ryus j and baruch j. the duty of mind: ethical capacity in time of crisis. disaster medicine and public health preparedness. 2018; 12: 657-662. https://doi.org/10.1017/dmp.2017.120. 2. university of pittsburgh school of medicine, department of critical care medicine. allocation of scarce critical care resources during a public health emergency; 2020. available from: https://ccm.pitt.edu/sites/default/files/univpittsbur gh_modelhospitalresourcepolicy.pdf. 3. beauchamp tl and childress jf. principles of biomedical ethics. eighth edition. new york: oxford university press; 2019. 4. edelstein l. the hippocratic oath: text, translation and interpretation. baltimore: the johns hopkins press; 1943. 5. kilner, j. who lives? who dies? ethical criteria in patient selection. new haven: yale university press; 1990. 6. institute of medicine committee on guidance for establishing crisis standards of care for use in disaster situations. crisis standards of care: a systems framework for catastrophic disaster response. washington, dc: national academies press; 2012.. https://doi.org/10.17226/13351. 7. callahan d. setting limits: medical goals in an aging society. new york: simon and schuster; 1987. 8. scripture quotations marked (niv) are taken from the holy bible, new international version®, niv®. copyright © 1973, 1978, 1984, 2011 by biblica, inc.™ used by permission of zondervan. all rights reserved worldwide. www.zondervan.com the “niv” and “new international version” are trademarks registered in the united states patent and trademark office by biblica, inc.™. 9. rubinson l, hick jl, hanfling dg, devereaux, av, dichter, jr, christian, md, talmor d, medina j, curtis, jr, and geiling ja. definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. chest. 2008; 133(5 suppl 1): 51s-66s. https://doi.org/10.1378/chest.07-2693. 10. texas advance directives act. texas health and safety code. 2020; §166.046. 11. chang a and walter lc. recognizing dementia as a terminal illness in nursing home residents. archives of internal medicine. 2010; 170(13): 1107-9. https://doi.org/10.1001/archinternmed.2010.166. acknowledgements: the full statement, which includes a more extended biblical and ethical defence of these conclusions, can be found at https://cmda.org/wp-content/uploads/2020/04/final-triage-and-resourceallocation.pdf. christian medical and dental associations, bristol, tn, usa. www.cmda.org correspondence: dr. paul hoehner, usa. pjhoehner@gmail.com cite this article as: hoehner p, beyda dh, cheshire wp, cranston re, dunlop jt, francis je, mitchell cb, onarecker c, riley dj, roberts ah, sullivan dm, toevs cc, yates fd, hook c. triage and resource allocation during crisis medical surge conditions (pandemics and mass casualty situations): a position statement of the christian medical and dental associations special task force. christian journal for global health. april 2020;7(1):45-55. https://doi.org/10.15566/cjgh.v7i1.387 © authors this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1017/dmp.2017.120 https://ccm.pitt.edu/sites/default/files/univpittsburgh_modelhospitalresourcepolicy.pdf https://ccm.pitt.edu/sites/default/files/univpittsburgh_modelhospitalresourcepolicy.pdf https://doi.org/10.17226/13351 https://doi.org/10.1378/chest.07-2693 https://doi.org/10.1001/archinternmed.2010.166 https://cmda.org/wp-content/uploads/2020/04/final-triage-and-resource-allocation.pdf https://cmda.org/wp-content/uploads/2020/04/final-triage-and-resource-allocation.pdf http://www.cmda.org/ mailto:pjhoehner@gmail.com https://doi.org/10.15566/cjgh.v7i1.387 http://creativecommons.org/licenses/by/4.0/ references editorial nov 2020. christian journal for global health 7(4) responding to epidemics and pandemics the current pandemic has brought many changes in our economic structures, clinical interactions, fellowship engagements, travel behaviors, social relationships, and communication platforms. it has been a time of fear, but also of hope amidst those challenges. as a response to these times and our call for papers on responding to pandemics, the journal has continued to receive a stream of articles related to covid-19 and justifying a second special issue on the subject. we feel this journal is unique in being able to document the special concerns faced by lowand middle-income countries in dealing with the pandemic and to report creative approaches in circumstances of limited resources. a principle feature of this issue is a series of case studies and short reports. gnanaraj jesudian and his colleagues describe how they made personal protective equipment from locally available materials and then trained hospital staff to use them to mitigate transmission in rural hospital settings. they used electronic communications for consultations while continuing to care for patients in a compassionate way. dr. jesudian also describes a method for teaching laparoscopic surgical techniques to trainees using low cost equipment, redeeming the time during lock down. jason paltzer and jason jonker found that it was feasible to continue peer alcohol recovery groups by doing them virtually. qais gasibat and mussab gasibat describe the progress of the pandemic in libya, a country already struggling with a civil war and an impaired economy. two pediatricians from india, jacob john and dhanya dharmapalan advocate for an effort to eradicate sars-cov-2 lest it become a permanent feature of the respiratory virus landscape with longterm adverse consequences. jean peteet and colleagues describe how an ngo organized care and containment for covid-19 in highly vulnerable slum communities in new delhi, india. as the epidemic has developed there has been both opportunity and need to update criteria for clinical diagnosis, particularly since there are limits to testing in resource-constrained circumstances. professors seshadri and john provide updated clinical criteria, revising their previous article in a letter to the editor. complementing the short reports is a more extensive account of how a christian ngo responded to unanticipated, new and unique challenges from the pandemic. sarah varughese recounts six areas in which decision making, planning and program execution were affected: alertness and preparedness, financial readiness, responsiveness in areas new to the organization, engagement with partners active in different areas and locations, consultations with experts, and leadership by those sharing appropriate values. the journal’s call for papers was on responding to epidemics and pandemics, but covid-19 was not the only subject addressed by the submissions. omololu and ayokunle fagunwa from nigeria recount the story of the english sweating sickness of the 15th and 16th centuries, describing its clinical, epidemiologic and historical features along with how the church responded. these two authors also offer a meditation on psalm 91 with notes on the comfort and promise it offers in a time of fear and loss. finally, there is a major review by professor bernt lindtjørn and thor henriksen from norway of the work of mission hospitals in southern ethiopia in dealing with infectious disease outbreaks over a period of more than fifty years. surely there are lessons here that are relevant today. finally, our managing editor, daniel o’neill has reviewed n. t. wright’s god and the pandemic: a christian reflection on the coronavirus and its aftermath. he helpfully summarizes wright’s critique of various responses and reflects on how he works out his fundamental emphasis on jesus’ suffering, death and resurrection as pattern for our https://journal.cjgh.org/index.php/cjgh/article/view/419 https://journal.cjgh.org/index.php/cjgh/article/view/385 https://journal.cjgh.org/index.php/cjgh/article/view/431 https://journal.cjgh.org/index.php/cjgh/article/view/431 https://journal.cjgh.org/index.php/cjgh/article/view/451 https://journal.cjgh.org/index.php/cjgh/article/view/403 https://journal.cjgh.org/index.php/cjgh/article/view/403 https://journal.cjgh.org/index.php/cjgh/article/view/471 https://journal.cjgh.org/index.php/cjgh/article/view/471 https://journal.cjgh.org/index.php/cjgh/article/view/401 https://journal.cjgh.org/index.php/cjgh/article/view/421 https://journal.cjgh.org/index.php/cjgh/article/view/449 https://journal.cjgh.org/index.php/cjgh/article/view/461 https://journal.cjgh.org/index.php/cjgh/article/view/433 https://journal.cjgh.org/index.php/cjgh/article/view/433 https://journal.cjgh.org/index.php/cjgh/article/view/473 2 editors nov 2020. christian journal for global health 7(4) understanding and involvement for suffering and renewal. we plan on publishing a separate issue with articles addressing changing landscapes in mission hospitals, capacity building for health workers, identifying health needs in low resource settings, and other topics in december. we always encourage submissions on any topic related to global health, development and christian service, but we want to call attention to a new call for papers on environmental concern, global health, and creation care that you can read alongside this issue. we also want to welcome lois armstrong, bmin, mphtm, phd(c) as associate editor for intercultural health, bringing her experience in nursing, midwifery, public health, health research and theological reflection to our editorial team. https://journal.cjgh.org/index.php/cjgh/cfp/environment commentaries october 2020. christian journal for global health, 7(4) the english sweating sickness of 1485-1551 and the ecclesiastical response omololu ebenezer fagunwaa and ayokunle oluwasanmi fagunwab a mth, phd (theology), federal ministry of health, abuja, nigeria, and microbiology phd candidate (microbiology) at the university of huddersfield, uk b ms, phd (agricultural engineering), ordained minister in redeemed christian church of god, and principal research officer, federal institute of industrial research, oshodi, lagos, nigeria abstract during the 15th and 16th centuries, five epidemics of a disease characterized by high fever and profuse sweating ravaged england. the disease became known as english sweating sickness because it started in england, though it also struck ireland and mainland europe. the infectious disease was reportedly marked with pulmonary components, and the mortality rate was estimated to be between 30% and 50%. the evidence of the “sweating sickness” story is medically fascinating and historically noteworthy as to its sudden appearance in 1485 and major disappearance in 1551. this was a period when the church of england broke away from the roman catholic church; and the then prince of wales, arthur tudor, died possibly of sweating sickness. the church played a vital role during those periods: responses were made in the form of treatment (in germany), ecclesiastical prayers, tailored worship, and devotions during those trying times, and the preservation of fragile records relating to the epidemics. key words: english sweating sickness; hantavirus; ecclesiastics; practical theology; sudor anglicus; epidemic. introduction the current covid-19 pandemic is unprecedented to the modern world, with arrays of restrictions, guidelines, and adjustments to a “new normal.” it is helpful to note that epidemics of plague caused by a virus are not new. one of the historic epidemics is the english sweating sickness from which we can learn. the english sweating sickness, also referred to as sudor anglicus, sweating sickness, english sweat, or the sweat, had five major epidemics between 1485 and 1551.1,2 among english locals, it has various names including “the swat called new acquittance, alias stoupe,” “hote ylles,” the “hote sicknes,” “stopgallant,” and “the posting sweat.”3,4 some people in the 16th century were of the opinion that the disease or a similar one may have been experienced among the greeks in the siege of troy (1260bc-1180bc), but there is no further evidence that is suggestive or confirmatory of such.5 there are three main classes of information about this disease, the first class being contemporary literary documents, chronicles of assembled references, and letters. the second class is the remarkable and widely cited account by dr. john caius in his a boke or counseill against the 21 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) disease commonly called sweate, or sweating sicknesse of 1552.5 the third primary source class were the parish registers containing death records covering that period.6 a further account was written in latin by le forestier, an eyewitness of the first epidemic.7,8 this paper describes sweating sickness and explores the historic record for ecclesiastical links and responses to the epidemic. historical significance the english sweating sickness was a turning point in english history. historically linked to the battle between the armies of henry tudor (later king henry vii, who reigned from 1485 to 1509) and king richard iii (reigned from 1483 to 1485), who lost support among the english people due to his harsh rule. this was in the era where the throne of england was controlled by the wars of the roses. to battle king richard, henry vii employed mercenaries from france. the invasion force crossed the english channel on 7th august 1485 landing in milton haven, pembrokeshire, wales and marched on to england. at bosworth field, leicestershire, england, henry’s army defeated richard iii on 22nd august 1485, a victory that allowed henry to be crowned as king.2 after the bosworth battle, the new king went to lincoln, where he caused supplications and thanksgiving to be made for his deliverance and victory, most likely at the lincoln cathedral, the world’s tallest building between 1311 and 1548. 9,10 however, it was commonly said among the people that his reign began with a sickness of sweat.9 the disease claimed the lives of many people including two lord mayors — thomas hills and sir william stokker, and six aldermen (deputy mayors) within one week.9 henry vii’s royal wedding was partly delayed because of the prevalence of sweating sickness. before the sweating sickness, he made an oath to marry elizabeth of york on christmas day of 1483. however, the wedding took place on the 18th january 1486, two years after the oath, no thanks to the sweating sickness.9 in addition, the king’s coronation was delayed due to the epidemic.4 in 1517, during the third epidemic, henry viii (1509-1547) cancelled his christmas celebrations as the disease affected important people, including ann boleyn, the king’s second wife, john colet, dean of st. paul’s london, cardinal wosley, brian tuke, the king’s treasurer, and the scholar, erasmus, in 1511.4 the fourth epidemic (15281529) affected not only england but the rest of europe.2,4 the british library catalogued the disease (on strip 42 of 195) as part of disasters visited by god on mankind. the sweating sickness was within the category covering the period from the fall of adam down to the death of archduke ferdinand ii of tirol in 1595.4 the epidemic has ecclesiastical significance. on protestantism, it affected the marburg colloquy in october 1529, a meeting that attempted to solve doctrinal disputes among protestants. the horror of the disease must have encouraged the reformers to reach rapid agreement on issues such as trinity, baptism, human governance, and authority, but they were unable to reach an agreement on the nature of the eucharist. this is reflected in martin luther’s letter to his wife as quoted in flood’s article: “sie seind hier toll worden mit schwei-schrecken, gestern haben sich bei funfzig geleget, deren seind eins oder zwei gestorben.” the english meaning is, “they have grown mad here with horror of sweat, yesterday there were fifty, of which one or two died.” clinical features contemporary descriptions described the sweating sickness disease onset as rapid, with no sign of warning and coming usually during night or early morning. chills and tremors follow by high fever and weakness were the first symptoms.2 body perspiration and rash followed and that could be fatal. heyman et al. suggest a mortality rate of 3050% after considering some contemporary reports where figures vary from 5-90%. going back to the 22 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) contemporary reports on signs and symptoms, le forestier reported, “sudden great sweating and stinking with redness of the face and of all the body,” and patients frequently had thirst, high fever, headache, and some black spots.7,11 le forestier experienced the first epidemic in 1485. another account in the 16th/17th century from bacon stated: persistent fever, with no spots or tainted body mass, malign vapour flowing to the heart, affect the circulatory system — “seized vital spirits.”9 sir francis bacon was born 10 years after the last major outbreak. bacon’s report was consistent in relation to high fever but contrasting to the black spots reported by le frostier. caius’ account on black spot states, “the other which come but by tymes and onely in certein partes, or broken, be not sufficient nor good, but very euill, of whose insufficiency, ij. notes learne: a swellyng in y partes with a blackenes, and a tinglyng or prickyng in the same.” caius witnessed the last major epidemic in 1551. taking all the accounts together, “spot” on the body is not a major sign of the disease, however some people could have it. a recent review described the autonomic nervous system as the main target with possible pathological involvement at the hypothalamus, serotonergic neurons, autonomic ganglia, peripheral sympathetic nerves, neuroeffector junctions, or eccrine glands.12 it was reported that the annals of merton college, university of oxford, contain records of treatment. though written in latin, a sentence from the record reads, “this . . . remedy was found against this pestiferous disease, that the infected person should be covered up warmly, not however excessively so, but covered moderately with clothes for twenty-four hours; for many have been suffocated by having been covered up excessively; let him drink warm beer, let no air get at him.”4 it must be noted that the works of caius contain similar treatments, to which we will not refer further. epidemiology and epidemics the epidemic appeared to be confined to the summer season; no outbreak was generally disseminated before june, and there were few evidences of the disease after october. additionally, dyer parish register research observed “a chain of infection which appears to be very fragile, easily broken to terminate the outbreak or to await further re-infection from outside.”6 the disease prevalence was stated by caius to be among the middle-aged, wealthy men and women.5 considering other evidences including the parish registers, the people who were affected were more diverse than reported from that one account.2,5 heyman’s et al.2 analysis on the origin of the disease supported the hypothesis that the english sweat was imported from siege of rhodes (greece, 1480) by the turks, who then were responsible for transmission onwards. there were five major epidemics of sweating sickness mentioned by various articles and described.2 the first epidemic was in 1485, first noticed among henry’s army that fought on bosworth field — a civil war between the houses of lancaster and york (see historical significance). the disease appears to have been known to both parties before the war, but fatal outbreak started after and raged until last day of october 1485. the second epidemic emerged in 1508, lasting from june to october. it was less widespread and less fatal and confined to england. in 1517, an epidemic confined to london occurred around june but was soon overshadowed by the plague in november of the same year. the fourth outbreak (1528) hit particularly hard and extended to the rest of europe as far as russia. the sweat sickness was responsible for the high mortality that devastated europe in 1528-1529, reaching as high as 5% in london. the last major outbreak (1551) was confined largely to england and brought terror as well. other mention of the sweat is in colchester, england (1578-1578), netherlands (1592), 23 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) cornwall, england (1644), and rottingen, germany (1802).13 ecological or meteorological triggers have been suggested for the outbreaks because of the irregularities in intervals (23, 9, 11, and 23 years) between the five epidemics.14 considering all the epidemics, england was hardest hit and reflective of the name “english sweating sickness.” “likely” causative organisms a virus, possibly hantavirus, is a suggestive causative organism of sweating sickness. it was suggested that sweating sickness was caused by an “old world hantavirus.”2,13 though a more recent review gives clinical comparisons between viruses, a definitive match remains elusive.12 in any case, the proposal of a viral disease with a rodent reservoir and an arthropod vector usually comes up in articles.6,15,16 an unusual hantavirus outbreak in southern argentina implicates human-human transmission, a rather uncommon route of transmission.17 a comparison was made of english sweating sickness to picardy sweat, hantavirus pulmonary syndrome (hps), and hemorrhagic fever with renal syndrome (hfrs). there is commonality to seasonality — summer, but duration, disease stages, and incubation times are very distinct.2 a thesis by dr. dyer on the causative agent favours an arbovirus, which retreats to an animal host between epidemics and during winter and then is transmitted to humans via some arthropod vector during spring periods where there are high activities by both host and vector. the outcome of the parish register research also suggested western england and welsh marshes as a probable reservoir since the 1551 outbreak started from there, and the first epidemic in 1485 appeared in the same region — possibly in shrewsbury, en route to bosworth battlefield.6 however, there is an account of possible infection pre-bosworth battle.2 the incubation period could be estimated between 1-44 days using ancient records,2 and that is in line with the incubation time of hantavirus infections. these observations support the likelihood of the causative organism being hantavirus, and the rural areas where there is plenty of food storage and supply should get the most concern.15 infectiousness parish registers indicate that the sweating sickness could be highly infectious. that a large part of the country was free of infection is a possible indication of previous high-level exposure to the causative organism or mysterious difficulty for a disease to be established in some districts. the registers show some concentration in families, which might indicate transmission by close contact.6 it is uncertain if sweating sickness created either temporary or life-long immunity. cardinal thomas wosley, the chaplain of king henry viii, suffered four attacks in a month in 1517 and got reinfected again in 1528.18 it was feared that the epidemic might be a hinderance to the king’s coronation — thankfully, it cleared before the date. sir francis bacon (1561-1626) noted in his book “history of the reign of king henry vii:” a disease then new: which by the accidents and manner thereof they called the sweating sickness. this disease had a swift course, both in the sick body, and in the time and period of the lasting thereof; for they were taken with it, upon four and twenty hours escaping, were thought almost assured. and as to the time of the malice and reign of the disease, ere it ceased; it began about the one and twentieth of september and cleared up before the end of october, insomuch as it was no hinderance to the king’s coronation, which was the last of october; nor, which was more, to the holding of the parliament, which began but seven days after.9 24 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) bacon also noted: and it appear by experience, that this disease was rather a surprise of nature obstinate to remedies, if it were in time to look unto.” however, his record will rule out the possibility of a haemorrhagic fever: “it was a pestilent fever, but not seated in the veins or humours, for that there followed no carbuncle, no purple or livid spots, or the like.” 9 the church response as mentioned earlier, the disease was catalogued as part of a disaster from god, but the church also wished that “may god make it turn out well” and even stated that the summer weather aggravated the disease.4 in flood’s article, he stated that “the afflicted doubtless put their trust in the saints and prayer,” 4 and a tract by peter wild give a stern evangelistic warning with the use of matthew 3:2 as the tract title “repent ye, for the kingdom of heaven is at hand.” like syphilis, the plague and other diseases of the time were widely interpreted by the church to be a chastisement from god. the contribution of the church may be said to be that of watchfulness — physical and spiritual; spiritual — prayer, worship, devotion; and medical writing of the clinical notes by a religious medical doctor and preservation of fragments of related vital documents. however, it was also reported that the uncertain times in europe in the 15th century led to fear and superstition with preaching that the “will of god” had brought plagues, earthquakes, floods, droughts, famine, disease, and war to the people.2 religiously affiliated institutions, such as oxford university, cambridge university, and universities at heidelberg, leipzig, tubingen, marburg, wittenberg, and rostock were closed for some time, perhaps to break the chain of infection.4 sweating sickness affected the meeting at marburg that aimed to resolve doctrinal disputes among protestants. martin luther’s letter to his wife contained the statement; “they have grown mad here with horror of sweat, yesterday there were fifty, of which one or two died”4 showed the reformers were both horrified and concerned to have ended the marburg colloquy rapidly and do no harm further. as to the church’s contribution to treatment, an english evangelist and reformer, robert barnes (or dr. anthony barus, a disguised name in germany) contributed to the introduction of the “english regimen” into germany as cure. a description of the regimen given in 1529: forbids the use of stifling feather bed and avoidance of any kind of chill, so the patient must be covered up with a blanket sewn to the bed. take moderate quantity of a warm, but not stimulating drink such as beer, and be refreshed with syrup of roses. patients were to be kept awake, by talking to them, putting rose water or aromatic vinegar under their noses or rubbing it on their forehead.4 a swedish bishop contributed the following: “the sweat along with other plagues inspired the first vernacular printed book on medicine, the litil boke by the swedish bishop benedictus kanuti (canutus) on the 1486 plague, which gives a graphic description of the sickness’s arrival in 1485.”19 the graphically illustrated book was reported to have helped people in sweden understand the outbreak happening in england. aside from watchfulness and medical treatment, a prayer against the sweating sickness existed in the english society.19 in june 1551, a complete liturgy “a thankes geuing to god used in christes churche” was authorised for use nationwide.20 the sudden onset and high fatality of the sweating sickness made it much feared including concern for a re-emergence. prayer was a vital tool at those times: it invoked the image of the lord in agony on the mount of olives. it was 25 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) noted that prayers were offered to invoke jesus, the “hevenly leche,” and his tormented body as sure protection against the contagion of sin.19 there was special nationwide worship. the focus of a prayer was thanksgiving to god despite the outbreak of the sweating sickness. in short, a thankes geuing to god used in christes churche replaced the liturgy in the book of common prayer (bcp).20 the prayer contained in keio univ. ms 120x.432.1 is twelve lines (in latin).19 oratio contra informitatem sudoris sub tuam protectionem confugimus ubi infirmi acceperunt virtutem et propter hoc tibi psallimus dei genetrix virgo: "ora per nobis beata mater christi ut liberemur in praesentia sudore tristi" : oremus domine i[es] hu christe qui nostrarum animarum pro salute in monte oliveti genibus flexis, sudorem effudisti concede propitius, ut tuae dulcissimae matris interventu a magni sudoris specie pestifera salvemur, omnes tibi supplicantes sudoris infirmitate ut vexati per virtutem beatissime marie virginis celebriter liberentur per christum dominum nostrum amen prayer against the sweating sickness the weak take refuge under your protection and because of this they have power to raise the virgin mother to "pray for us blessed mother of christ to be delivered in the presence of sad sweat." we pray o lord christ who, for the health of our souls on the mount of olives bent your knees, sweating abundantly, grant that your sweet mother of intervention pray through the great deadly perspiration to find safety, all you who have to beg in weakness, sweating and worried by virtue of the blessed virgin ceremoniously delivered to the christ our lord, amen. (editor’s translation) another response to the epidemics was devotion and coping in such times. between 1500 and 1539 (following the dissolution of syon house), many instructional works were written and printed in local languages, including a daily exercise and experience of death by richard whitford.19 the piece was a devotional for coping during the epidemic. this piece may be a forgotten spiritual guide, written during a time of various epidemics. richard was a welsh catholic priest, a friend to scholar desiderius erasmus and known for his devotional writings.21 next, let’s talk about how the church ensured that there were preserved documents of the epidemic with a focus on the account of a christian doctor. dr. john caius, former president of the royal college of physicians and a committed christian, painstakingly documented his experience of the 1551 epidemic. the archaic english writing of caius is not like our modern english, but he appears to have three aims. in his words: i wyll plainly and in english for their better vnderstandynge to whome i write, firste declare the beginnynge, name, nature, and signes of the sweatynge sickenes. next, the causes of the same. and thirdly, how to preserue men frō it, and remedy them whē they haue it.5 [putting this to modern english]: i will plainly and in english for their better understanding to whom i write, first declare the beginning, name, nature, and signs of the sweating sickness. next, the causes of the same. and thirdly, how to prevent men from it and remedy them when they have it. dr. caius responded to the pressing need of that time — christians should also indulge in strengthening the faith of others during the trying times by allaying the fear of the disease in their hearts. stigmatization or neglect of infected persons should be discouraged among christians, and they should be willing to give empathy and care 26 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) to affected persons (jas 2:14-17, is 58:6-12). when we don’t know much about the aetiology of a disease, the church sometimes attributes the sufferings to sin. attributing sinful nature as the cause of the suffering of infected persons encourages stigmatization. in addition, the church as an ecclesiastical body on earth, endowed with god-fearing scientists and researchers who have been gifted with heavenly gifts and revelations from the all-knowing god. they should engage in holistic research founded on best practices mixed with faith, prayer, and diligence in god to bring solution (light) to the darkness brought about by the epidemic (matt 5:13-16, is 42:6-9). in the same manner, today’s church should emulate the early church in record keeping of epidemic outbreaks as this will assist in dealing with future pandemics. lastly, psalm 91 is a text where we can find solace during epidemics. it is about being strong in time of pestilence — “you shall not be afraid of the terror by night, nor of the arrow that flies by day.” the safety in this text goes beyond physical protection and transcends into the eternal; “with long life (eternity) i will satisfy him and show him my salvation.” conclusion like the sweating sickness, covid-19 has been viewed, at least during the beginning of the outbreak, as chastisement from god. heathen or redeemed, we are all affected with the current coronavirus pandemic. divine punishment or not and being mindful of the past, it is imprudent to regard sweating sickness as an extinct disease. it should be viewed as an epidemic that occurred at comparatively long intervals and that we should strive to understand now for a better response should it or a variant surface in the future. this presentation is by no means exhaustive of what we know of sweating sickness nor of the church’s response to the epidemic at various times. more records still need to be explored. references 1. foster mg. sweating sickness in modern times. contributions to medical and biological research. 1919;1:52-8. 2. heyman p, simons l, cochez c. were the english sweating sickness and the picardy sweat caused by hantaviruses? viruses. 2014;6(1):151–71. https://doi.org/10.3390/v6010151 3. roberts l. sweating sickness and picardy sweat. bmj. 1945;2(4414):196. 4. flood jl. safer on the battlefield than in the city: england, the ‘sweating sickness,’ and the continent. renais studies. 2003;17:147-76. https://doi.org/10.1111/1477-4658.00015 5. caius j. a boke, or counseill against the disease commonly called the sweate, or sweatyng sicknesse. made by ihon caius doctour in phisicke. very necessary for euerye personne, and muche requisite to be had in the handes of al sortes, for their better instruction, preparacion and defence, against the soubdein comyng, and fearful assaultying of thesame [sic] disease. imprinted at london: by richard grafton printer to the kynges maiestie. 1552. available from: http://name.umdl.umich.edu/a17535.0001.001 6. dyer a. the english sweating sickness of 1551: an epidemic anatomized. med his. 1997;41(3):362–84. https://doi.org/10.1017/s0025727300062724 7. le forestier t. tractatus contra pestilentiam thenasmonem et dissinteriam [latin]. rouen, france: jacques le forestier; 1490. available from: [at france national library of medicine] http://visualiseur.bnf.fr/visualiseur?destination=gal lica&o=numm-053176 8. le forestier t. venyms feuer of pestilens [latin].london, uk: norman md; 1495. 9. bacon f. bacon's history of the reign of king henry vii. [stereotyped ed]. [with notes by lumby jr.]. cambridge, uk: cambridge university press; 1901. available from: https://hdl.handle.net/2027/loc.ark:/13960/t4kk9sw4 j 10. lincoln cathedral archive. timeline — lincoln cathedral. 2018 [cited 2020 aug 20]. available from: https://lincolncathedral.com/historyconservation/timeline/ https://doi.org/10.3390/v6010151 https://doi.org/10.1111/1477-4658.00015 http://name.umdl.umich.edu/a17535.0001.001 https://doi.org/10.1017/s0025727300062724 http://visualiseur.bnf.fr/visualiseur?destination=gallica&o=numm-053176 http://visualiseur.bnf.fr/visualiseur?destination=gallica&o=numm-053176 https://hdl.handle.net/2027/loc.ark:/13960/t4kk9sw4j https://hdl.handle.net/2027/loc.ark:/13960/t4kk9sw4j https://lincolncathedral.com/history-conservation/timeline/ https://lincolncathedral.com/history-conservation/timeline/ 27 fagunwa & fagunwa november 2020. christian journal for global health, 7(4) 11. hunter p. the english sweating sickness, with particular reference to the 1551 outbreak in chester. rev infect dis. 1991 [cited 2020 aug 30];13(2):303-6. available from: http://www.jstor.org/stable/4455857 12. cheshire wp, van gerpen ja, sejvar jj. sudor anglicus: an epidemic targeting the autonomic nervous system. clin auton res. 2020;30:317–23. https://doi.org/10.1007/s10286-020-00698-x 13. heyman p, cochez c, hukić m. the english sweating sickness: out of sight, out of mind? acta medica acad; 2018;47(1):102-16. http://doi.org/10.5644/ama2006-124.221 14. lowe ej. natural phenomena and chronology of the seasons. london, uk: bell and daldy; 1870; 1. 15. thwaites g, taviner m, gant v. the english sweating sickness, 1485 to 1551. new eng j med. 1997;336(8),580–2. https://doi.org/10.1056/nejm199702203360812 16. taviner m, thwaites g, gant v. the english sweating sickness, 1485-1551: a viral pulmonary disease? med hist. 1998;42(1):96–8. https://doi.org/10.1017/s0025727300063365 17. wells rm, sosa estani s, yadon ze, enria d, padula p, pini n, et al. an unusual hantavirus outbreak in southern argentina: person-to-person transmission? [hantavirus pulmonary syndrome study group for patagonia] emerg infect dis.1997;3(2):171–4. http://dx.doi.org/10.3201/eid1309.070708 18. gwyn, p. the king’s cardinal: the rise and fall of thomas wosley. london: barrie and jenkins. 1990. p. 58, 440. 19. snell w. a prayer against the sweating sickness: oratio contra informitatem sudoris. [kei univ. ms 120x. 432.1]. 1997 [cited 2020 aug 21]. available from: http://koara.lib.keio.ac.jp/xoonips/?xoops_session=k af655jtbgost0d7nhu6f9fqi7 20. mears n, ryrie a. worship and the parish church in early modern britain. farnham, surrey, uk: ashgate publishing limited. 2013. [special nationwide worship and the book of common prayer in england, wales and ireland, 1533–1642]; p. 31– 72. 21. jenkins rt. whitford, richard [died 1542?] [priest and author]. dictionary of welsh biography.1959 [cited 2020 aug 18]. available from: https://biography.wales/article/s-whit-ric-1542 peer reviewed: submitted 31 aug 2020; accepted 8 oct 2020; published 9 nov 2020 competing interests: none declared. acknowledgements: appreciation is due to all authors for documents on the sweating sickness, from the first epidemic to the last. sincere appreciation goes to those who preserved these records, including the digitalized manuscripts and those who continue to preserve such historic events for our use now and in the future. correspondence: dr. omololu fagunwa, nigeria fagunwaomololu@yahoo.com cite this article as: fagunwa oe, fagunwa ao. the english sweating sickness of 1485-1551 and the ecclesiastical response. christ j glob health. november 2020;7(4):20-27. https://doi.org/10.15566/cjgh.v7i4.449 © authors this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://www.jstor.org/stable/4455857 https://doi.org/10.1007/s10286-020-00698-x http://doi.org/10.5644/ama2006-124.221 https://doi.org/10.1056/nejm199702203360812 https://doi.org/10.1017/s0025727300063365 http://dx.doi.org/10.3201/eid1309.070708 http://koara.lib.keio.ac.jp/xoonips/?xoops_session=kaf655jtbgost0d7nhu6f9fqi7 http://koara.lib.keio.ac.jp/xoonips/?xoops_session=kaf655jtbgost0d7nhu6f9fqi7 https://biography.wales/article/s-whit-ric-1542 mailto:fagunwaomololu@yahoo.com https://doi.org/10.15566/cjgh.v7i4.449 http://creativecommons.org/licenses/by/4.0/ references commentary may 2019. christian journal for global health 6(1) health, rights, and culture: reflections on the meanings of the word "rights" from a cross-cultural health worker lois joy armstronga a bsc, mphtm, research co-ordinator, epidemiology and research dept, duncan hospital, bihar, india abstract crossing cultures challenges the way one thinks about health and rights. cultural anthropology provides a framework that helps clarify these issues by categorising cultures by their dominant method of governing behaviour and maintaining social order: 1. guilt-innocence cultures, 2. honour-shame cultures, and 3. fear-power cultures. rights do not easily fit in either honour-shame cultures or fear-power cultures as compared to guilt-innocence cultures. jesus uses honour-shame language in his teachings regarding the care of the poor and neglected, rather than the language of rights. understanding the culture of the bible, as well as the culture in which you are working can help provide alternate methods of carrying out health work. jesus also addresses greed, the deceptive trap of rights, where people always want more. in the book of revelation, there is one right available to all who have clean robes — the right to the tree of life; the leaves of this tree provide healing of for all nations. key words: rights, health, culture as i cross between two cultures, some situations relating to rights are hard to comprehend. here are three examples. • soon after landing in australia, i turned on the tv, and a lady was discussing the right of a woman to have a breast reconstruction if she had had a mastectomy due to breast cancer. my stomach turned as i had just returned from another part of the world where treatment of breast cancer was a privilege only available to the wealthy. • it is well known that babies born at health facilities are more likely to survive than those that are born at home, but what do you do when a woman is brought to hospital for the birth of a boy baby, but when the family knows she is only having a girl, they keep her at home for the baby's birth. • a veterinarian friend was talking about how much antivenom is used to treat pets bitten by snakes in australia. how many people die in other parts of the world where they have no access to this essential medicine? living cross culturally for most of the last 18 years has challenged me to think about rights and health and how they fit in different cultures. then, trying to line this up with biblical material has resulted in a few struggles in my mind. the bible talks about our standing up for the poor and marginalised, but at the same time, giving up our own rights as jesus also did (phil 2:6–8). have we no rights? and, my rights, my god were books that early influenced my thinking.1,2 is it right for me 65 armstrong may 2019. christian journal for global health 6(1) to be telling other people to stand up for their rights when i am called to give up my own? are these mixed messages? the meaning of “right” and “rights” the english word “right,” has numerous meanings as noun, adjective, and verb. in this setting, we are referring to the noun which includes meanings, such as: entitlement, privilege, due, justification, claim, permission, merit. two hebrew words from the old testament give this meaning: mishpat and tsedeq/tsedaqah. the greatest number of old testament references occur in the prophets—not surprising as they are calling the people of israel to live according to the law, god’s directions to live a just and right life.3 the psalmist speaks of god standing up for the rights of the poor as does the book of job.4 only one greek word matches this sense of the word, right, in the new testament, exousia. it is usually translated to ‘power’ or ‘authority’ and only occasionally as ‘right’. these include: the right of those who receive jesus to become children of god5, the rights of apostles to food and family6, the right to eat sacrificial food 7 , the right of the potter to do with clay what he likes8, and then, in revelation, two references to the right to the tree of life and one reference to the right to sit on the throne with jesus.9 interestingly, all four references from the johannine writings come with conditions—those who receive jesus, those who overcome, and those who wash their robes. none of the references in the previous paragraph comes from the lips of jesus during his time on earth—those in revelation come from the ascended jesus in john’s patmos vision. however, there are many references to jesus talking about justice and caring for the neglected and overlooked, such as in the story of the sheep and the goats in matt 25:31–46. jesus does not call people to obey the law like the old testament prophets because in the sermon on the mount, jesus explains his teaching is completing, or fulfilling, the law. the pharisees who tried so hard to keep the law ended up being condemned by their actions of injustice. with jesus expanding the meaning of the law, it is not surprising that he does not use the language of rights, but he still calls people to care for the poor, the outcast, and those without a voice. cultural anthropology may provide us with an explanation regarding the way jesus addresses the issue. culture and rights culture is defined as “learned and shared attitudes, values, and ways of behaving.”10 in 1946, ruth benedict described three frameworks which exist to govern behaviour and maintain social order.11 all frameworks can exist in any culture but usually one predominates, and thus, the culture is described by the dominant pattern. these three groups are: 1. fear-power cultures: here, the world is in the control of gods and spirits. the behaviour of humans is influenced by seeking to appease these capricious powers who govern the good and bad happenings in life. most commonly, this is described as occurring in animistic, tribal cultures, but it plays a very significant role in folk religions and is a much greater influence in majority world honour-shame cultures than in the west. health, for people in fear-power cultures, is in the hands of the gods/spirit world. some will accept this fatalistically, while others will invoke a greater power to overcome the spiritual being responsible for the ill health. 2. honour-shame cultures: in these communal cultures, behaviour is driven by the need to seek honour and avoid shame by adhering to the community standards. these tend to be more hierarchical cultures. in many honour-shame cultures, ill health still falls primarily under the realm of fear-power beliefs. at the same time, some health conditions would be associated with shame, e.g., mental health, epilepsy, disability. ill health, thus, means exclusion for people with shameful health issues. 3. guilt-innocence cultures: these cultures have a strong, internal sense of right and wrong, but also have strong legal systems to support right and wrong behaviour. these cultures are predominantly individualistic cultures which 66 armstrong may 2019. christian journal for global health 6(1) value equality and fairness. much of the responsibility for health in these cultures is put on the individual to maintain healthy lifestyle choices. rights, in general, are about individuals and fairness, and are often connected with laws or legal systems and so these sit very comfortably within a guilt-innocence culture. however, rights do not fit so easily within a fear-power culture or an honourshame culture. health and rights in honour-shame cultures honour–shame cultures make up the largest part of the non-western world today, and this is where some of our biggest global health challenges exist. making laws regarding health in these cultures is unlikely to change behaviour. people will not feel guilty about breaking these laws, but they will feel ashamed when they are caught breaking the law. they are more likely to seek the honour of the community in preference to the law. laws that cannot be enforced lose their power. mortality reporting and surveillance, used to assess health statuses, persistently struggles in honour-shame cultures. attempts to understand problems in health are seen as shaming the persons, or the country involved. exposure of poor health outcomes can lead to information being hidden rather than exposed. is there an alternative way to change behaviour in an honour-shame culture? does the biblical material give us any clues? although jesus did not use the language of rights, he often used honour-shame language and sometimes used it very strongly. a detailed account is beyond the space available here but includesd words like loyalty, glory, inheritance, humiliation, purity, unclean, and dishonour. try replacing the word “blessed” by “honoured” in the beatitudes, e.g., “honoured are the poor in spirit, for theirs is the kingdom of heaven.”12 a number of new testament passages make more sense when you read with honour-shame eyes.13 jesus treated the disadvantaged with respect and care, but he shamed the leaders of the community over the way they treated the poor, widows, and orphans. jesus gave honour to those who treated children and the “least of these” with respect. this is in line with the writer of proverbs who wrote, “he who oppresses the poor shows contempt for their maker, but whoever is kind to the needy, honours god.”14 using patronage positively in honourshame cultures patronage is a concept within hierarchical honour-shame cultures with which people from egalitarian cultures are less familiar. alternate words to “patrons” could be benefactors, supporters, sponsors, investors, backers, donors, champions, guardians, defenders, or advocates. patrons have a responsibility to care for those in their patronage while the clients are obliged to give their allegiance to the patron.15 in the old testament, israel’s king, a patron, was to keep a copy of the mosaic law with him as a reminder of how he was to care for his people.16 both paul and peter describe the purpose of governments as being for the good of the people, to bring unity and co-operation by encouraging right behaviour and punishing wrongdoing.17,18 leaders who fail to care for their sheep and seek their own gain, are reproved in both the old and new testaments.19 working with patrons, or those who have more, may be an important model in improving health outcomes in honour-shame cultures. these leaders need to be taught that they are responsible to use their influence and resources wisely and for the good of the people in their protection. we must train these leaders to realise that their role is to help others. by helping them to see this, they will gain honour when they make improvements to the health of their community and may have more impact than when they shame people with bad outcomes. it is important to model this in the organisations in which we work as well as seeking to find ways to promote this model in other settings. for example, dil se (from the heart), a program that runs alongside the general nurse 67 armstrong may 2019. christian journal for global health 6(1) midwifery program in emmanuel hospital association hospitals, has sought to help nurses become “christ centred, consistently caring, and clinically excellent” (personal communication, emmanuel hospital, 2018). it is important, when mentoring students and junior health professionals, to teach and to display biblical principles of leadership instead of falling prey to existing power systems. the reason many of us work in global health is our passion to see improvements in health for those overlooked and neglected: poor, women, children, disabled, mentally ill, those suffering from tuberculosis, snakebite victims, etc. my motivation of “to whom much is given, much will be required” is shared by many.20 in this way, we can also become patrons, not in a negative paternalistic sense, but as we bless, shepherd, empower, and provide for the good of others. salvation motifs in honour-shame cultures when reading the bible with honour-shame “glasses” on, we find there are two salvation motifs: 1. inclusion into the community and 2. status reversal.13 given the close connection between healing and salvation, especially in luke, these two motifs are worth considering regarding how we work in global health. both these motifs are seen in the way jesus was at work: lepers are healed and sent to the temple for inclusion back in the community;21 the outcast bleeding woman is called “daughter;”22 the gadarian demoniac is returned to his community clothed and in his right mind;23 the widow from nain, whose only son dies, has her world turned right side up again, as her only son is raised from the dead.24 the following is a favourite health-related story of “inclusion into the community.” m, one of the hospital domestic staff, was outside the front gate of the hospital when she noticed an unkempt young woman being teased by a group of young men. realising that this young woman had a mental health problem, she took her by the arm, leading her away from those taunting her. those taunters said, “she is not your daughter,” to which m replied, “but she is someone’s daughter,” and she led her into the hospital. this young woman was treated at the hospital’s expense with staff from the community team and the ward caring for her as she had no known relative to care for her. she began to improve and one of the security guards recognised her as someone from his neighbouring village. she was returned to her family and continued to receive follow up care from the community mental health team. rights and health in fear-power cultures a majority of the world is made up of predominately honour-shame cultures, but the influence of the fear-power culture is much greater than in western countries.13 as mentioned previously, much of the understanding about health in honour-shame cultures lies within the framework of the fear-power culture. if health or ill health is in the hand of the gods, what right does one have to health? the power concepts carry over into regular health systems in many cultures. when a new medicine or a new health service arrives, people from fear-power cultures are likely to see the new medicine, treatment, or the new doctor, as the greater power. if that power fails to bring healing, then they run to a more prestigious and expensive health facility because these are seen to be more powerful. in chronic diseases, this is particularly a problem as cure is not possible. people waste endless amounts of time and money seeking help at bigger and better health services. a poster advertising a new super-speciality hospital in a rural town has as its motto, “the power to heal.” there is a great need for humility as we introduce ourselves as health workers, as servants of the great healer. he is omnipotent, but we need to be careful not to portray ourselves as all powerful. we need to make a special effort to make sure we care for the fearful and powerless who often “melt away” unseen in our health facilities.25 “one number-one voice,” has become 68 armstrong may 2019. christian journal for global health 6(1) the surveillance motto for our local epidemiology team. making sure cases are counted in surveillance gives a voice to many who might go unnoticed. this “behind the scenes,” part of health care can be a powerful tool in speaking up for the powerless. a problem with rights luke 12:13–15 is a challenging introduction to the story of the rich man who builds bigger barns to hold his expanding wealth. it begins by a man in the crowd asking jesus to tell his brother to give him his fair share of the inheritance. jesus tells the man he does not think it is his place to make the judgement. then jesus turns to the crowd and says, “take care! protect yourself against the least bit of greed. life is not defined by what we have, even when you have a lot.”26 here is a man standing up for his inheritance rights and jesus turns around to the crowd and raises the issue of greed. jesus has identified the trap that exists in asking for our rights, the trap to always want more. staff from our community health team tell me how some of the lowest caste people are always looking for someone lower than themselves who they can lord it over. this very same issue of greed was identified by a scientist as the problem in environmental issues. i used to think that top environmental problems were biodiversity loss, ecosystem collapse and climate change. i thought that thirty years of good science could address these problems. i was wrong. the top environmental problems are selfishness, greed and apathy, and to deal with these we need a cultural and spiritual transformation.27 the direction of rights being exercised is important. we are told to stand up for the rights of others, especially the disadvantaged, but we are warned of the potential problem of standing up for our own rights. would it be better if we teach, even the most disadvantaged, that it is honourable if they stand up for the rights of others? this would then mean teaching the same message to all. when we tell people to stand up for their rights, are we mixing our messages and creating more problems? creating a culture of thankfulness and respect for others and loving our neighbour as ourselves may be less likely to promulgate the abuse that grasping after rights can bring. rights in a pleasure-pain culture it has been suggested that in the west, the guilt-innocence culture is being eroded by a painpleasure culture.28 in this setting, people aim to avoid pain and seek what brings them pleasure. where do rights fit in this culture? as this framework is driven by what people feel, the standard for the feeling is, not the god’s, the community, or the law, but self. it might be argued that an individual’s rights in this culture is what they feel is right for them. this would explain the plethora of rights appearing in the west, both in health and other areas of rights. a right to health for all cultures the language of rights may not be appropriate towards improving health in all cultures. what might seem good can become an insatiable grasping for more. using the idea of patronage to train leaders who care for and empower those in their circle of influence can be one alternate way of working; using project designs that develop inclusion of outsiders into community can be powerful; avoiding being caught up into existing power systems; helping people who are overlooked and neglected towards a status where they are valued by themselves and others, can also bring improvement in health. teaching all people to value and care for others is important. amazingly, the bible speaks to people from all cultures. it also requires culturally sensitive skills on our part to communicate the message, in word and deed, enabled by the holy spirit.29 the leaves of the tree of life are for the healing of the nations.30 the right to the tree of life is available to those who have washed their robes.31 this right, in all its fullness, is available to people from all cultures. 69 armstrong may 2019. christian journal for global health 6(1) references 1. williamson, m. have we no rights? chicago: moody press; 1957. 2. wells r. my rights, my god. london: monarch; 2000. 3. isaiah 10:2; 32:7; jeremiah 5:28. [new international version has been used unless specified otherwise]. 4. psalm 9:4; 140:12; job 36:6. 5. john 1:12. 6. 1 corinthians 9:4,5. 7. hebrews 13:10 8. romans 9:21 9. revelation 2:7; 22:14; 3:21. 10. grunlan sa, myers mk. cultural anthropology – a christian perspective. 2nd ed. grand rapids: zondervan; 1988. 11. benedict r. the chrysanthemum and the sword. usa: houghton mifflin; 1946. 12. matthew 6:1-4; matthew 25:31-46. 13. georges j and baker md. ministering in honourshame cultures – biblical foundations and practical essentials. illinois: ivp; 2016. 14. proverbs 14:31. 15. patronage: a visual explanation [internet] [cited 2019 apr 3]. available from: http://honorshame.com/patronage-a-visualdefintion/ 16. deuteronomy 17:18-20. 17. romans 13:1-7, 1peter 2:13-17. 18. hughes d, bennett m. god of the poor. cumbria: om publishing; 1998. 19. isaiah 56:11; jeremiah 23:1-2, ezekiel 34; zechariah 11:17; acts 20:28-31, 1 peter 5:2-4, jude 1:12 20. luke 12:48. 21. luke 17:11-16 22. luke 9:40-46. 23. luke 8:26-36. 24. luke 7:11-15. 25. battacharji s. low-cost effective care unit [internet]. vellore, tamil nadu, india: christian medical college; 2007. [in home of a healing god video] available from: http://www.cmchvellore.edu/gallery.aspx?pid=mainalbum 26. luke 12:15. in the message, copyright © 1993, 2002, 2018 by eugene h. peterson. used by permission of navpress. all rights reserved. represented by tyndale house publishers, inc. 27. speth g. in conversation with host steve curwood [internet] [first aired on 2015 feb 13] [cited 2018 nov 21]. available from: http://winewaterwatch.org/2016/05/we-scientistsdont-know-how-to-do-that-what-a-commentary/ 28. williams d. introducing the pain-pleasure worldview [cited 2018 nov. 20]. 2018 may 18. available from: https://au.thegospelcoalition.org/article/introducingpain-pleasure-worldview/ 29. zechariah 4:1-6. 30. revelation 22:2. 31. revelation 22:14. peer reviewed: submitted 28 nov 2018, accepted 26 mar 2019, published 31 may 2019 competing interests: none declared. correspondence: lois joy armstrong, research co-ordinator. epidemiology and research dept, duncan hospital, bihar, india. loisjarmstrong@gmail.com cite this article as: armstrong lj. health, rights and culture: some reflections on the meanings of the word “rights” from a cross-cultural health worker. christian journal for global health. may 2019; 6(1):64-69. https://doi.org/10.15566/cjgh.v6i1.269 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://en.wikipedia.org/wiki/the_chrysanthemum_and_the_sword http://honorshame.com/patronage-a-visual-defintion/ http://honorshame.com/patronage-a-visual-defintion/ http://www.cmch-vellore.edu/gallery.aspx?pid=mainalbum http://www.cmch-vellore.edu/gallery.aspx?pid=mainalbum http://winewaterwatch.org/2016/05/we-scientists-dont-know-how-to-do-that-what-a-commentary/ http://winewaterwatch.org/2016/05/we-scientists-dont-know-how-to-do-that-what-a-commentary/ https://au.thegospelcoalition.org/article/introducing-pain-pleasure-worldview/ https://au.thegospelcoalition.org/article/introducing-pain-pleasure-worldview/ http://creativecommons.org/licenses/by/4.0/ book review may 2019. christian journal for global health 6(1) global health means listening by raymond downing, manqa, 2018 adamu addissiea a md, mph, ma, phd, associate professor, addis ababa university; program leader for gender, health, and theology, ethiopian graduate school of theology (egst), ethiopia global health can help to ensure its relevance and effectiveness by continuing to monitor not just what happens to people, but especially what those people think about what’s happening to them. in other words, listen. is it possible for global health, as an enterprise, to listen to what people think and want, and blend its expertise with that? or is it too late?1 in global health means listening, dr raymond downing illustrates how listening in global health is important and timely based on his many years of experience as a physician and educator in africa. all in all, it is a terrific resource for any global health expert and specifically for those with faith-based values. dr. downing, according to his own words, is someone “stuck” in his version of global health—living where he works (not just visiting), working for health systems (not introducing new ones), and personally cooperating with colleagues (not just introducing programs and surveys). drawing from his observations at two international conferences, he describes the majority of global health programs to be also “stuck” in a technical, scientific, vertical, even imperialistic approach. though he is an expatriate caucasian-american, his over 30 years of lived and reflective experience in remote and rural parts of africa make him a person worthy of being listened to when he writes about his perspectives on global health. the book is structured into four sections. part i has chapters with reflections on global health: its definitions, understandings, and evolution. all the chapters in this part are stories and reflections on global health from the author’s own experiences in africa and observations at global health conferences. part ii deals with reflections on global health based on the author’s readings and experience related to his aids work. this part has more of an academic element. part iii contains reflections based on the author’s 10-year engagement in initiating, running, and teaching a family medicine training program at moi university in kenya, and is based on dialogue with a student from duke university. while the earlier three parts are applicable to global health in the broader sense, part iv is dedicated specifically for spiritual reflections on global health, biblical mandates, and reflections from the perspective of a medical missionary. two major themes guide the whole evolution of the book, “global health” and “listening.” the author discusses and illustrates what global health is and demonstrates the importance of listening in global health. he gives an introduction to global health concepts and terminology as well as to listening in global health followed by an overview of the whole volume. in the various sections and chapters, he discusses the evolution of terminology in global health over the years and illustrates it from his experiences. the book is a contribution to a redefinition of global health. many attempts to re-define global health have been made, for better or worse. whatever the intentions, there seems to be a growing consensus that global health needs re-thinking to enable appropriate responses to health realities in the world. dr downing makes an excellent contribution to that end. 95 addissie may 2019. christian journal for global health 6(1) dr. downing presents his thoughts about the need to listen in order to understand the other, i.e., the people whom we intend to serve in all the cycles of health and disease, between “global health scholars and activists in the west and those in receiving countries.”(p 37) his major point is that there is an absence of listening in contemporary global health practices, especially between westerners and africans. according to him, the listening approach is meant to be a natural way of doing global health and actually is not something new. it is a living principle from long ago which over time has become neglected and undermined. he emphasizes both why we need to listen and how to listen in global health. this is illustrated well with living examples of real stories about real people. the beauty of the book is that it is written on the basis of about three decades of personal reflections. this is a book not of theories but of praxis and life reflections. as i was reading his reflections, i was imagining him walking, talking, discussing, treating, etc. i felt like i was on a journey with him, at times laughing, at times questioning, and at times arguing with him. he mixes academic and journalistic styles of writing. i am convinced that readers of all walks of life such as practitioners, managers, and medical personnel will enjoy reading the book for its style, respecting the writing for its content, and strong, troubling, and challenging message. he combines a particular style of personal reflection with personal encounters from working in global health and based on his reading over the years. he begins the book with a compelling story. this illustrates how listening operates within a culture in an institution, but also at an interpersonal level, and shows the need for mediation and inner, deeper listening in the business of saving lives. while enjoying the flow of the plots in each of the chapters and the style of writing, i also was trying to grasp the point he was making. accordingly, i was able to personally gather three key messages from the book. the first was the fact that global health is beyond numbers and statistics. it is about people with real stories, about lives changed, and human nature, emotions, culture, and feelings. health defined to mean wholeness is the aim of global health—saving lives which cannot be done fully without paying attention to the deeper roots of the dangers at personal and societal levels beyond the viruses and the bacteria causing diseases. disease is beyond biology and the physical body. it is social, emotional, spiritual, economic, and cultural. healing also needs to address the whole, complete cycle of disease and its dimensions. the second point was the need for being deliberate and intentional about listening in global health. dr. downing remains critical of the persistent superiority complex by global health practitioners over the beneficiaries, which is, at its heart, a result of lack of listening. on the contrary, listening requires humility, under-standing, conviction, determination, and sacrifice. listening is arriving there with one’s whole self, ears, intentions, body, mind, sensitivity, and imagination. one needs to arrive primarily for fuller meaning, understanding, and informed action. listening is not spontaneous, but needs active effort. it does not happen passively. the third message goes to the faith-based element of global health. the last section of the book offers reflections and perspectives, as well as practical challenges to the faith-based global health community. missionary medicine and colonial medicine have failed to listen to the traditional african forms of healing over the years, and the global health trend needs to take a better approach than that. listening creates synergy between our contributions and the existing reality, including the spiritual. there are also three areas where i would offer some critique. the first is the question of generalizability of the reflection to global health. though originally from a western setting in the usa, downing’s lived experiences are mostly from his focused years providing medical missionary services in eastern africa— specifically kenya. as someone coming from a different country in the east african region, i can very well agree with his thoughtful and contextual reflections, especially as these observations explain concepts very close to my setting. this 96 addissie may 2019. christian journal for global health 6(1) makes me believe that his reflections apply mainly to the sub-saharan african context but may not fully apply to other settings. a second critique involves the varieties and levels of listening in global health in various forms. the best listening needs to be a two-way process where communication is reciprocal and complete. by the same token, listening in global health would entail listening not only from the perspective of the recipients and partners, but also the recipients listening to what global health workers bring of value. dr. downing has made good reflections on the locals’ understandings in his own words, but i wondered if added perspectives might have been evident if their own words and expressions had been used. additionally, there is listening from beyond the practitioner such as from policy makers and the leadership of international organisations and actors in global health. last, but not least, one could ask for strategies for listening in global health. are there practical tools for listening? i would have preferred a section with practical suggestions on how to listen. this made me think of a book on a similar theme by sussan vitalis, a medical missionary, on how to hear god’s direction at life’s cross roads. she included practical levels of listening to the will of god in her vocation and ministry.2 i understand that it is difficult to prescribe methods for listening to the multifaceted levels and dimensions in global health. it is also to be noted that this may have been beyond the scope of the book. possibly other experts will complement this in the future. my reviews above and conclusions below are possibly influenced by who i am, a medical doctor who worked in east africa for most of the two decades of my professional life as a clinician, then as a public health practitioner and academician. by way of conclusion, finding the right balance is my approach. the western approach to global health and healing medicine has been useful and will continue to be useful but needs to be complemented with local knowledge and supported by the existing resources to strike the right balance. i am not arguing that the traditional african approach to healing is better than the western one. rather both have their pros and cons. thus, the best approach will be to cross fertilise and find a model of care where the global is married to the local, and both are listening. this seems a very romantic idea but it is not an easy task. we all are fascinated by the importance of listening in other aspects of life such as family, work, etc. but often we fail to realise that listening is a task which does not happen by merely wishing. one needs to work intentionally to develop listening skills depending on the context, the language, and the prevailing communication techniques used locally. according to the book, listening in global health is listening to the global and the local, and requires the right attitude and intentional emotional readiness from the global health practitioner. i recommend that this book be read by all actors in the field of global health, government officials, multilateral organisations, academic entities, mission agencies, local ngos, and, last but not least, the african or developing world practitioners and decision-makers who need to be heard. i end with a quote from one of the well-read contemporary management and leadership writers, steven covey. i do wish the grace and wisdom of listening for all of us engaged in the global health arena. to relate effectively... we must learn to listen. and this requires emotional strength. listening involves patience, openness, and the desire to understand— highly developed qualities of character. it is so much easier to operate from a low emotional level and to give high-level advice.3 references 1. downing r. global health means listening. nairobi: manqa books; 2018. 2. vitalis s. still listening: how to hear god's direction at life's crossroads. idaho: elevate faith: 2017. 3. covey sr. the 7 habits of highly effective people. new york: free press, simon & schuster; 2014. 97 addissie may 2019. christian journal for global health 6(1) peer reviewed: submitted 9 feb 2019, accepted 18 feb 2019, published 31 may 2019 competing interests: none declared. correspondence: dr. adamu addissie, associate professor, department of preventive medicine, school of public health, addis ababa university; program leader for gender, health, and theology, ethiopian graduate school of theology (egst), addis ababa, ethiopia. adamuaddis@yahoo.com cite this article as: addissie a. global health means listening by raymond downing, manqa, 2018. christian journal for global health. april 2019; 6(1):94-97. https://doi.org/10.15566/cjgh.v6i1.285 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ book review may 2019. christian journal for global health 6(1) hostility to hospitality: spirituality and professional socialization within medicine. balboni mj, balboni ta. oxford, 2019 alan gijsbersa a mbbs, fracp, facham, dtm&h, pgdipepi, associate professor of medicine, university of melbourne; president of iscast, board member, international christian medical and dental association and former chairman of the christian medical and dental fellowship, australia this book argues for the integration of religion and spirituality into the delivery of health care. it is the product of a fruitful collaboration between tracy balboni, a radiation oncologist and palliative care specialist, and michael balboni, a congregational minister and sociologist. their collaboration is strengthened by the support of the harvard medical community and the longwood christian community. the latter is a post-modern monastery of healthcare students living, studying, and praying together across the street from the harvard medical school. the book has also been funded by a grant from the john templeton foundation, so it has a good pedigree. it is a great book and worth engaging with, especially engaging on those parts with which i disagree! for it is only through disagreement and dialogue that we gain further enlightenment on this important topic. the title is taken from a quote by henri nouwen, moving people from hostis to hospes, but the reference is not clear enough to be able to find the context of the quote. it is an unfortunate title, and we will need to unpack the concept of hostility below. content the book looks at the rise of modern hospital care. it explores the sociological factors informing that care and seeks to provide a place for a contribution of religion and spirituality to that care. the balbonis identify four big forces informing american hospital care: the scientific and technological dimension, the market and business dimension, the legal and bureaucratic dimension, and the hospitality and compassion dimension. they then argue that a return to religion/spirituality will strengthen the hospitality/care dimension of american hospital health delivery. the book asks three key questions: 1. why is spiritual care infrequently provided by clinicians to patients with serious illness? 2. is, and if so, how is spirituality connected to medicine’s basic social structures? 3. is partnership between medicine and spirituality/religion possible given our secular and pluralistic milieu? the first question is initially addressed by a survey of cancer patients at four hospitals associated with harvard and boston universities. these surveys show that patients are spiritual and they would like to address spiritual issues, but that they do not often have these needs addressed by their medical professionals. the balbonis list three reasons why spiritual care is so infrequently provided by medical clinicians. each reason is highly contestable. the first is that hospitals have evolved from institutions 102 gijsbers may 2019. christian journal for global health 6(1) of care to institutions of recovery and cure, with the corollary that hospitals are institutions of science and technology committed to curing people. the second reason is that physicians see themselves as scientists, and that science and religion are in conflict. the third reason is that, with the camouflaging of death, the need for religion disappears. this section closes with a discussion of the loss of religion/spirituality due to the sacred-secular divide, the separation of body from the soul, and the divide between public facts and private values. taking their cue from charles taylor’s magisterial a secular age1, they decry medicine’s immanent frame in contrast to religion’s transcendent frame. the second section of the book addresses the relation between spirituality and medicine’s basic social structures. the balbonis start by defining religion and spirituality. they define spirituality somewhat controversially as a life centred in the person(s) and or objects(s) of one’s chief love— however individually understood and pursued. they define religion as the individual and social structures that flow from and facilitate that chief love, including beliefs, practices, relationships, and organizations. they criticise those (like me!) who separate spirituality from religion. they also criticise the secular world which, according to their accounts, has no place for the transcendent and theological reasoning. but they argue that medicine needs theology. historically, hospitals have arisen on the basis of a theology of care for the sick as a noble calling from god. belief in a rational god led to the belief in a rational world which allowed for the development of a science for rational medical care. they then develop a theology of medicine, a theology they say is based on the three abrahamic faiths: judaism, christianity, and islam, for they are monotheistic. ironically, they start their theology from the hippocratic oath, a polytheistic document. they move on to the writings of judaism and ben sira, where physicians are respected, for god has called them to this task. they then look at jesus and the example of agape love in the gospels, emphasising compassion for the sick, and move on to how this was developed in the early church through the amalgamation of hippocratic medicine and christian compassion in the practice of basil of caesarea (d. 379). the balbonis identify islam’s commitment to the dignity and unity among humans and the particular merit of providing alms for those less well off, including the sick. the physician in islam is one of the wise ones, respected in islamic society. summarising their theology of medicine, they argue that god alone heals, and humans are called to be compassionate to all humans suffering illnesses. a religious vision for medicine recognises the unity of body and soul, provides hospitality for the sick in the presence of the divine, and recognises that medicines are a gift from god. the balbonis then develop a theology of the patient-clinician relationships challenging the “scientific” object-observer metaphor in favour of a more relational model. they argue that there is a sacramental nature to medicine, pointing to the transcendent nature of life. in addressing the third question, they explore the partnership of religion/spirituality to medicine, given the secular and pluralistic framework in which medicine is practised. they do this by resisting immanence and arguing for a greater transcendent world view to medicine. they address some problematic rapprochement strategies, in particular, rejecting “spiritual generalists” in favour of a religious particularist approach. they finish by appealing to end hostility to religion and arguing for the introduction of religion as a basis for developing a hospitable and caring form of medicine in the modern delivery of health care. critique there is a lot to agree with in this book. i support their overall thesis of seeking to reintroduce spirituality and religion into the delivery of clinical care, but at many points, i find that i disagree with their approach and reasoning. i am with them in 103 gijsbers may 2019. christian journal for global health 6(1) resisting reductionism with its temptation to dehumanise care by a fragmentary mechanistic approach to a person’s sickness. this occurs especially with sub-specialisation which can obstruct a holistic approach to sickness and health. i agree with them that, as christian clinicians, we need to learn how to cross the spirituality gap between the patient’s spiritual and religious beliefs on the one hand and the lack of spiritual care tools the secular clinician has on the other. i also agree with the need to develop a theology of medicine and a theology of health care. however, i find myself to be like owen barfield to cs lewis, a friend who disagrees with almost everything his friend sees and argues!2 it is disappointing that the complex practice of hospital medicine has been reduced by these authors to a unidimensional technological science driven by business and administrative dimensions. clinical medicine is a practical discipline based on science, but it is also a humanity and an art. we clinicians were taught by role models who embodied the highest values of humanity in the delivery of care to the patients. they embodied the virtues of care and concern that we sought to emulate. these mentors, whether christian or secular, took seriously their role as ‘doctors’ (the word means ‘teachers’) who taught their patients what their disease was, and how patients would manage that disease with the help of their medical carers. they created a team with care of nursing and therapy staff committed to the best outcome possible for the patient. the biopsychosocial model is more than simply a recognition that the bio, the ‘psycho’ (the greek word for ‘soul’), and the social are important dimensions in the care of patients, but the model argues that humans have multiple layers of complexity and that each of these layers interact with each other.3 good clinical practice has always recognised the need to address all aspects of the patient’s life in order to manage the clinical problem holistically. this included the human dimension, irrespective of whether the doctor believed a person had or did not have (or was or was not) a soul. there is a reduction in interest in the religious/spiritual dimension of clinical care in modern medicine, as the authors’ data shows, but i am not sure it can be blamed on a drive for cure rather than a drive for care. clinical medicine has always been about “cure seldom, relieve often, and comfort always,” and that commitment remains in spite of the loss of religious input. we need to look elsewhere to find the reason for the loss of religious input. it may go right back to the people of god forgetting moses’ injunction in deuteronomy 8:618. i have discussed the loss of religion with my secular colleagues. they agree with me that this is much more a drift of religion/spirituality into irrelevance than a hostile reaction to it, and that in spite of the loss of religion, there is still considerable humanistic care in their practice. do physicians see themselves as scientists and, therefore, in conflict with religion? both aspects of that statement are contestable. while there is a science to the art of clinical medicine, there is still the art of actual practice which cannot be reduced to science. most physicians, i suspect, have not read anything about the philosophy of science, nor is there a well thought out philosophy of the science of clinical practice. most clinicians simply practice without developing a formal statement of the science and art of what they are doing. secular hospitals usually have a formal mission, vision, and values statement expressing the ethos of what they are about, and all have a mandatory ethics committee to ensure that research on patients conforms to ethical norms. so modern secular physicians do not see themselves as scientists, nor do they see themselves as in conflict with religion;4 they simply do not see the relevance of religious commitments to their ethical clinical care. there may be some hostility to religion in some quarters, but the bulk of secular medicine regards religion as optional for those who are into that sort of thing, but largely irrelevant to the bulk of the care we deliver. i take the main thesis of the book, namely the spirituality gap between therapist and patient, but i find their explanation for 104 gijsbers may 2019. christian journal for global health 6(1) the spirituality gap as due to a scientific hostility to religion unconvincing. the humane care of the patient has figured prominently in my clinical experience both in secular and christian institutions, and there are regular articles on this human dimension of clinical care in reputable medical journals. when i was a registrar in the 1970s, elizabeth kubler-ross’s on death and dying5 was widely discussed. i recall her comment that when chaplains were called on to care for the dying, high churchmen would hide behind the sacraments and low churchmen would hide behind the bible. neither had the skills to engage with the person as a person. ross represents a secular humanistic approach to dying patients that should be highly commended, even though it contains no theology and does not discuss humans as souls. the authors blur the distinction some writers make between spirituality and religion. the balbonis simply see religion as the outward working of spirituality. i have some difficulty in the way they define spiritualty as ‘chief love’, and then in the way they uncritically accept religion as something good worth commending. i often encounter patients who say they are spiritual but not religious, and there are plenty of other thinkers in this area who are trying to include spirituality without formal religion. why not formal religion? religion, particularly now that institutional sexual abuse has been exposed, is rejected for good reasons. such a rejection is not new. the carpenter of nazareth for confronting the religion of the day, and his followers, suffered considerable religious persecution. this is not a rejection of religion, but a simple pointed comment that religion is not always beneficial. even in clinical practice, we encounter patients who have been damaged by formal religion, and proper spiritual care requires the clinician to help the damaged patient find healing in that area. and what of the concept of spirituality? the basic word ‘spirit’ is related to breath and liveliness. thus, an inspired person has lots of life, and a spirited person or animal is very lively. conversely, a dispirited person has lost their liveliness, and a person who has expired has lost their breath and is dead. the holy spirit breathes life into the dead and gives life for the future. in my area of clinical practice, addiction medicine, we often quote carl jung’s famous dictum “spritus contra spiritum” (the divine spirit driving out the spirit of alcohol) as a further exploration of the place of spirituality in addiction care. spirituality is not just about care for the dying, but a wholistic exploration of meaning and purpose for those struggling with existential questions. there are other dimensions to spirituality that need exploration. harvard psychiatrist george vaillant, in his spiritual evolution6, argued that spirituality was found in the emotions in the limbic system, rather than a rational, lexical activity. in the end, i was able to persuade dr. vaillant that the lexical and the limbic go together7 and that spirituality is not just about love but also about truth, justice, mercy, and equity. the kingdom of god is the upside-down kingdom which seeks justice for the marginalised and the oppressed. it is not just about individuals but also about humans in society. the implications of this will be explored below. the last two paragraphs might fall into the trap of regarding spirituality as good, whereas religion is bad. i do not think that. some spiritualities are bad, and some religions are good. a patient’s spirituality/religion needs more careful evaluation than either being ignored or simply affirmed. is there really hostility in secular society towards religion/spirituality? once we have a more nuanced view of spirituality and religion, we can see where some of the hostility might arise. those who have suffered abuse from priests and other religious people, or who know those who have suffered such an abuse, would well feel justified to be hostile. women, especially, have reason to feel that a hierarchical patriarchal religion deserves to be treated in a hostile fashion. however, for the bulk of my colleagues (and indeed even my christian colleagues) religious commitments are not directly relevant to clinical care. 105 gijsbers may 2019. christian journal for global health 6(1) is hostility the best description of the current situation in hospital medicine? it may be so in boston, where not so long ago puritans abused quakers. modern secular society quite rightly condemns the hanging of mary dyer and other boston martyrs. those were the days of magisterial christianity—christianity enforced and defended by state laws— and most christians these days prefer to see their faith stand on its own two feet rather than be enforced by the state. the us view of the separation of church and state has some justification, but in spite of this, for the most part, there is simply a secular indifference. to label that as hostility creates unnecessary barriers between christians and the secular world. a more thoughtful approach might well create better bridges. i have some explaining to do if i were to lend this book to my secular colleagues. the immanent/transcendent anthropology can also be contested. i looked in vain in the book’s rather scarce index to find any discussion on psychology, psychospirituality, and neurophilosophy. i agree with the writers’ contention that a diminished anthropology can affect clinical practice. thus, in the field of psychiatry if one reduces human distress to depression and sees that as a chemical imbalance of the brain, clinical care will be rather limited. humans are more than a set of chemical receptors, and human distress has personal, social, and relational dimensions. it also has a spiritual dimension. we do not need to invoke an immaterial soul to deal with this problem well. there is a vast literature on what the balbonis call the transcendent dimension of humans which does not invoke theology or a dualist anthropology. consciousness, qualia, emotions, perceptions, the sub-conscious, the exercise of reason, and the exercise of the will all spring to mind. each of these dimensions could be bundled up into what the balbonis call the soul, but this is unnecessary, and even christian neuro-philosophers suggest that the traditional understanding of the soul needs a major rethink.8,9,10 the modernist fact/value distinction is also challenged by the post-modern understanding that all facts are theory laden and that no commitment is objective and value-free. this is good news for christians for it acknowledges that there is no valuefree secular space. thus, christians can come to the secular marketplace with their commitments and expect to be respected for those commitments. this describes a secular space more in keeping with an indian society which respects and allows space for all religious commitments, hindu, muslim, christian, jain, etc., respecting the different commitments and common values, or as karl barth put it, the proclamation of christ is neither “hidden nor diluted.”11 why try to define spirituality and religion? some complex activities, like baseball (or its slower cousin, cricket) are better described than defined. spirituality is like that—the attempt to define it as one’s first love trivialises the rich complexity of the term and centres it too much on the individual. i commend the spirituality of the kingdom of god as a richer alternative, and i will explore its implications below. it is a pity that spirituality here has only been applied to the oncological population. if spirituality, as outlined above, is about liveliness, hope, meaning, justice, and truth, then spirituality should be more than just ideas applied to the end of life. i, personally, have found this to be a rich vein in dealing with addictions and mental health. i find the balbonis’ theology of medicine somewhat limited. their theology centres on three theses: 1. the human body and soul must be treated together, 2. that hospitality is the foundational motive driving clinicians and hospitals, and 3. that medicine is a divine gift. this is disappointing, for if theology (which after all was the queen of the sciences) is the science of god, then god is the subject of theology, and we need to centre it far more on god than on what we 106 gijsbers may 2019. christian journal for global health 6(1) are doing. when we do, we find that one of the central themes of scripture is that god heals. in fact, salvation and healing are closely linked. a theology of medicine has to ask questions about the relation between sin and sickness, salvation and healing. this may be difficult in the area of care for the dying, and we, as christians, need to challenge the hubris of doctors playing god, but we are still agents of hope and healing of life and purpose. we then come to the fraught issue of divine action in a mechanistic universe and how we, as spirit/flesh amphibians, stand in the interface between the seen world of the everyday and the unseen world of the kingdom of god. we also need to develop a theology of suffering and address the question of the existence of god despite suffering. i have found myself encountering non-medical thinkers trying to develop a modernist grand unified theory of everything, in this case limited to a grand unified theory of medicine, whereas we postmodernists are far more circumspect in what we think we can achieve with our patients; we know fragments only. i recently asked a very respected consultant physician interested in the history of medicine what his philosophy of medicine was. his reply, “to be humble and to learn from your mistakes.” hardly a grand unified theory but more suitable to the wisdom of the book of proverbs than a learned dissertation! i have difficulty with defining spirituality as “first love.” this leads to a find a niche of spirituality in extending the hospitality and care dimension into modern clinical practice and centring spiritual care on the individual only. but what if spirituality centred on the kingdom of god, the rule of god over every aspect of life and that that rule was characterised by righteousness, justice, mercy, truth, compassion, and equity? what if this spirituality sought to develop a body of christ here on earth committed to the rule of god in every aspect of life, including the scientific and technological, the business and market dimension, the legal and bureaucratic dimension, as well as the hospitality and compassion dimension? there is a spirituality of health delivery and the need to challenge the unjust structures, especially in the united states, where families can be only one sickness away from bankruptcy and destitution.12 christians in the us need to challenge the fear of socialism and the worship of the dollar in order to provide for the poor and the marginalised, just as god expects. bureaucratic management of healthcare is not unspiritual, it is deeply affected by justice and truth. science is about truth, and technology is about justly implementing that truth. this will require confronting unjust and devious practices like deceit in research and drug companies’ temptation to suppress adverse outcomes or false advertising. there is so much more to spirituality of health than the laudable wish by the balbonis to enhance the clinical encounter with an exploration of spirituality with the dying patient. what if we humanised medical care according to the attitudes of the one true human, jesus christ, and sought to bring about his hidden kingdom of salt and light? conclusion having laid out my reservations, may i applaud the balbonis for their work and research? they are to be commended for entering such a fraught area and raising such an important issue. i will be one with them in developing the spiritual dimension of clinical care in the secular world, and if i ever travel to boston, it would be good to spend some time in their community for mutual benefit and encouragement (romans 1:11). references 1. taylor c. a secular age. cambridge, ma: belknap press of harvard university press; 2007.p. 539-93. 2. wilson an. cs lewis, a biography. london, uk: collins; 1990.p.64. 3. engel ge. the clinical application of the biopsychosocial model. am j psychiatry. 1980;137:525-44. https://doi.org/10.1176/ajp.137.5.535 https://doi.org/10.1176/ajp.137.5.535 107 gijsbers may 2019. christian journal for global health 6(1) 4. mcgrath ae. why study history? in science and religion a new introduction. 2nd edition. oxford, uk: wiley-blackwell; 2010: 9-16. [also brooke jh. science and religion. cambridge, uk: cup;.1991]. [both authors heavily criticise the thesis that there is a conflict between science and religion.] 5. kubler-ross e. on death and dying: what the dying have to teach doctors, nurses, clergy and their own families. new york: macmillan; 1969. 6. vaillant ge. spiritual evolution: how we are wired for faith, hope and love. new york: broadway books; 2008. [231pp.] 7. gijsbers aj. book review – spiritual evolution [internet]. available from: https://iscast.org/journal/review/gijsbers_a_201006_vaillant_review 8. gijsbers aj. the dialogue between neuroscience and theology [internet] [cited 2019 mar 21]. available from: http://www.iscast.org/rough_diamonds/past_paper s/gijsbers_a_200307_neuroscience_and_theology.pdf 9. brown ws, murphy n, malony hn. whatever happened to the soul? scientific and theological portraits of human nature. minneapolis, mn: fortress press; 1998. 10. jeeves ma, berry rj. science, life and christian belief: a survey and assessment. leicester, uk: apollos; 1998. [esp chapter 10, brains, minds and behaviour] 11. barth k. god here and now. oxford, uk: routledge classics; 2003. p. 2. 12. campbell av. health as liberation, medicine, theology and the quest for justice. cleveland, oh: pilgrim press; 1995. peer reviewed: submitted 4 april 2019, accepted 17 april 2019, published 31 may 2019 competing interests: none declared. correspondence: alan gijsbers, international christian medical and dental association, australia. gijsbersaj@optusnet.com.au cite this article as: gijsbers a. hostility to hospitality: spirituality and professional socialization within medicine. balboni mj, balboni ta. oxford, 2019. christian journal for global health. may 2019; 6(1):101-7. https://doi.org/10.15566/cjgh.v6i1.299 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://iscast.org/journal/review/gijsbers_a_2010-06_vaillant_review https://iscast.org/journal/review/gijsbers_a_2010-06_vaillant_review http://www.iscast.org/rough_diamonds/past_papers/gijsbers_a_2003-07_neuroscience_and_theology.pdf http://www.iscast.org/rough_diamonds/past_papers/gijsbers_a_2003-07_neuroscience_and_theology.pdf http://www.iscast.org/rough_diamonds/past_papers/gijsbers_a_2003-07_neuroscience_and_theology.pdf http://creativecommons.org/licenses/by/4.0/ the first 1,000 days: a crucial time for mothers and children — and the world by roger thurow, hachette book group, 2016 daniel w. o’neilla a md, mth, managing editor, cjgh; assistant professor of family medicine, university of connecticut school of medicine, usa roger thurow, a senior fellow for global food and agriculture at the chicago council on global affairs, wrote this book to highlight the vital stage in the human life cycle of the formative first 1000 days (f1000d) from conception and to make the concepts tangible to the common reader. as stated in the introduction, this book supports a “revolutionary movement” (p18) to focus development resources and attention on this time period when malaria, diarrhea, and the “neglected stepchild” of nutritional deficiencies (historically <1% of international development aid and affecting half the world’s population, p 9) can have profound effects on economies and global well-being. he builds on the 2004 copenhagen consensus when economists placed nutrition strategies, especially in early childhood, as highest priory after hiv1; the 2007 world bank awakening to the f1000d as a key to “human capital development,”2 and the landmark 2007-8 lancet series on early childhood as the “critical window of opportunity,” and “an enormous unfinished agenda.”3,4 thurow advances this agenda through this book by following, in a reporter-like fashion, four specific family units embedded in communities in four corners of the earth: rural northern uganda, northern india, the highlands of guatemala, and the south side of chicago, usa. he explores the relevant science, economics, politics, and development innovations, weaving these creatively throughout the stories in a captivating narrative tapestry. he uses four sections, like acts in an epic play, to focus on the life cycles of families in these four regions from early stages of pregnancy to birth, the first year, and the second year — the critical first thousand days. part one: pregnancy he begins with an account of brenda and esther’s journey through pregnancy in uganda where micronutrient deficiencies (e.g., vitamin a and iron), particularly during pregnancy, are being addressed with world vision programs, introducing the orange-flesh sweet potato and iron-containing beans which were already demonstrating some health benefits. he then paints a vivid picture of a low caste village in uttar pradesh, a populous and impoverished state characterized by a 55% incidence of stunting (small for age due to malnutrition), a 50% incidence of anemia in pregnant women, 63 infant deaths per 1000 live births, and maternal mortality of 345 per 100,000 live births. the latter number is well above the global rate of 210. he traces the work of vishwajeet kumar, founder of the community empowerment lab at johns hopkins university. he sensed a calling to community-based empowerment to reduce these dismal statistics through addressing traditional practices rooted in the caste system, culture, and spirituality to overcome fatalism.5 thurow then introduced the characters mohana and shamkali, whose progress would be traced throughout the book. switching scenes, thurow then introduces susana menchu, an indigenous guatemalan woman and her family who were receiving training from primero pasos, a nutrition program to address the income disparities and cultural tastes of a potato 24 o’neill aug 2020. christian journal for global health 7(3) based diet leading to one of the worst malnutrition, stunting, and parasitic infestation rates in the americas. paradoxically, many other nutritious vegetables are grown and exported, and it took a concerted political will on the part of the ruling class to develop the zero hunger pact to take action on hunger and disparities. the effects are well-studied in guatemala.6 then the scene switches to patricia in innercity chicago whose pregnancy benefitted from the ounce of prevention program, her committed doula patricia, catholic charities, and mayor emmanuel’s program of correcting the poor nutrition and “food deserts” in the city — what was described as, “malnutrition amid abundance,”(p. 69) like the examples for the other countries. the messages in these stories are, “uniformly mundane — and revolutionary” (p. 74) – that investing in micronutrients during pregnancy and avoiding obesity from excessive empty calories (underand overnutrition) has profound life-cycle effects on health and survival. deficiencies in protein, omega-3 fatty acids, iron, zinc, iodine, thiamine, selenium, folate, and vitamin a and d affects fetal neurological development. the author contextualizes the approach in these countries in detail as each pregnant woman approaches their due dates, struggling to obtain quality prenatal care, adequate water, sanitation, and hygiene. he paints a picture of the extremes of limited resources in birth facility descriptions in vivid detail. part 2 – birth thurow describes the perilous birth process for these four regions in stark detail, sharing statistics on how one million babies perish per year at birth globally — usually from birth asphyxia, infection, or prematurity. simple interventions such as soap and water, resuscitation devices, antiseptic cord cleanser, antibiotics for sepsis, and steroids for premature fetal lung maturity could save many lives. immediate chest swaddling, drying the newborn to prevent hypothermia, and overcoming barriers to support breast-feeding the newborn were elaborated in each context. the economic, cultural, seasonal, and social factors that affect birth location and timing are described as a “lottery,” but are subject to intervention for improved outcomes. photos of the people described in the book make their reality and opportunity more palpable and real to the reader. part 3 – the first year this section of the book continues the chronicles that started with the death of mohana’s infant daughter in india of an infectious respiratory disease, a community bout of dysentery from a chronicallycontaminated well, and the recovery of brenda’s son after medical intervention and the subsequent challenge of malaria treatment. diarrhea killed 600,000 children in 2013 — a preventable and treatable illness. he notes that 660 million people still access unsafe water sources, and 2 billion people do not use adequate latrines or practice adequate hygiene. susy in guatemala applied standard nutrition and wash methods to avoid chronic environmental enteropathy from infants ingesting contaminated items, which leads to stunting and poor cognitive development. he then traces the innovative agricultural work of howdy bouis who championed the growth of crops designed to include needed micronutrients. the transition to solid food for these infants requires complementary feeding — diverse fruits and vegetables with breast feeding to avoid stunting and facilitate strong development. part 4 – the second year the final section emphasizes the allurement of undocumented immigration to the united states for the guatemalan family ostensibly to procure a better life for their daughter and the perils that present. jessica’s struggle continued as teen mother through public high school in chicago while retaining her aspirations for her daughter, and shyamkali’s hardworking husband, rajender, took responsibility for their 5, then 6 girls. 25 o’neill aug 2020. christian journal for global health 7(3) economic down-turns and corruption undermined the effectiveness of programs targeting the f1000d in guatemala. the key role parents play in infant and toddler cognitive and social development by “tuning in, talking more, and taking turns” and the science behind it was explained (p. 232), and thinking beyond just child survival was critical. the four acts conclude on the childrens’ second birthdays. epilogue the book ends with a hopeful but challenging plea that describes the estimated annual loss us$3.5 trillion globally caused by stunting and child malnutrition. the world bank, united nations, the gates foundation, and many other organizations have begun to focus efforts on nutrition and the f1000ds to fight intractable poverty in a multidimensional approach. the un’s ban ki-moon noted, “children are agents of change” and thurow added that, though progress is being made, and setbacks do occur, the movement will be secure if it can “grab ahold of our collective conscience.” (p. 259) assessment this book indeed appeals to the conscience, especially the christian conscience, providing four very real contexts where the importance of the f1000ds is magnified. the stories are captivating and at times heart-wrenching, although the narrative can be a little hard to follow, as it kept skipping back and forth between characters and locations. the intercalation of both global health statistics and accounts of the engagement of activists, researchers, and organizations created a compelling case for the priority of the f1000d. given his agricultural background, it is no surprise that thurow emphasizes that aspect of the f1000d throughout the book: “nutrition is the cornerstone of all development efforts.” (p. 250) the book includes a reading group guide with thought-provoking questions and a brief list of ways to get involved. many of the organizations mentioned are christian ones. although it not an academic book replete with references, it has appeal for the common reader who would desire to make a difference in the world, giving them a clearlydefined place in the life cycle to do just that. further developments since the book was released in 2016, the nurturing care for early childhood development (ecd): a framework for action and results was launched in many countries from august 2017 to may 2018.7 the ecd action network, partnership for maternal, newborn, & child health, who, world bank group, and unicef have all advanced this movement. ecd was included in the sdgs (4.2) in 2015. the landmark lancet series on ecd in 20178,9,10,11 with an added emphasis on the preconception stage of development in 201812,13 reinforced the concept that there are huge downstream effects on health, education, just societies, and job creation. a research gap exists in studying the effect of faith on the f1000ds.14 the multi-faith moral imperative convened by the world bank garnered collective will in 2018 to focus on women and early childhood for faith-based strategies in poverty alleviation.15 religious commitment’s effect on parenting is one such area being explored.16 olusanya from nigeria is a leader in prioritizing ecd by applying the best evidence for timely intervention in lics.17 deangulo from peru emphasized how christian faith can inform an emphasis on this vital developmental period, which he proposed should be considered a new paradigm for global health.18 lundie and hancox in this issue supports a much needed call for the church to play a significant role in the f1000ds.19 the first 1,000 days: a crucial time for mothers and children — and the world is an 26 o’neill aug 2020. christian journal for global health 7(3) excellent place for fbos, global health practitioners, and churches around the world to begin being sensitized to the need to become engaged with this most pressing global health need. references 1. behrman jr, alderman h, hoddinott j. hunger and malnutrition. copenhagen consensus — challenges and opportunities [internet]. 2004 feb 19. available from: https://www.copenhagenconsensus.com/sites/defau lt/files/hunger_and_malnutrition_070504.pdf 2. world bank group. early childhood development. understanding poverty [internet]. available from: https://www.worldbank.org/en/topic/earlychildhoo ddevelopment 3. grantham-mcgregor s, cheung yb, cueto s, glewwe p, richter l, et al. developmental potential in the first 5 years for children in developing countries. lancet. 2007 january 6;369(9555):60-70. https://doi.org/10.1016/s01406736(07)60032-4 4. walker sp, wachs td, gardner jm, lozoff b, wasserman ga, pollitt e, et al. child development: risk factors for adverse outcomes in developing countries. lancet 2007;369:145-57. https://doi.org/10.1016/s0140-6736(07)60076-2 5. vishwajeet kumar: tedxchange @ tedxdelhi [internet]. bill & melinda gates foundation. available from: https://www.youtube.com/watch?v=ftbxx4dgks m 6. hoddinott j, maluccio ja, behrman jr, flores r, martorell r. effect of a nutrition intervention during early childhood on economic productivity in guatemalan adults. lancet. 2008;371(9610):411–6. https://doi.org/10.1016/s0140-6736(08)60205-6 7. who. nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. 2018. available from: https://apps.who.int/iris/bitstream/handle/10665/27 2603/9789241514064-eng.pdf 8. black mm, walker sp, fernald lch, andersen ct, digirolamo am, lu c, et al. early childhood development coming of age: science through the life course. lancet. 2017;389(10064):77–90. https://doi.org/10.1016/s0140-6736(16)31389-7 9. richter lm, daelmans b, lombardi j, heymann j, boo fl, behrman jr, et al. investing in the foundation of sustainable development: pathways to scale up for early childhood development. lancet. 2017;389(10064):103–18. https://doi.org/10.1016/s0140-6736(16)31698-1 10. britto pr, lye sj, proulx k, yousafzai ak, matthews sg, vaivada t, et al. nurturing care: promoting early childhood development. lancet. 2017;389(10064):91–102. https://doi.org/10.1016/s0140-6736(16)31390-3 11. chan m, lake a, hansen k. the early years: silent emergency or unique opportunity? lancet. 2017;389(10064):11–3. https://doi.org/10.1016/s0140-6736(16)31701-9 12. stephenson j, heslehurst n, hall j, schoenaker dajm, hutchinson j, cade jf, et al. before the beginning: nutrition and lifestyle in the preconception period and its importance for future health. lancet. 2018. https://doi.org/10.1016/s0140-6736(18)30311-8 13. fleming tp, watkins a, velazquez ma, mathers jc, prentice am, stephenson j, et al. origins of lifetime health around the time of conception: causes and consequences. lancet. 2018. https://doi.org/10.1016/s0140-6736(18)30312-x 14. bartkowski j p, xu x, levin m l. religion and child development: evidence from the early childhood longitudinal study. social science research. 2008;37(1):18-36. https://doi.org/10.1016/j.ssresearch.2007.02.001 15. the moral imperative. results for children: highlevel advocacy forum on investing in early childhood development [internet]. annual meetings of the world bank and imf. bali, indonesia. 2018 sept. available from: https://jliflc.com/wp/wpcontent/uploads/2018/09/mi-bali-wb-imfannual-meetings-concept-final1.pdf 16. goeke-morey mc, cummings em. religiosity and parenting: recent directions in process-oriented research. current opinion psych. 2017;15:7–12. http://dx.doi.org/10.1016/j.copsyc.2017.02.006 17. olusanya bo. priorities for early childhood development in low-income countries. j dev behav pediatr. 2011;32: 476–81. https://doi.org/10.1097/dbp.0b013e318221b8c5 18. de angulo jm, losada ls. the emerging health paradigm in the 21st century: the formative first 1000 days of life. chr j glob health. nov https://www.copenhagenconsensus.com/sites/default/files/hunger_and_malnutrition_070504.pdf https://www.copenhagenconsensus.com/sites/default/files/hunger_and_malnutrition_070504.pdf https://www.worldbank.org/en/topic/earlychildhooddevelopment https://www.worldbank.org/en/topic/earlychildhooddevelopment https://doi.org/10.1016/s0140-6736(07)60032-4 https://doi.org/10.1016/s0140-6736(07)60032-4 https://doi.org/10.1016/s0140-6736(07)60076-2 https://www.youtube.com/watch?v=ftbxx4dgksm https://www.youtube.com/watch?v=ftbxx4dgksm https://doi.org/10.1016/s0140-6736(08)60205-6 https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf https://doi.org/10.1016/s0140-6736(16)31389-7 https://doi.org/10.1016/s0140-6736(16)31698-1 https://doi.org/10.1016/s0140-6736(16)31390-3 https://doi.org/10.1016/s0140-6736(16)31701-9 https://doi.org/10.1016/s0140-6736(18)30311-8 https://doi.org/10.1016/s0140-6736(18)30312-x https://doi.org/10.1016/j.ssresearch.2007.02.001 https://jliflc.com/wp/wp-content/uploads/2018/09/mi-bali-wb-imf-annual-meetings-concept-final1.pdf https://jliflc.com/wp/wp-content/uploads/2018/09/mi-bali-wb-imf-annual-meetings-concept-final1.pdf https://jliflc.com/wp/wp-content/uploads/2018/09/mi-bali-wb-imf-annual-meetings-concept-final1.pdf http://dx.doi.org/10.1016/j.copsyc.2017.02.006 https://doi.org/10.1097/dbp.0b013e318221b8c5 27 o’neill aug 2020. christian journal for global health 7(3) 2016;3(2):113-28. https://doi.org/10.15566/cjgh.v3i2.38 19. lundie re, hancox dm. the local church and the first thousand days of a child’s life. chr j glob health. 7(2);june 2020. https://doi.org/10.15566/cjgh.v7i2.323. submitted 15 june 2020, accepted 17 june 2020, published 5 aug 2020 competing interests: none declared. dr. o’neill is the co-chair of the evidence working group of the moral imperative. correspondence: dr. daniel o’neill, connecticut, usa. dwoneill@cjgh.org cite this article as: o’neill dw. the first 1,000 days: a crucial time for mothers and children — and the world by roger thurow, hachette book group, 2016. christ j for global health. aug 2020; 7(3):23-27. https://doi.org/10.15566/cjgh.v7i2.407 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.15566/cjgh.v3i2.38 https://doi.org/10.15566/cjgh.v7i2.323 mailto:dwoneill@cjgh.org https://doi.org/10.15566/cjgh.v7i2.407 http://creativecommons.org/licenses/by/4.0/ review article dec 2020. christian journal for global health 7(5) the changing landscape of mission medicine and hospitals in sub-saharan africa samuel adu-gyamfia, mariama marciana kuusaanab, benjamin dompreh darkwac, lucky tomdid a phd, senior lecturer, department of history and political studies, kwame nkrumah university of science and technology, ghana b phd, lecturer, department of history and political studies, kwame nkrumah university of science and technology, ghana c mphil(c) and teaching assistant, department of history and political studies, kwame nkrumah university of science and technology, ghana d ma(c) and teaching assistant, department of history, university of new brunswick, canada abstract missions have played numerous developmental roles towards the achievement of economic and social advancement including the provision of healthcare. from their entry into africa, they have employed numerous methods in order to introduce their christian faith. the construction of schools and hospitals, engagement in public health campaigns, provision of relevant services for the poor, and spearheading the provision of formal education, among others, have been the most effective mechanisms. the activities of missionaries have taken different dimensions as their scope continues to change over time. nevertheless, existing literature shows little data on the changing landscape of mission medicine and hospitals in africa. using a systematic literature review approach, the current study discusses the changing landscape of mission medicine and hospitals in sub-saharan africa. this contribution dwells partly on the missionary theory of medical practice to define most of the services of these faithbased organization (fbos) in africa. findings from the study have revealed that mission hospitals have established schools and training schemes that allow them to train medical personnel to complement the limited number of health personnel on the continent. in the twenty-first century, they have contributed to achieving the targets of the millennium development goals (mdgs) and the sustainable development goals (sdgs), especially aspects that focus on health. it is evident that while the focus, methods, and partnerships have changed, missions in healthcare have not diverted their attention from sharing the gospel of jesus christ. key words: changing landscape, christian, mission, medicine, africa, hospitals 66 adu-gyamfi, kuusaana, darkwa & tomdi introduction the humanitarian activities of missionaries over the years cannot be gainsaid. throughout history, they have played significant developmental roles without necessarily shifting from their main goal of evangelizing lost souls. from exploration to medical care, missionaries like david livingstone and cardinal charles lavigerie, among others, have played significant roles in africa to open up the interior and the people for the spread of the christian gospel.1 missionary groups employed numerous mechanisms to make disciples. they constructed schools and hospitals, engaged in public health campaigns, provided charity for the poor, and contributed cheaper social welfare programmes as their most effective tools.2, 3 the establishment of hospitals and dispensaries stood as the most effective soul-winning mechanism for many christian missions.4,5,6 their public health role has been crucial in incorporating the principles of biomedicine as a viable option in african pluralistic medical tradition. since the colonial era, medical missions have been active in most former colonies.7 among the motivations for engaging in the act of healing are spreading the gospel, making healthcare more accessible, and providing holistic care.7,8 missionary medicine and its role in africa does not involve the treatment of physical ailments alone.9 aside from that, missionaries have promoted and provided hope and encouragement for the sick.7 also, medical missionaries have provided what hardiman termed as an “all-round therapy” intended to civilize the so-called “primitive people,” getting them closer to christian modernity.9,10 thus, christian missions resorted to treating both the physical problem of diseases and the spiritual problem of sin.8 the african belief in the social causative theory, which regards diseases as the actions of demons or as a result of a misdemeanor, has resulted in the acceptance of missionary medicine and its continuous utilization.11,12 also, missionaries’ medicine has thrived in africa due to their intervention given to the poor and needy.8 the above, coupled with social changes in african societies, have informed various indigenes to embrace christianity.13 significantly, christian missionaries have used christianity as an alternative system of belief to meet both physical and spiritual needs for the sick and healthy.9,10,13 their approach, however, has been described to be mostly curative. in the case of uganda, doyle is of the view that, at their inception, missionaries used diseases and their positive rush-in to offer counselling and support as bases to win converts for christ.8,14 regardless of the above, medical missions are mostly regarded as the pioneers—and, in the early days, the only sources—of biomedicine in most areas of africa, particularly in the rural centers.15 also, since the colonial era, missionaries have made attempts, in collaboration with states, to bridge the healthcare gap between the rich and the poor.8 in effect, in africa, missionaries’ strategies have, among other things, aimed at addressing the inadequacy of the state provision of healthcare.15 a survey of key literature on mission medicine has revealed that the major areas of interest for medical missions included treating diseases tagged as unclean among africans: hanson’s disease (leprosy) and blindness, among others. they also paid attention to maternal and child health as well as public health and hygiene. in colonial tanganyika, medical missions provided vaccination campaigns, education for new mothers on hygiene, cleanliness, and the care for babies in addition to conducting research on sleeping sickness.4 some scholars associate missionary medicine with the colonial state and activities arising within the same period.14 other literature shows the various roles and motives of medical missions in africa and other parts of the world. that notwithstanding, literature on the changing landscape of mission hospitals remains scant. there exist some data on current mission medicine and hospitals.16,17,18,19,20 nevertheless, the literature has not been directed toward the changing landscape of missions and their contribution toward the attainment of sustainable 67 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) development goals (sdgs) and millennium development goals (mdgs), particularly, in the area of health. it is, therefore, imperative to reexamine missions’ changing contributions toward health delivery in africa. theoretical underpinnings of missionary medicine theoretically, there is no monolithic approach to explain and understand the activities of christian missions. many scholars have propounded varied theoretical assumptions to define the activities of christian medical missions. nevertheless, the current discourse finds the missionary theory of praxis a best fit, which holds that missions engage in medical interventions as the examples of christ in the bible.5,21 christian missions have always found it a necessary responsibility to inform people about the gospel before judgement day; christians hold the belief that christ would not return until the gospel reaches all people.22 in africa, christian missions resorted to employ strategies that would draw indigenous africans and prepare them for heaven.15, 22 one of the major strategies employed was the provision of medical care. theoreticians of mission medicine believe that missionaries, at inception, defined healthcare provision as part of christianity and a responsibility of christians arising from the bible.23 references to jesus’ holistic healing and caring for the sick, as evidenced in matthew 25 and in the parable of the good samaritan (luke 10:25– 34),21 forms the underlying ethical rationale for their medical activities.5 the theory reckons that christian missionaries have used teaching and healing, as jesus christ did, as a major prerequisite to spreading god’s love.21 to a larger extent, the theory of missionary praxis emphasizes the welfare of children. the child is used as iconography, against which missionaries provide medical care for the child and the mother.24 in africa, it was evident, in the early days, of missions as the central place of children and their mothers in christian rhetoric manifested in the provision of maternal and child care.4 within the theoretical framework, sin and suffering are intertwined.25 african physical suffering, thus, reflected the sickness of their soul.5,25 every sufferer was, therefore, regarded a sinner whose soul needed to be saved while being relieved from physical pains. this alludes to proponents’ views on disease as misery and, hence, craving for missionary medicine.4 it can be suggested that medical missionaries used the above assumptions as justification for their commitment to healthcare. this, to a larger extent, is used as a premise by some scholars to argue that missionaries mostly used medicine to win converts.4,8 following this view, a study on uganda argues that the quality of care could be limited by the decision to attain the maximum number of potential converts.8 as a strategy, some medical missions were likely to focus mostly on “where most converts could be won,” and not necessarily where medical provision was in dire need.4 since their inception in africa, the activities of christian missions in the area of healthcare have undergone significant changes over time. as a result, this study contributes to the discourse on mission medicine by discussing the continuities and changes in medical missionary praxis. the current study attends to christian medical practice as missionaries’ means of attaining a social intercourse with local people over time. essentially, in this discourse, we regard missionary theory of medical praxis as an effective therapy for both sin and physical suffering and a means of acquiring recognition among the local people. materials and methods we conducted a systematic literature review in various journals, books, and databases related to missionary medicine and their roles as well as the changing landscape in africa and other developing economies. also, references of these studies were reviewed to identify other studies worthy of contact. 68 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) we used google scholar to search for data following these themes and keywords: such as “mission medicine,” “mission hospitals,” “changing roles of mission hospitals,” “services of mission hospital,” “theory of mission medicine,” “ownership of mission hospitals,” “mission hospitals and sdgs and mdgs,” and “missions and state collaborations.” pubmed, elsevier, jstor, brill, sciencedirect, wiley, and emerald insight were other databases that were utilized. key words searched included “africa.” materials published in english that discuss missionary medicine were chosen. manual search was performed in books such as hardiman (2008),9 twumasi (1975),26 good (2004),25 and karanja (2009),27 among others. also, data was taken manually from relevant journals. we determined the praxes of missionaries and their roles in the delivery of healthcare as well as the continuities and changes of their activities over the years. information was analyzed thematically. we focused on missionary medicine and practice, ownership of mission hospitals, the kind of diseases treated, and changes in missionary medical activities and their activities which supported states to reach the mdgs and sdgs. results we reviewed over 70 sources concerning the changing roles and other points of interests of mission hospitals in africa. our focus was on missionary activities since the era of their inception to contemporary times. for a fair representation of africa, the materials are categorized under regional distributions of the continent. table (1) below shows our findings from the literature and areas covered. 69 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) table 1. findings . discussion the mission of missionary medicine aside from healing, missions have used various strategies to accomplish their goal of introducing christ to africa. initially, they established contacts with the people to build relationship before introducing them to christianity. it has been reported that missionaries first established contacts by visiting and teaching children and women bible stories and lessons.28 why women? women and children were the most vulnerable group and were more likely to be theme relevant materials regions covered theories of mission medicine vaughan, 1991; hardiman, 2006; doyle, 2015; choi, 2017; good, 2004; jennings, 2006. tanzania, asia, africa the mission of mission hospitals spencer, 2016; doyle, 2015; karanja, 2009; bhebhe, 2009; mudzanire, 2017; dirar, 2006; calvi and mantovanelli, 2019; wilkinson, 1991; adu-gyamfi and oware, 2018. zimbabwe, tanzania, kenya, eritrea, ghana services provided by mission hospitals in africa hokkanen, 2006; covey, 2001; ferngren, 1992; wilkinson, 1991; spencer, 2016; addai, 1997; doyle, 2015; mckay, 2007; hardiman, 2006; mohr, 2009; snis, 2010; adu-gyamfi and marfo, 2018; jennings, 2008. south africa, ghana, tanzania, africa, worldwide. changing landscape of mission hospital snis, 2010; grundmann, 2008; morgan, 2013; olakanmi and perry, 2006; mudzanire, 2017; fralick et al., 2019. tanzania, ghana, south africa, togo, zimbabwe staffing of mission hospitals green et al., 2002, olakanmi and perry, 2006; forrest 2009; wong, 2006; kumwenda, 2006; gilla and carlough, 2008, mclennan, 2014; katelyn, 2019; kotzee and couper, 2006; vasanthakumar, 2006; boulenger and criel, 2012. zambia, south africa, subsaharan africa, africa, cameroun. sources of income for mission hospitals wood, 1991; doyle, 2015; wood, 2001; green et al., 2002, adu-gyamfi 2019 ghana, rwanda, sub-saharan africa, south africa, tanzania shift from the emphasis on sin delkeskamp-hayes, 2006; doyle, 2015; hardiman, 2006; fursdon, 2003; dobbelaere, 1979; morhee and morhee, 2006; henshaw et al., 2008. kenya, ghana, nigeria, belgium, africa, asia extension of services wood, 2001; jehu-appiah et al., 2014; adugyamfi and oware, 2018; loewenberg, 2009; vaughan, 1991; fursdon, 2003; schmid et al., 2008; mike and makombe, 2018. ghana, kenya, zambia, malawi, zimbabwe, africa, worldwide change in ownership of mission hospitals green et al., 2002; snis, 2010; wong, 2006; wood, 2001; doyle, 2015 south africa, tanzania, ghana, liberia state and mission hospitals schmid et al., 2008; snis, 2010; loewenberg, 2006; jennings, 2006; doyle, 2015; schneppen, 2000; mike and makombe, 2008; prill, 2012, boulenger and criel, 2012, anderson, 2017. ghana, tanzania, south africa, nigeria, zimbabwe, namibia, africa, uganda, chad, cameroun, madagascar, liberia mission hospitals and sdgs mike and makombe, 2008; grundmann, 2008; munson, 2012; omorogbe et al., 2012, forrest, 2009; gilla and carlough, 2008; johanson and claypool, 2018; calvi and mantovanelli, 2019; bath, 2018; sharkey, 2002; anderson, 2017. ghana, tanzania, south africa, nigeria, zimbabwe, namibia, africa. guatemala, northern sudan, madagascar 70 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) receptive to the initial stages of missionary activities. vulnerability in this context does not necessarily reflect their propensity to receive the gospel; we use vulnerability to reflect conditions faced by women in an era of war, disease outbreak, and famine among other calamities.29 nevertheless, the teaching of women and children proved inadequate at this stage. consequently, missionaries considered different approaches in fulfilling their goals which included the use of education and medicine.8,25 the use of medicine was intended to draw people into medical centers where the gospel was shared.27 in zimbabwe, scholars reckoned that mission medicine was used as a bait to draw people to hospitals and medical centers to be evangelized.30,31 curing diseases, therefore, was instrumental in acquiring new converts among the sick and their families.32 though the use of women and children as first contacts proved inadequate, in some cases, for christian outreach, it is noteworthy that the child as a symbol of helplessness and vulnerability prompted missions to regularly direct their attention toward children. a majority of missionary medicine focused on maternal and child health. the african inland mission (aim) in colonial tanganyika, for instance, put up a maternity home at kola ndoto to educate and provide “western” birth procedures and preventive and curative medicine for the sick.4 after independence, mission antenatal clinics in tanganyika were twice the number of those constructed by the government.4 this enhanced missionaries’ contribution to maternal care. also, missionaries sometimes resorted to waiving or reducing fees for the vulnerable, needy, and the poor.8 for example, in 2003, fursdon reported that in kenya, mission hospitals had through time mainly targeted the poor, orphans, and widows within the community who were confronted with healthcare challenges.7 in uganda, too, it was reported that missionaries, in their early years, reduced and waived most of their healthcare costs based on patients’ economic status.8 this was partially attributed to a compassionate view of diseases as misery on one hand and the consideration of the poor as amenable to conversion. since people generally want to avoid and remove sickness when it occurs, the sick have always created an audience for the word of god, hence intensifying missionaries’ goal of leading new souls to the house of god.4,33 scholars have argued that the quality of care, in some instances, was proportional to what was needed to reach the maximum number of potential converts.7,8 specifically, doyle (2015) reports that missionaries in uganda provided second-grade services for africans who were seen not to be prospective converts.8 the new christian converts in africa enjoyed the services of western medicine provided by the missionaries as they were devoid of paganism.14 in this respect, medical missions contributed immensely toward the introduction of a new medical system which suppressed african indigenous systems.4,13,26 in other words, african encounters with the missionaries alienated most of the former’s indigenous practices. in contemporary times, there has been a rush in africa for what is foreign or exotic. in their current study among ghanaians, adu-gyamfi et al. (2020) reported that ghanaians in kwawu still rely on indigenous medicine, but to a lesser extent. due to the changing nature of culture, the indigenes, and especially the youth, utilize everything foreign, including biomedical practices, at the expense of indigenous practices.34 services provided by mission hospitals in africa since time immemorial, africans refer to certain diseases such as leprosy, convulsion, and epilepsy among others as unclean. historically, people afflicted with such ailments were mostly marginalized within societies.35 mission medicine responded to the needs of these neglected patients— a role similar to that of jesus’. in consonance with disease as misery, missionaries helped to relieve lepers, the blind, and the handicapped of their 71 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) maladies.6 as jesus’ healing paid attention to the lame, blind, lepers, the speechless, and the disabled, among others, missionaries resorted to the provision of hospitality care for these people to reflect jesus’ example which became the fulcrum around which soul-winning revolved.36 the presence of the various medical missions in africa ran concurrently with their activities of providing healthcare to the local populace. significantly, they served as a source of spiritual encouragement to the sick and those who were grieving.7,33 historically, some missionaries developed the view that offering any help—even if basic—was better than what the traditional medical practitioners (tmps) could provide. aside from the provision of healthcare, other medical missions trained local people to become practitioners. in madagascar, the london missionary society (lms) offered training programmes in biomedicine to local malagasy.37 in some fields, local people provided services including nursing, midwifery, and vaccination programmes. some missions refrained from the treatment of what they deemed incurable disease. their inability to treat lunacy or mental health forced medical missions in malawi to influence the government to put up asylums.6 in these circumstances, we infer that missionaries informed the colonial administration about some neglected health tasks.6 the goal was to treat common diseases as a means of establishing social intercourse with the local people. to that extent, mission medicine was twofold—serving as a means to converting the sick and promoting good health. during colonialism in africa, ghana in particular, almost all the government hospitals were situated in urban areas.38 missionaries penetrated villages to set up clinics and dispensaries.8 in sudan, missionaries were the pioneers of dispensaries in both rural and urban places.39 also, the scarcity of government medical services in rural areas compelled missionaries to supply medical care for government officials posted to these areas.6,40 in colonial tanzania, “it was the mission that became the driving force of maternal and child welfare in the territory that set the examples to be used by the colonial medical administration and allowed the colonial state to claim it was fulfilling its mandate.”4 without the services of mission hospitals in africa, the majority of the interior population would never have had a taste of and access to biomedical healthcare even to today.4,41 put differently, missionary medicine was the only option for scientific medical care for most of the africans in rural areas during the colonial era.1 at the dawn of their establishment, the agogo and elim mission hospitals in ghana and tanzania, respectively, pioneered rural medical care directed mainly toward community and lay person’s health.42 most sources argue that mission medicine, at its inception, was more curative than preventive.4,5,8,28 why curative? under christian medicine, only the patient is viewed with sympathy and as the one who needs medical and spiritual assistance and not the one who has a high likelihood of getting afflicted. until recently, missionaries mostly provided cure for the sick and not preventive mechanisms for the community as a whole. with reference to the missionary theory of praxis, the treatment of common diseases like malaria and eye and skin diseases were means to achieve their goals.5 this individualistic position is in contrast to public health laws found in the bible. for example, adugyamfi and marfo (2018) have argued that the holy bible serves as a health law.43 of seminal importance is the fact that “according to the bible health laws, the simple principle of keeping the environment clean and avoiding the intake of items such as alcohol, fat, and blood is a powerful preventive measure for complicated and lethal diseases.”43 the changing landscape of mission hospitals the history of medicine in africa has acknowledged the contribution of the activities of 72 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) medical missions prior to and during the colonial era.42 “christian religion and care of the sick have traveled a long way together in the course of history; as a result, they are now inseparable.”23 specifically, scholars argue that missionary medicine in africa began around the 1850s.1 since their inception, medical missions have been influential in the establishment of hospitals and the spread of western medicine.44 starting always with minimal beds and equipment, mission hospitals have, over the years, acquired central stage in healthcare services across africa.29,45,46 historically, early christian missionaries created western medical centers in many african and asian countries.44 over the years, mission hospitals and hospitals in general have witnessed changes in their modus operandi in the field of medicine. the following sections discuss the various transitions through which mission hospitals have gone. they include transitions in financing, staffing, shift from emphasis, extension of services, changes in ownership, and the relationship between states and mission hospitals. sources of income for mission hospitals missionaries have had varied sources of income. around the 1990s, mission hospitals were reported to use resources, especially financial resources, more rationally than any other institution.16 these resources have assisted their social and medical interventions to complement the state’s healthcare resources. church hospitals in africa now struggle to deliver quality healthcare due to less funding.47 medical institutions and hospitals are forced to charge to cope with funding shortfalls. in congo, a majority of the in-patients of church hospitals faced considerable challenges concerning their medical bills.47 before the second world war, most religious institutions relied on patients’ fees for their income.8 this discouraged the poor from attending their clinics.8 that notwithstanding, missions claimed patients were never denied treatments if they lacked the ability to pay for their healthcare.8 around the 1950s, in uganda, the medical bills of disadvantaged people such as lepers, the blind, and crippled were waived.8 to address challenges of funding, most mission hospitals in contemporary times receive funding from non-governmental organizations and international non-governmental organizations.16 this idea is stressed by green et al.: . . . sources of funding have also changed, with a shift away from a structure where the majority of external income comes from those motivated to promote religious activities to one where there is a greater contribution from secular sources such as bilateral and multilateral donors, international ngos, and national government as well as user charges.19 while outside agencies have been supporting these institutions financially and technologically, most of the african governments have provided little support.16 a study by the swiss network for international studies in 2010 revealed that the agogo presbyterian hospital in ghana and elim hospital in tanzania received funding from swiss mission’s headquarters in switzerland.42 also, it has been suggested that most mission hospitals in africa today receive subventions from government in either a formalized service agreement or on contract basis.19 historically, church health services relied on the experience of user charges as the main mode of financing and generating revenue for their activities.8 in this contemporary era, an increasing number of community based prepayment schemes operated by both churches and governments provide a source of revenue for the wider health sector.19,48 an example of this scheme is the national health insurance scheme (nhis) in ghana and the community-based health insurance scheme (cbhis) of rwanda.48 kenya, tanzania, and ethiopia among other countries in africa are following this example. 73 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) staffing of mission hospitals staffing of mission hospitals has been a challenge since the inception of mission medicine. despite the high levels of mortality among missionaries and the local population, most missionaries acted slowly in recognizing the need for training local medical personnel.19 in their earliest times, most missionary societies actively desisted from engaging medical workers not members of their society.19 earlier, mission hospitals were mostly staffed by a single doctor and his/her assistant.1 over the years, mission hospitals relied on local people as staff to deliver healthcare services to the indigenous population. certainly, as medicine has developed over time, mission hospitals have required more personnel.46 in response, missionary doctors began training local practitioners to assist them.1,49 the increasing workload on the expatriate compelled missionaries to rely solely on local experts and volunteers in their medical activities.1 in 1943, at msoro in zambia, the universities’ mission to central africa also employed local orderlies.50 some of these orderlies—including william katumbi—injected, dispensed medicine, and used a microscope to diagnose patients.50 in contemporary times, increasing demand for biomedicine and personnel have compelled missionaries to recruit national doctors not necessarily key members of their mission.47 expatriate doctors, mostly volunteers, still continue to be the backbone of most mission hospitals.20,47 the tokombere hospital, a catholic mission hospital in cameroon, depends on expatriates as a source of both personal and financial resources.51 recently, the number of long-term, expatriate, medical missionaries has declined.47 in 2001, wood reported that, after the 10-year civil war, liberia had only one expatriate doctor, and most of the mission hospitals were planning to hand-over their operations and facilities to local churches.47 one huge change in medical missions has been the transformation from medical missions into teaching hospitals. currently, many mission hospitals incorporate educational departments to train african doctors. in cameroon, the banso baptist hospital and mbingo hospital provide training for health personnel.52 the pan-african academy of christian surgeons (paacs) has been training african physicians and surgeons to beef-up the limited african medical personnel and surgeons, in particular.53 the paacs organize training programmes at several mission hospitals across africa in countries including gabon, cameroon, niger, malawi, tanzania, and kenya.53 also, the tenwek mission hospital in kenya is among others that have established schools that train students in health-related programmes. the college of health science of tenwek hospital, which started as a nursing school in 1987, continues to train kenyan registered community nurses yearly.54 the hospital still offers chaplaincy training to students enrolled on health related programmes. the main aim is to complement the medical staff of africa.54 this notwithstanding, there are still skilled personnel who act as both leaders and laborers in mission hospitals and clinics.20,47 the low number of both national doctors and foreign personnel in mission hospitals undermines the goal of extending healthcare to majority of the african population.16,47 the lack of personnel in rural south africa, where most mission hospitals in the country are located, adequately affects the delivery of healthcare.55 mission hospitals have fewer personnel because most secular hospitals receive comparatively higher remuneration.20 human resource shortages in mission medical institutions continue to pose threats to their operations. across africa, missionary health institutions find it challenging to hire experienced and well-trained medical personnel due to financial constraints and relatively higher remunerations taken by health workers in most secular hospitals.56 a shift from the emphasis on sin in the christian scheme of things, the relationship between disease and sin provides a 74 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) framework for responding to the needs of the sick to enable him to understand himself as a “subject of his disease.”56 missions have resorted to treating both the physical problem of suffering and the spiritual problem of sin.8 this in itself reduced attendance and attention to mission hospitals and the activities of medical missions. the missions were largely unhappy about practices such as polygamy. this became a deterrent for polygamists and those who did that which the missions abhorred from seeking support from same. in contemporary times, christian hospitals have limited their emphasis on medical care as a remedy for sin. with an interest in the natural causation theory, diseases are not necessarily socially constructed. scientific knowledge of disease, believed to emanate from god, needed to be applied; the indigenes needed to be disengaged from their old practices.4 without an emphasis on sin, the attention of medical missions and hospitals have shifted to disease as misery. increasing attendance at mission hospitals is taken as a positive response to this shift.8 our findings have revealed that medical missions today do not rely on “spreading the gospel” as the basis to establish new hospitals.7 with increasing secularization, most mission hospitals have limited their evangelizing mission. mission hospitals have been controlled by the codes and ethics of their mother churches. initially, these codes prohibited them from performing abortion, sterilization, artificial insemination, birth control, and family planning.57 the literature notes a breach in some of these codes due to increasing secularization and medical rationality.57 a study in ghana has reported that mission hospitals now practice both medical and surgical abortion.58 in nigeria, mission hospitals provide treatment for the complications of either an induced or spontaneous abortion performed elsewhere, not by mission hospitals.59 extension of services and focus on new epidemics after independence, mission hospitals in former colonies remained paramount in the provision of healthcare. despite their challenges, specific missions have rapidly expanded community health services.46 in ghana alone, there are about 245 hospitals controlled and owned by faith-based organizations.60 ten of such mission health centers are situated in kumase, in the asante region of ghana.13 church hospitals in contemporary times have extended their services to include the treatment of common diseases and the performance of surgical operations.17 aside from expatriate missionary doctors, african mission hospitals have also deployed national doctors not necessarily from the denomination of the specific mission.47,16 christian missions initially focused on treating the most common diseases like malaria, ailments of the eyes, and skin diseases. with sickness as an embodiment of misery, christians in africa have continued to ensure the treatment of the poor and the vulnerable who require medical attention. by 2001, missionary facilities had diversified with mission hospitals treating about half of africa’s total patients with hiv/aids.47 fursdon (2003) reported that missionaries are interested in the poor, hiv patients, orphans, and widows among other terminally ill patients as well as patients with chronic diseases and the outcasts.7 in 2009, in tanzania, st. joseph’s hospital focused on the top three causes of mortality in the country, namely, hiv/aids, malaria, and pneumonia.17 in zambia and malawi, missions have collaborated with other organizations in controlling the rise in hiv/aids epidemics.61 powell (2014) described a coalition of seven churches that provided a sustainable programme for hiv prevention and care in zambia.62 when zimbabwe recorded her first hiv/aids case in 1985, missions and their hospitals advocated for behavioral change.63 many of south africa’s aids 75 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) campaigns have been spearheaded by missionary groups.64 in ghana, the christian health association of ghana (chag) unified mission hospitals in ghana and is second to the government as the largest provider of health care, catering for 35-40% of the nation’s population.61 in zimbabwe, mission health institutions are grouped under the zimbabwe association of church-related hospitals (zach). over the years, zach has established partnerships with the government to run national programmes widening the scope of the state’s provision of healthcare and has increasingly become the primary vehicle for preventive health programmes.63 over the years, missionaries and their hospitals have been delivering training schemes to healthcare professionals in response to the epidemiologic transition across the african region. in 2018, cage and rueda reported that around 1925, some 500 indigenous nurses across 116 hospitals and 366 dispensaries were trained across the continent by missionaries.65 during the outbreak of the ebola disease in 2014: the christian health association of liberia (chal) partnered with u.s.based international medical association (ima) world health to train healthcare professionals, community health volunteers, and religious and traditional leaders on the transmission, symptoms, treatment, and prevention of ebola. the chal was also involved in procuring personal protective equipment (ppe) for health workers to prevent infection, critical to keeping healthcare centers operating . . . many government hospitals in liberia were closed due to the lack of equipment.66 in the era of the ebola outbreak, too, christian mission hospitals in liberia, nigeria, guinea, senegal, and sierra leone pioneered mass education, treatment, and provision of medical supplies for the indigenes.66 change in ownership of mission hospitals at the dawn of their establishment, most mission hospitals were managed by international missionary organizations.19 most of these facilities today are owned, managed, and staffed by the national church and local committees.42 from the 1920s, various medical stations of the london missionary society across africa were handed over to local committees.42 management of many mission hospitals is a joint venture between the church mission and government.47 another contemporary concept of hospital management era is “twining.” this explains the complex relationship between mission hospitals and their respective headquarters in europe and other parts of africa that allows technology, personnel, and financial resources to be transferred.19,47 since independence, most medical missions have been supported by the state and further incorporated into national health systems.8 the state and mission hospitals most church hospitals have now been secularized and incorporated into national healthcare systems. the christian health association of ghana (chag), an umbrella organization that coordinates the activities of all mission hospitals, is in continual liaison with the ministry of health.61 about 23% of the available hospital beds in kenya are provided by missionary hospitals.67 in cameroon, about 40% of the national healthcare is provided by missions.51 in the twenty-first century, the budgets of most missionary hospitals in africa are now provided by the state, rendering the former as mere civil servants.42 this notwithstanding, most of the hospitals have to provide a significant amount of the budget on their own. the african states have adopted various regulations to take over the missionary hospitals. in south africa, the government resorted to the relocation of mission hospitals.42 in 1961, the swiss mission in southern africa was ordered by the government to transfer 76 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) their main hospital from the elim village to a new area. subsequently, the state negotiated for the takeover of the missionary hospital through formal purchase.42 around 1950s, the south african government started to increase its financial contributions to the budgets of mission hospitals to gain control over these institutions.42 of all the missionaries in tanganyika, the catholics and the lutherans over the years developed large medical institutions that have been subsequently integrated into the medical infrastructure of tanganyika.17 in 1896, after recognizing the richness of their infrastructure, the french in colonial madagascar established formal control over the hospitals built by the london missionary society.37 missions are gradually losing their authority as the sole owners and controllers of their hospitals to contemporary governments in africa. there is a growing concern on the level of support provided by the state toward the mission medicine. although governments in africa appear to be supportive, many stakeholders of missionary medicine in africa fear a government formal control over the medical sector hitherto controlled by the missions.8,24 in the 1970s, the government of tanganyika massively nationalized most of the missionary medical centers.24 specifically, the state has transitioned the ocean road hospital in dar-es-salaam to government dominion of the hospital’s administration and operations.68 in nigeria, too, the plateau state’s government in 1975 started taking over the mission hospitals and schools.69 some states in africa today have regulations that allow missionary doctors to be transferred to any hospital within the country.42 in nigeria, most mission doctors were replaced with national doctors.69 although some missions still remain as the owners and sole controllers of their health institutions, they are contracted frequently to deliver public services that are financed by governments.44 the ministries of health in countries such as cameroon, tanzania, chad, and uganda have contracted mission hospitals to work in underserved areas.51 the contractual agreement in cameroon started from the early 2000s.51 mhike and makombe (2018) argue that “since hiv/aids epidemics and its treatment became standardized in the 1990s, the governments have targeted mission hospitals to run awareness campaigns and dispense drugs in affected rural communities.”63 the governments in namibia, south africa and most countries within the region of west africa have experienced increasing support from mission hospitals in the fight against hiv/aids.66,70,71 commencing in the 1980s, mission health institutions in zimbabwe have aided the state by spearheading the zimbabwe expanded programme for immunization (zepi), diarrhoeal disease control program (ddcp), and the national nutrition programme.63 mission hospitals and sdgs christian medicine in africa has been changing in response to a changing world. since the colonial era, the rural poor have been poorly represented in healthcare. the state’s neglect of these people subjected them to poverty and a high rate of mortality.63 in response, missionaries extended their medical activities towards the poor and often the rural poor. christian hospitals have transcended the idea of healing disease to promoting holistic health and well-being.72 significantly, it has moved from being curative medicine to preventive care.23 currently, it appears intuitive that the inadequacy of public health systems across africa, coupled with the change in disease epidemiology have cautioned christian missionaries and their hospitals to focus on preventive medicine. missionaries also promote healthy living. missions and mission hospitals, in particular, have played major roles toward the attainment of goal three of the sustainable development goals, promotion of good health for all.73 this was necessitated by campaigns and the 77 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) creation of awareness of the need for good sanitary conditions and safe drinking water.23,49 the namibia evangelical theological seminary (nets) engages in seminars on hiv/aids and its impact on society.70 during the ethnic war of 1994 in rwanda, missionaries in goma, congo (an area where about 50,000 people had died from cholera), introduced a water sanitation system to stem the spread of cholera among the rwandan refugees.74 in zimbabwe, the collapse of state-provided health services allowed mission hospitals to bridge the gaps within the healthcare sector.63 scholars argue that mission hospitals have greater access to both personnel and international resources than governments’ healthcare centers in working towards the achievement of mdg 5 (improving maternal health).20 this has enabled mission hospitals to develop training for infectious diseases.20 since its inception, they have paid special attention to training traditional birth attendants (tbas) in safe methods of delivery in africa.23 the training of local midwives has produced a considerable reduction in maternal health challenges.4,24 scholars suggest that people proximate to the location of church-based [or faith-based] health centers and hospitals do better in terms of “health habits, such as hygienic practices, maternal and perinatal care, and disease awareness.”24 mission hospitals champion proper nourishment and hygienic living conditions, “without which people would continue to become sick.”23 missionaries have pioneered human resource training, drug provision, and healthcare funding toward the achievement of sdg 3.18 churches in africa and their mission hospitals continue to advocate for the provision of care, including access to reproductive care, which is in line with sdg 5.23 research in kenya provides evidence that missionary hospitals advocate for behavioural change through periodic healthcare education aside from the provision of medical care.67 mhike and makombe (2018) show how states in sub-saharan africa increasingly deploy the services of missions and missionary hospitals to arrive at their sdg and mdg targets.63 conclusion the landscape of mission medicine and hospitals in africa is changing. since inception, missionaries in africa have deployed numerous methods for drawing members for their respective denominations. education and medical services were among the measures which became successful in winning more souls for christ. this study discusses the changing landscape of mission medicine in africa with particular attention to missionaries’ activities towards sdgs and mdgs as well as their relationship with state and african governments. the study has revealed that medical missions at inception targeted the poor, women, and children who could not afford the cost of scientific medical services. with the changes witnessed, however, missions and their hospitals have now extended their services from being only curative to offering palliative, preventive, and public health programmes. today, missionaries contribute immensely towards reduction of africa’s burden of hiv and non-communicable disease and other emerging epidemiology across the continent. in contemporary times, upon the realization of african limited personnel and medical infrastructure, missionaries have developed schools and teaching hospitals to train local personnel to complement the inadequate african healthcare personnel. their training schemes have over the years been important in the emergence of african medical and surgical personnel for both local and foreign needs. today, faith-based institutions still stand as major assets upon which most governments in africa rely concerning healthcare. funding, however, has become a major concern for these institutions as african governments provide little support for them. this notwithstanding, most mission hospitals 78 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) maintain ties with their founding boards, mostly overseas, for all forms of assistantship ranging from the transfer of monetary goods to technology and human resources. in this study, it has been reported that some mission hospitals have been nationalized by local governments with government controlling major parts of their activities. nevertheless, church health service priorities continue to be related to their mission statement and their community or denomination. references 1. olakanmi op, philip a. medical volunteerism in africa: an historical sketch virtual mentor. ama j ethics. 2006 dec; 8(12):863-70. https://doi.org/10.1001/virtualmentor.2006.8.12.mhst1 -0612 2. hoon c. between evangelism and multiculturalism: the dynamics of protestant christianity in indonesia. social compass. 2013 dec;60(4):457–70. https://doi.org/10.1177/0037768613502758 3. adu-gyamfi s, awuah db, amakye-boateng k. the economic history of health non-governmental organizations in ghana. afr rev of econ finan. 2019 dec;11(2):338-64. 4. jennings m. healing 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2006. p. 193-226. 51. boulenger d, criel b. the difficult relationship between faith-based health care organisations and the public sector in sub-saharan africa: the case of contracting experiences in cameroon, tanzania, chad and uganda. studies in health services organisation & policy. 2012;(29). available from: https://www.itg.be/files/docs/shsop/shsop29.pdf 52. christian medical fellowship (cmf). mission directory [internet]. 2020. available from: https://www.cmf.org.uk/global/hsp/?s=77 53. g4 alliance. pan african academy of christian surgeons [internet]. available from: http://www.theg4alliance.org/about-pan-africanacademy-of-christian-surgeons 54. world medical mission. tenwek hospital, banet, kenya. samaritan purse [internet]. 2020. available from: https://www.samaritanspurse.org/medical/missionhospitals-tenwek-hospital-bomet-kenya/ 55. kotzee t, couper i. what interventions do south african qualified doctors think will retain them in rural hospitals of the limpopo province of south africa? [internet]. rural remote health. 2006 sep;6(3). [about 1 pg]. available from: https://www.rrh.org.au/journal/article/581 56. delkeskamp-hayes c. sin and disease in postchristian culture: an introduction. christian bioethics: non-ecumen studies med moral. 2007 jan;12(2):1-5. https://doi.org/10.1080/13803600701290875 57. dobbelaere k. professionalization and secularization in the belgian catholic pillar. japanese j relig studies. 1979 jun;6(1/2):39-64. 58. morhee ras, morhee esk. overview of the law and availability of abortion services in ghana. gh med j. 2006;40(3):80–86. https://doi.org/10.4314/gmj.v40i3.55256 59. henshaw sk, adewole i, singh s, bankole a, oyeadeniran b, hussain r. severity and cost of unsafe abortion complications treated in nigerian hospitals. int perspec sexual repro health. 2008 apr;34(1):4050. https://doi.org/10.1363/ifpp.34.140.08 60. jehu-appiah c, sekidde s, adjuik m, akazili j, almeida sd, nyonator f, et al. ownership and technical efficiency of hospitals: evidence from ghana using data envelopment analysis. cost eff resour alloc. 2014 apr;12(9): https://doi.org/10.1186/1478-7547-12-9 61. schmid b, thomas e, olivier j, cochrane jr. the contribution of religious entities to health in subsaharan africa. [study commissioned by bill & melinda gates foundation] [internet]. unpublished https://doi.org/10.1163/002242009x12529098509803 https://doi.org/10.5167/uzh-150871 https://doi.org/10.15406/ahoaj.2018.02.00091 https://www.britannica.com/science/hospital https://www.samaritanspurse.org/medical/how-we-serve-mission-hospitals/ https://www.samaritanspurse.org/medical/how-we-serve-mission-hospitals/ http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.1058.1019&rep=rep1&type=pdf http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.1058.1019&rep=rep1&type=pdf https://www.itg.be/files/docs/shsop/shsop29.pdf https://www.cmf.org.uk/global/hsp/?s=77 http://www.theg4alliance.org/about-pan-african-academy-of-christian-surgeons http://www.theg4alliance.org/about-pan-african-academy-of-christian-surgeons https://www.samaritanspurse.org/medical/mission-hospitals-tenwek-hospital-bomet-kenya/ https://www.samaritanspurse.org/medical/mission-hospitals-tenwek-hospital-bomet-kenya/ https://www.rrh.org.au/journal/article/581 https://doi.org/10.1080/13803600701290875 https://dx.doi.org/10.4314%2fgmj.v40i3.55256 https://doi.org/10.1363/ifpp.34.140.08 https://doi.org/10.1186/1478-7547-12-9 81 adu-gyamfi, kuusaana, darkwa & tomdi dec 2020. christian journal for global health 7(5) report. arhap, 2008 may. available from: https://open.uct.ac.za/handle/11427/24388 62. powell c. working together for global health goals: the united states agency for international development and faith based organizations. christian j global health. 2014 nov;1(2):63-70. 63. mike i, makombe ke. mission and state health institutions: “invisible” public-private partnerships in zimbabwe, 1980-1999 [internet]. studia hist. ecc. 2018;44(1):1-12. http://dx.doi.org/10.25159/24124265/3330 64. burchardt m. faith in the time of aids: religion, biopolitics and modernity in south africa. london: springer; 2016. 65. cage j, rueda v. saving souls, hurting bodies: missions, health investments, and hiv prevalence in sub-saharan africa. vox. 2018 mar. available from: https://voxeu.org/article/missions-health-investmentsand-hiv-prevalence-sub-saharan-africa 66. christian connections for international health (ccih). reports from the 2014 faith-based ebola response [internet]. 2014. available from: https://www.ccih.org/cpt_resources/reports-from-the2014-faith-based-ebola-response/ 67. fort al. the quantitative and qualitative contributions of faith-based organizations to healthcare: the kenya case. christian j global health. 2017 nov;4(3):60-71. https://doi.org/10.15566/cjgh.v4i3.191 68. schneppen h. early days of the ocean road hospital in dar es salaam: from mission hospital to government hospital. sudhoffs arch. 2000;84(1):6388. 69. evangelical church of west africa. ecwa evangel hospital. 2017 aug. available from: https://en.wikipedia.org/wiki/ecwa_evangel_hospit al 70. prill t, ed. mission namibia: challenges and opportunities for the church in the 21st century. 3rd ed. nottingham: grin verlag; 2012. 71. adogame a. hiv/aids support and african pentecostalism: the case of the redeemed christian church of god (rccg). j health psy. 2007 may;12(3):475–84. https://doi.org/10.1177/1359105307076234 72. munson r. changing priorities and practices in christian missions: case study of medical missions [internet]. 2012 aug. available from: https://missionmusings.files.wordpress.com/2012/08/c hanging-priorities-in-christian-missions.pdf 73. omorogbe ve, omuemu vo, isara ar. injection safety practices among nursing staff of mission hospitals in benin city, nigeria. ann afr med. 2012 jan;11(1):36-41. http://dx.doi.org/10.4103/15963519.91020 74. kim mc. missionary medicine in a changing world [internet]. 2005. available from: https://missionexus.org/missionary-medicine-in-achanging-world/ peer reviewed: submitted 30 june 2020, accepted 15 oct 2020, published 21 dec 2020 competing interests: none declared. correspondence: samuel adu-gyamfi, kwame nkrumah university of science and technology, ghana. mcgyamfi@yahoo.com cite this article as: adu-gyamfi s, kuusaana mm, darkwa bd, tomdi l. the changing landscape of mission medicine and hospitals in africa. christian journal for global health. december 2020; 7(5):65-81. https://doi.org/10.15566/cjgh.v7i5.417 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://open.uct.ac.za/handle/11427/24388 http://dx.doi.org/10.25159/24124265/3330 https://voxeu.org/article/missions-health-investments-and-hiv-prevalence-sub-saharan-africa https://voxeu.org/article/missions-health-investments-and-hiv-prevalence-sub-saharan-africa https://www.ccih.org/cpt_resources/reports-from-the-2014-faith-based-ebola-response/ https://www.ccih.org/cpt_resources/reports-from-the-2014-faith-based-ebola-response/ https://doi.org/10.15566/cjgh.v4i3.191 https://www.ncbi.nlm.nih.gov/pubmed/11068515 https://en.wikipedia.org/wiki/ecwa_evangel_hospital https://en.wikipedia.org/wiki/ecwa_evangel_hospital https://doi.org/10.1177/1359105307076234 https://missionmusings.files.wordpress.com/2012/08/changing-priorities-in-christian-missions.pdf https://missionmusings.files.wordpress.com/2012/08/changing-priorities-in-christian-missions.pdf http://dx.doi.org/10.4103/1596-3519.91020 http://dx.doi.org/10.4103/1596-3519.91020 https://missionexus.org/missionary-medicine-in-a-changing-world/ https://missionexus.org/missionary-medicine-in-a-changing-world/ mailto:mcgyamfi@yahoo.com https://doi.org/10.15566/cjgh.v7i5.417 http://creativecommons.org/licenses/by/4.0/ abstract introduction theoretical underpinnings of missionary medicine materials and methods results discussion a shift from the emphasis on sin extension of services and focus on new epidemics conclusion references editorial aug 2020. christian journal for global health 7(3) a focus on the first 1000 days: research, collaboration, and reflection this supplemental issue gives clear focus on the early years of the human life cycle as a key to global economic, social and health development. in 2007, the world health organization’s commission on the social determinants of health recognized early childhood development (ecd), defined as prenatal to 8 years, as a “powerful equalizer” and “a critical foundation for their entire life course.” this includes the physical, social, emotional, language, and cognitive domains – strongly influencing basic learning, school success, economic participation, social citizenry, and health.1 evidence supporting this focus was emerging in 2007 from the international child development steering group and published in the medical literature.2 the importance of faith and religion on ecd was also evident in the early childhood longitudinal study.3 the impact of early childhood stimulation on labor markets followed in 2014.4 then in 2015, evidence from the joint workshop by the institute of medicine, national research council, and the centre for early childhood education and development, ambedkar university, delhi showed the need for prioritizing early childhood in any development agenda.5 in 2015, the sustainable development goals (sdgs) included target 4.2 “ensure that all girls and boys have access to quality early childhood development, care and preprimary education.” early childhood outcomes were also linked to sdgs 1 (end poverty), 2 (end hunger and improve nutrition), 3 (health for all at all stages), 5 (gender equity), and 16 (end violence against children).6 evidence continued to mount for the high value of investing in ecd for sustainable development. there is a demonstrably large downstream return on investment – effecting health, education, just societies, job creation, and poverty alleviation. key risk factors such as lack of cognitive stimulation, micronutrient deficiencies (iron, zinc, iodine, omega-3, etc), early trauma, lack of social bonding, environmental toxins, and many other factors have been identified. roger thurow identified some of these in his book the first 1,000 days, which is reviewed in this issue. dr bolajoko olusanya, a member of our editorial board and the executive director of the centre for healthy start initiative, lagos, nigeria, notes that ecd is, “considered the foundation for subsequent educational and vocational attainment at the individual level and the overall human capital and economic development at the population level.”7 in this issue she offers an excellent editorial on the subject of inclusiveness and the christian responsibility toward the young and vulnerable. the world bank group’s emphasis on human capital development for poverty alleviation and shared prosperity during this time included early childhood. in 2015, the moral imperative to end extreme poverty (mi) was formed as a collaborative which brings together religious and faith-based organizations and the world bank group into a broad forum to advance a faith-based action framework to end extreme poverty and realize sustainable development goals.8 the mi recognized that there are significant evidence and policy gaps in this focus on childhood, especially the first 1000 days. dr. o’neill has been working as cochair of the evidence working group of the moral imperative, which works with the advocacy working group to enhance the evidence base from fbos in this focus area of early childhood as an inter-faith collaborative among other things. https://journal.cjgh.org/index.php/cjgh/article/view/407/755 https://journal.cjgh.org/index.php/cjgh/article/view/407/755 https://journal.cjgh.org/index.php/cjgh/article/view/427 2 aug 2020. christian journal for global health 7(3) the academic world has begun reinforcing the ecd focus. in 2016, harvard university’s center for the developing child stated, the capacities developed during childhood are the building blocks of a wellfunctioning, prosperous and sustainable society, from positive school achievement and economic self-sufficiency to responsible adult behavior and lifelong health. when we give children today what they need to learn, develop, and thrive, they give back to society in the future through a lifetime of productive citizenship.9 we published an article by jose miguel deangulo and luz stella losada from bolivia in 2016 which gave a comprehensive summation of the emerging evidence as well as a theological perspective on high priority the first 1000 days.10 we have included a link to that article in this issue’s table of contents. further momentum for multilateral organizations and networks emerged in 2018. the who, along with the world bank, unicef, early childhood development network (ecdan),11 partnership for maternal, newborn, and child health (pmnch),12 and every woman-every child,13 published the landmark work “nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential,” launched at the 71st world health assembly in may, 2018.14 at the word bank annual meetings in bali, indonesia in october 2018, the mi met and we subsequently drafted a document “results for children: the moral imperative’s core message for action to secure wellbeing outcomes for early childhood.” this further affirmed this global trend to study and create policies at government level with the strategic cooperation and assistance of fbos and local faith communities.15 “the resourcefulness of faith, and the assets and services of faith institutions are critical to the wellbeing outcomes.”16 the goal was to sensitize and enhance local faith communities and fbos to support this important agenda and build capacity locally in each country. we are pleased to publish the first mixed methods study of its kind by ruth lundie and deborah hancox from south africa who describe the church’s key role in supporting the first 1000 days (f1000d).we hope this will stimulate more research and application at the local faith community level. building on these collaborations and bolstered by the existing evidence, we call for more study of the role of fbos and the contextualized application of the teachings of our respective faiths. this will consolidate the guidance on practical approaches to supporting families to provide nurturing care in the earliest years of life, considering policies, enabling health system, and prompting relevant actions in other sectors. we also hope it will provide guidance to countries in their decisions to scale up effective interventions, to mobilize resources, to monitor progress, and to achieve results, demonstrating clear returns on cross-sectoral investments. there remains a clear call for research and reflection on the interface between the christian faith and early childhood as formative for the good life. the incarnation gives us a revolutionary model which can change the world. jesus’ remarkable conception, loving gestation in mary, humble birth, displaced infancy under parental protection, and galilean toddler life under foreign occupation gives us all hope that despite all the risks to early life, these tender beginnings can lead to abundant life, and be shared throughout the whole world. references 1. irwin lg, siddiqi a, hertzman c. early childhood development: a powerful equalizer. final report for the world health organization’s commission on the social determinants of health. june 2007. [internet] available from: https://www.who.int/social_determinants/resources/ec d_kn_report_07_2007.pdf 2. grantham-mcgregor s, cheung yb, cueto s, glewwe pl, richter l, strupp b, and the international child development steering group. developmental https://journal.cjgh.org/index.php/cjgh/article/view/38/360 https://journal.cjgh.org/index.php/cjgh/article/view/38/360 https://journal.cjgh.org/index.php/cjgh/article/view/323 https://journal.cjgh.org/index.php/cjgh/article/view/323 https://www.who.int/social_determinants/resources/ecd_kn_report_07_2007.pdf https://www.who.int/social_determinants/resources/ecd_kn_report_07_2007.pdf 2 aug 2020. christian journal for global health 7(3) potential in the first 5 years for children in developing countries. lancet. 2007;369:60-70. http://dx.doi.org/10.1016/s0140-6736(07)60032-4 3. bartkowski, john p. ; xu, xiaohe ; levin, martin l. religion and child development: evidence from the early childhood longitudinal study. social science research, 2008, vol.37(1), pp.18-36. https://doi.org/10.1016/j.ssresearch.2007.02.001 4. gertler p, heckman j, pinto r, et al. labor market returns to an early childhood stimulation intervention in jamaica. science. 30 may 2014;344(6187):9981001. https://doi.org/10.1126/science.1251178 5. financing investments in young children globally: summary of a joint workshop by the institute of medicine, national research council, and the centre for early childhood education and development, ambedkar university, delhi. washington (dc): national academies press (us); 2015 feb 27. https://www.ncbi.nlm.nih.gov/books/nbk284690/#se c_046 6. raikes a. target 4.2. university of nebraska college of public health. [internet] available from: http://uis.unesco.org/sites/default/files/documents/targ et-4.2-early-childhood-development-sustainabledevelopment-agenda_abbie-raikes_university-ofnebraska_2016-en.pdf 7. priorities for early childhood development in lowincome countries. journal of developmental & behavioral pediatrics issue: volume 32(6), july/august 2011, pp 476-48. https://doi.org/10.1097/dbp.0b013e318221b8c5 8. world bank group. global religious and faith-based organization leaders issue call and commitment to end extreme poverty by 2030. 9 april 2015. [internet] available from: https://www.worldbank.org/en/news/pressrelease/2015/04/09/global-religious-faith-basedorganization-leaders-issue-call-commitment-endextreme-poverty-2030 9. center on the developing child at harvard university (2016). from best practice to breakthrough impacts: a science-based approach to building a more promising future for young children and families. [internet] available from: http://www.developingchild.havard.edu 10. deangulo jm, losada ls. the emerging health paradigm in the 21st century: the formative first 1000 days of life. christian journal for global health (nov 2016), 3(2):113-128. https://doi.org/10.15566/cjgh.v3i2.38 11. early childhood development action network. [internet] available from: https://www.ecdan.org/ 12. the partnership for maternal, newborn & child health. [internet] available from: https://www.who.int/pmnch/about/en/ 13. every woman every child. united nations. [internet] available from: https://www.everywomaneverychild.org/ 14. world health organization. nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. [internet] available from: https://apps.who.int/iris/bitstream/handle/10665/2726 03/9789241514064-eng.pdf?ua=1&ua=1 15. arigatou international. faith actors high level advocacy forum on investing in early childhood goes down in bali. 16 oct 2018. [internet] available from: https://endingchildpoverty.org/en/news/in-thenews/436-faith-actors-high-level-advocacy-forum-oninvesting-in-early-childhood-goes-down-in-bali 16. moral imperative. results for children: the moral imperative’s core message for action to secure wellbeing outcomes for early childhood. october 2018. [internet] available from: https://www.ccih.org/wpcontent/uploads/2018/10/moral-imperativestatement-2018.pdf http://dx.doi.org/10.1016/s0140-6736(07)60032-4 https://doi.org/10.1016/j.ssresearch.2007.02.001 https://doi.org/10.1126/science.1251178 https://www.ncbi.nlm.nih.gov/books/nbk284690/#sec_046 https://www.ncbi.nlm.nih.gov/books/nbk284690/#sec_046 http://uis.unesco.org/sites/default/files/documents/target-4.2-early-childhood-development-sustainable-development-agenda_abbie-raikes_university-of-nebraska_2016-en.pdf http://uis.unesco.org/sites/default/files/documents/target-4.2-early-childhood-development-sustainable-development-agenda_abbie-raikes_university-of-nebraska_2016-en.pdf http://uis.unesco.org/sites/default/files/documents/target-4.2-early-childhood-development-sustainable-development-agenda_abbie-raikes_university-of-nebraska_2016-en.pdf http://uis.unesco.org/sites/default/files/documents/target-4.2-early-childhood-development-sustainable-development-agenda_abbie-raikes_university-of-nebraska_2016-en.pdf https://doi.org/10.1097/dbp.0b013e318221b8c5 https://www.worldbank.org/en/news/press-release/2015/04/09/global-religious-faith-based-organization-leaders-issue-call-commitment-end-extreme-poverty-2030 https://www.worldbank.org/en/news/press-release/2015/04/09/global-religious-faith-based-organization-leaders-issue-call-commitment-end-extreme-poverty-2030 https://www.worldbank.org/en/news/press-release/2015/04/09/global-religious-faith-based-organization-leaders-issue-call-commitment-end-extreme-poverty-2030 https://www.worldbank.org/en/news/press-release/2015/04/09/global-religious-faith-based-organization-leaders-issue-call-commitment-end-extreme-poverty-2030 http://www.developingchild.havard.edu/ https://doi.org/10.15566/cjgh.v3i2.38 https://www.ecdan.org/ https://www.who.int/pmnch/about/en/ https://www.everywomaneverychild.org/ https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf?ua=1&ua=1 https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf?ua=1&ua=1 https://endingchildpoverty.org/en/news/in-the-news/436-faith-actors-high-level-advocacy-forum-on-investing-in-early-childhood-goes-down-in-bali https://endingchildpoverty.org/en/news/in-the-news/436-faith-actors-high-level-advocacy-forum-on-investing-in-early-childhood-goes-down-in-bali https://endingchildpoverty.org/en/news/in-the-news/436-faith-actors-high-level-advocacy-forum-on-investing-in-early-childhood-goes-down-in-bali https://www.ccih.org/wp-content/uploads/2018/10/moral-imperative-statement-2018.pdf https://www.ccih.org/wp-content/uploads/2018/10/moral-imperative-statement-2018.pdf https://www.ccih.org/wp-content/uploads/2018/10/moral-imperative-statement-2018.pdf references case study nov 2020. christian journal for global health 7(4) adaptation to virtual congregational peer recovery groups during covid-19 jason paltzera, jason jonkerb a phd, assistant professor of epidemiology, baylor university, united states of america b crosswalk ministries, united states of america abstract: complex humanitarian disasters and emergencies like covid-19 can disrupt needed mental health services such as substance use recovery programs. physical distancing requirements can further exacerbate existing mental health disorders or initiate additional ones. individuals benefiting from congregational peer recovery programs can find themselves in a state of extreme stress and be at an increased risk of relapse. transitioning to virtual platforms can help congregational peer recovery groups maintain a connection with group participants, share spiritual and physical encouragement, and mitigate potential relapse. this case study identifies the concerns and benefits of virtual recovery groups and the potential for hybrid groups moving forward. key words: congregational peer recovery, covid-19, virtual, alcohol use disorder introduction according to the world health organization, three million deaths annually are associated with alcohol misuse.1 increased alcohol misuse is associated with times of severe stress due to neuroadaptations in the stress/reward pathway feeding back to even greater cravings for alcohol.2,3 the coronavirus disease 2019 (covid-19) pandemic is a time of unknown, severe, chronic stress for individuals that may initiate or exacerbate existing alcohol misuse or increase the risk of relapse among those in recovery. as high stress levels continue during and after the peak of the pandemic related to experiencing severe illness, death, or unemployment, many individuals will likely progress further into harmful substance use as a coping strategy.3 in addition, humanitarian disasters like covid-19 can disrupt needed mental health services such as substance use recovery programs. religiosity, religious service attendance, and faith-based peer recovery programs are important protective factors against alcohol or other drug misuse.4-6 a congregational peer recovery program is defined as a program facilitated through a faith community mobilizing the resources of the congregation including religious beliefs and values to guide participants through their recovery. a peerbased model is used to create trust and acceptability from the beginning. evidence-based practices, from psychology and sociology, are incorporated that 29 paltzer & jonker nov 2020. christian journal for global health 7(4) support the congregation’s beliefs. this short report will briefly review the empirical evidence for these protective factors, describe a faith-based peer recovery model that leverages these protective factors, discuss acceptability of a virtual meeting adaptation due to covid-19, and share implications for future research. religiosity and recovery the study of religion has resulted in a strong evidence base for the salutary effects of religiosity and religious participation on health and wellbeing.5,7 in a recent study, chen and colleagues found that women who attended religious services at least once per week had a 68 percent lower hazard of death from suicide, unintentional alcohol or other drug overdose, and chronic liver disease and cirrhosis and 33 percent lower hazard among men.7 studies have found religiosity to be important for individuals in recovery as a pathway to social support, connection to a higher power, feelings of gratitude, and engagement with grace and forgiveness.5,8 in fact, a systematic review of studies on religiosity and substance abuse found significant reductions in substance use along one or more dimensions of religiosity.9 religion is an important source of coping and professional support. in some contexts, clergy are contacted at higher proportions than mental health professionals and psychiatrists among individuals seeking help for behavioral and mental health conditions.10 leveraging religiosity, religious service attendance, and participation with congregational groups are important aspects to protect against stress-induced increases in alcohol and other mental health disorders. given the desire to seek assistance from clergy, minimal evidence and literature is available on congregational peer recovery programs. twelve step facilitation (tsf) groups, the model for alcohol anonymous, has been the focus of most studies in this space. a recent cochrane review found that a manualized tsf program resulted in 42 percent abstinence the year following treatment compared with 35 percent in a cognitive behavioral therapy (cbt) program.11 the authors suggest that most of the difference is due to the manualized tsf emphasis on attending associated programs following treatment.11 however, other faith-based or congregational peer recovery programs such as celebrate recovery and resilient recovery have not been studied systematically. initial studies of the living grace groups (now called transform groups) support the use of congregation-based recovery services in reducing psychiatric symptoms alongside improvements in recovery and spirituality (based on the theistic spiritual outcome survey).12 such congregationbased peer recovery groups offer individuals in recovery with a culturally appropriate peer group, consistent engagement with grace through the group, and connections for subsequent referrals and resources for additional services such as food and health screenings.12 resilient recovery groups resilient recovery is a faith-based, peer-led, weekly, support group model designed by a professional counselor and a pastor from crosswalk ministries in arizona. resilient recovery started in 2012 and currently includes three groups in three states in the united states of america. since 2012, approximately 300 individuals have interacted with resilient recovery through local groups or the national retreat. the groups are guided by a publicly available workbook called “the ultimate guide to resilient recovery.” the workbook includes 18 lessons that focus on grace, forgiveness, and healthy reliance on god, rather than putting pressure on individuals with addictions to change things outside of their control. even though resilient recovery used faith-based content, groups are open to individuals of all faiths as well as the non-religious. partnerships are established with local residential treatment centers, which refer individuals to the group based on individual interest. each lesson is introduced through a passage from the bible, a main point related to recovery, meditation on biblical law and gospel, pronouncement of the gospel, and tips 30 paltzer & jonker nov 2020. christian journal for global health 7(4) and traps to consider for the week. the balance and integration of a christian law-gospel approach is a unique aspect of resilient recovery compared with other twelve step facilitation models. this short report highlights one example of a resilient recovery group from maricopa county transitioning from face-to-face to a virtual format as an adaptation strategy associated with covid-19 physical distancing guidelines. methods in reaction to the physical distancing guidelines to prevent the spread of covid-19, a resilient recovery group of 15 members stopped meeting for a period of three weeks. following the three-week hiatus, virtual meetings commenced over a premium zoom video conferencing account. the premium account offered fewer restrictions regarding time limits and number of attendees while being available through desktop, laptop, or mobile platforms. thirteen of the 15 members continued to attend the virtual group. a qualitative research strategy was used to assess the feasibility and acceptability of transitioning to a virtual platform. over the initial three weeks, the peer facilitator used an observational and unstructured focus group approach to gather information regarding the feasibility and acceptability of the virtual meetings. the facilitator conducted a thematic analysis to identify common benefits and concerns generated from the focus group. the information used for this report was collected anonymously as part of an informal evaluation of the group transitioning from a face-to-face to a virtual platform. an irb review was not required since individual-level outcomes or behaviors were not collected as part of this process evaluation. results concerns initial concerns included limited access to the internet and limited proficiency with technology. privacy issues were also voiced by some participants given the sensitivity and legal nature of issues related to discussing topics of recovery and relapse. some members lamented the loss of physical proximity and the ability to see everyone, hug one another, or sing together. one participant commented, “i keep hearing that the group sang in person. why can’t we still do that? we could sing with a youtube video you share on your screen for all of us.” another commented, “i’d like to see the person speaking when the question is open to the group.” those calling into the group may not have video capacity resulting in the loss of visual connection for those individuals. these concerns suggest that virtual groups fill some needs but may require face-to-face components to allow participants to experience actions of acceptance and forgiveness in addition to words of acceptance and forgiveness. individuals with past physical or emotional abuse may distrust individuals in their social network, and such physical acts become important to start building trust-based relationships to support recovery efforts. benefits most of the group affirmed the effectiveness of virtual meetings. even those who could only attend by phone because they lacked internet access expressed that the groups were helpful. all members supported the continued use of virtual meetings as an adjunct to in-person meetings when physical distancing restrictions are lifted. participants reported that without the virtual meetings, they would not have access to a recovery group syntonic to their religious convictions. a virtual participant commented, “we can meet with people who need resilient but don’t live in the phoenix metro area. it is a safe gathering for sharing. most of all, it is a group grounded in the savior.” perceived benefits of the virtual groups were 1) inclusion and participation by individuals from diverse parts of the city and from other states, 2) reduced driving time for individuals living more than 30 minutes from the group’s physical location, 3) the return of individuals who had moved away from the location where the physical group was being held, and 4) the ability to 31 paltzer & jonker nov 2020. christian journal for global health 7(4) form a virtual community around the resilient recovery program’s core philosophy for ongoing support in between meetings. discussion the stated concerns suggest the importance of ensuring privacy, which was being addressed by and included some aspect of face-to-face, physical interaction alongside virtual group meetings. having complementary access to a known and supportive group when physical attendance is a barrier may increase the effectiveness of faith-based recovery groups and should be studied further. individuals going through recovery may experience frequent moves and disruption in care and support. remote access to virtual or hybrid congregational peer support groups could increase the continuity, compliance, and long-term effectiveness of a participant’s recovery as the individual is already known by the members of the group with established trust and congruence in religious beliefs. physical attendance may prove to be necessary for sustainability and greater effectiveness given the needs to experience actions associated with forgiveness, acceptance, and grace, critical components of the recovery pathway. behavioral outcomes associated with this transition were not collected for this short report, and additional research is needed to evaluate the comparative effectiveness of virtual groups relative to traditional face-to-face groups and hybrid peer recovery groups. conclusion the covid-19 pandemic has forced peer recovery groups to consider alternative options in order to continue providing support. the resilient recovery program explored the option of virtual group meetings through an unstructured focus group, which proved to be an acceptable and feasible model for facilitating congregational peer recovery groups. the concerns included privacy and connectivity issues. the benefits included greater accessibility and inclusion, especially among those that move away from their known group, reduced drive time, and the opportunity to maintain social connection in between group meetings for ongoing support. the information in this short report suggests that a hybrid congregational peer recovery model may be as or more effective than traditional face-to-face peer groups and deserves greater study. references 1. world health organization. global status report on alcohol and health – 2018 [internet]. poznyak v, rekve d, editors. geneva, switzerland; 2018. available from: https://www.who.int/substance_abuse/publications/gl obal_alcohol_report/en/ 2. koob g, kreek mj. stress, dysregulation of drug reward pathways, and the transition to drug dependence. am j psychiat. 2007;164(8):1149-59. https://doi.org/10.1176/appi.ajp.2007.05030503 3. clay jm, parker mo. alcohol use and misuse during the covid-19 pandemic: a potential public health crisis? lancet public health. 2020;5(5):e259. https://doi.org/10.1016/s2468-2667(20)30088-8 4. grim bj, grim me. belief, behavior, and belonging: how faith is indispensable in preventing and recovering from substance abuse [internet]. j relig health.2019 jul 29; 58:1751-2(2019). https://doi.org/10.1007/s10943-019-00898-4 5. vanderweele tj. religious communities and human flourishing. curr dir psychol sci. 2017;26(5):476-81. https://doi.org/10.1177/0963721417721526 6. chatters lm. religion and health: public health research and practice. annu rev public health. 2000;21:335-67. https://doi.org/10.1146/annurev.publhealth.21.1.335 7. chen y, koh hk, kawachi i, botticelli m, vanderweele tj. religious service attendance and deaths related to drugs, alcohol, and suicide among us health care professionals [internet]. j amer med assoc psychiat. published online: 2020 may 6.. https://doi.org//10.1001/jamapsychiatry.2020.0175 8. vanderweele tj. activities for flourishing: an evidence-based guide. j posit school psychol. 2020;4(1):79-91. available from: https://www.journalppw.com/index.php/jppw/article/ view/163 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 32 paltzer & jonker nov 2020. christian journal for global health 7(4) 9. chitwood dd, weiss ml, leukefeld cg. a systematic review of recent literature on religiosity and substance use. j drug issues. 2008;38(3):653-688. https://doi.org/10.1177/002204260803800302 10. wang ps, berglund pa, kessler rc. patterns and correlates of contacting clergy for mental disorders in the united states. health serv res. 2003;38(2):64773. https://doi.org/10.1111/1475-6773.00138 11. kelly jf, humphreys k, ferri m. alcoholics anonymous and other 12-step programs for alcohol use disorder. cochrane database of systematic reviews. 2020(3) art. no.: cd012880. https://doi.org/10.1002/14651858.cd012880.pub2 12. rogers eb, stanford ms. a church-based peer-led group intervention for mental illness. ment heal relig culture. 2015;18(6):470-81. https://doi.org/10.1080/13674676.2015.1077560 peer reviewed: submitted 3 aug 2020, accepted 24 aug 2020, published 9 nov 2020 competing interests: none declared. correspondence: jason paltzer, baylor university, united states of america. jason_paltzer@baylor.edu cite this article as: paltzer j, jonker j. adaptation to virtual congregational peer recovery groups during covid-19. christ j glob health. november 2020; 7(4):28-32 https://doi.org/10.15566/cjgh.v7i4.431 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v7i4.431 about:blank introduction religiosity and recovery resilient recovery groups methods results discussion conclusion references original article may 2019. christian journal for global health 6(1) spiritual care visualized john s. lunna a vicar, pastor, grace episcopal church; chaplain, hospice hawaii, united states of america abstract years ago, the author was asked by a prominent palliative care leader if spiritual care could be conveyed in a ladder format as pain management had been by the world health organization (who). many practitioners think about spiritual care as a way to identify and address spiritual distress. it is a way to address spiritual distress and so much more. in this article, an attempt has been made to depict spiritual care visually. spiritual care providers and others will tell you that along with spiritual distress, there is also a powerful resource that spirituality provides. the spiritual care ladder endeavors to show both aspects, along with their relationship to one another and their interconnectedness. this is not a resource for assessing spirituality; it is meant to help people better understand it and to visualize it so that the tools will be more helpful. several valuable tools have been included in this article for the assessment of spirituality and faith components of a person’s life. key words: spiritual care, palliative care. introduction in 1986, the world health organization (who) developed a three-step ladder (figure 1) to help doctors and other medical professionals to picture and treat cancer pain in a simple and systematic way.1 this article will begin to develop a ladder to address spiritual care with this model in mind. the idea of creating a visual instrument for the spiritual component is both intriguing and intimidating. the typical three step ladder, which is used around the world for physical pain management, has worked well as an image for understanding pain levels and interventions. a spiritual care graphic will require a different kind of look to better appreciate the interplay involved. we may start with spiritual issues and problems, but then we need to find space for another attribute. figure 1 27 lunn may 2019. christian journal for global health 6(1) spiritual care is also about making use of one’s deepest resources to cope with and deal with the challenges of life, including that of a terminal illness—of impending loss. so, could we think about three steps up and three steps down? one set of three represents the spiritual resources and the spiritual foundation of our lives, and the other set of three represents the challenges and/or pain that can result from that foundation being shaken/threatened. which one is up and which one goes down? how can we see the integral relationship between them? the steps are meant to be a guide that helps us connect to or engage with a person’s story. we start where the patient is when we encounter them. the pain relief ladder uses a predominately pharmacologic approach. if the pain is moderate, then we try this, this, and then this. a spiritual care model will look at the physical, the psychosocial, and spiritual aspects as interdependent. culture, community, and family will impact the situation and the outcome. the model offered here will have a christian leaning. it can also be used as a basic model, with slight adaptation, with any faith group or even with someone who is “spiritual, but not religious.” (arguably it could be used with an atheist as well.) the basic concepts are universal, whereas the supporting examples will mainly come from one tradition (in this case, christian). developing a model the model that will be used here is known as the penrose stair2 (or what mc escher called “ascending and descending”) as our representation of the spiritual care ladder. roger penrose, its creator, and mc escher, an artist who developed it, spoke of it representing the “impossible”—a stairway that perpetually ascends or descends. by utilizing such a model, we can more easily visualize the three steps of faith or belief that act as spiritual foundations. we can also visualize spiritual issues and challenges, and see their ultimate connection, their basic relationship. the apostle paul suggests a similar idea in relation to the christian hope when he tells us in romans 5:34 (nrsv)3,, “we also boast in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope.” there is a paradoxical (or we could say impossible or at least puzzling) relationship between faith and doubt, strength and weakness. spirituality and faith let us begin with the three steps of faith or belief. here, we travel not so much to the height as to the depth of that faith/belief as we move from 1 to 2 to 3. it could look something like this (figure 2):  3. being core/foundational beliefs, grounding, glue of our life.  2. practicing practical beliefs, some may be untested by the person.  1. knowing meaningful practice/ ritual. in the first step—meaningful practice/ritual— we could include prayer, sacraments (baptism, communion, and anointing), worship, scriptures, readings, religious services, and devotional time. one could also add many more. figure 2 28 lunn may 2019. christian journal for global health 6(1) the second step—practical beliefs—might include confession and forgiveness, expressing and accepting love, trust in god’s grace and love (romans 8.28: “we know that all things work together for good for those who love god, who are called according to his purpose.”) in the third step—core/foundational beliefs— things like god is love, god is just, god is omniscient, omnipotent, and omnipresent (“knows all things,” “all powerful,” and “present everywhere”) and the belief in grace, hope, love, and faith might be included. these three steps are interconnected. the strength of that connection will depend on the foundation—on step three. here, we are reminded of jesus’ parable about the two houses—one built on rock and one built on sand. ritual, practice, and practical beliefs will withstand the “storms” of life if they have a solid foundation at their core. it does not mean that they will not be shaken or tested, but they will remain. if the core is poor, the steps might not withstand the storm, and a true “crisis of faith” may result. the good news for christians is that god can change that sandy foundation into stone; we will examine this further as we look at how, as paul suggests in romans 5, “suffering produces... hope.” spiritual distress now, let us look at the three steps of spiritual issues, challenges, and problems. (figure 3) as seen in step one — the initial question is most often “why?” or “why me?”  3. despair there is no god. life isn’t worth living. i am alone.  2. sorrow/separation god has abandoned me. i feel out of control.  1. question/confusion why? why me? it starts with “why.” the first step is “why? why me?” as we begin to face the reality that we have a lifethreatening illness and may die soon, we often start to wonder why it is happening to us. this is human; this is normal. this is a question that cannot be answered by someone else. it is a question that invites us to explore our depths. at this step, the primary intervention on the caregiver’s part is “listening.” the philosopher epictetus said, “we have two ears and one mouth so that we can listen twice as much as we speak.”4 here, our words should be sparse—used to help the person clarify their question and maybe remind them of the resources that are at hand. this may include scripture, other inspirational books, music, and the arts. for many, the end result of this questioning is shifting to a new question—one like “what now? the second step is “god has abandoned me.” this could be seen as one of the answers to the “why” question—“this has happened because god has abandoned me.” for some reason, this inner questioning has not provided a satisfactory or acceptable answer; it has not come up with a new direction or question to follow. again, the primary intervention on the caregiver’s part is “listening.” this may be the time to refer to a spiritual care figure 3 29 lunn may 2019. christian journal for global health 6(1) counselor or other counselor. they will explore the feelings behind this sense of abandonment and will try to help the person move in the direction of “what now?” the third step is “there is no god.” or “i am alone.” this comes from the depth of the soul, a place that, for the moment, feels empty and vacant. st. john of the cross, a 16th century carmelite, referred to this kind of experience as the “dark night of the soul.”5 can we get to this place if we have a solid foundation? of course we can. jesus asked this question from the cross, “my god, my god, why have you forsaken me?” (matthew 27:46b) jesus was in this place on the cross. this can be a place of growth, a place where we explore what we can trust, who we can trust, and what is actually meaningful and, therefore, consequential in our lives. “listening” remains the primary intervention, but this listening may need to be by a “trained listener” (e.g., palliative care/hospice chaplain, spiritual director). this place requires work and sorting out. it is a time of soul searching—deep and often painful soul searching. henri nouwen suggests the following: but what i would like to say is that the spiritual life is a life in which you gradually learn to listen to a voice that says something else, that says, “you are the beloved and on you my favor rests.” i want you to hear that voice. it is not a very loud voice because it is an intimate voice. it comes from a very deep place. it is soft and gentle. i want you to gradually hear that voice. we both have to hear that voice and to claim for ourselves that that voice speaks the truth, our truth. it tells us who we are. that is where the spiritual life starts — by claiming the voice that calls us the beloved.6 in i kings 19:11b-12, we read of elijah meeting god. “now there was a great wind, so strong that it was splitting mountains and breaking rocks in pieces before the lord, but the lord was not in the wind; and after the wind an earthquake, but the lord was not in the earthquake; and after the earthquake a fire, but the lord was not in the fire; and after the fire a sound of sheer silence.” in the kjv we read, “a still small voice.” one struggle with the model is where to place steps 1 and 3 on the model. an argument can be made for either placement—at the top or the bottom. there is a mysterious connection between the challenges that we face and the source of grace, hope, love, and faith in our lives. it is in this space that we profoundly encounter god. in the penrose stair, this space has been highlighted between the two sets of three steps. towards meaning and transcendence in its depth (shown in purple/dark shading), there is a connection between the challenges we experience and our core beliefs. (figure 4) those core beliefs provide a foundation from which doubt, questioning, and anger can be encountered. ultimately, this is where growth is possible. it is in this space that spiritual transformation takes place. i hearken back to paul in romans 5:3-4 “... we also boast in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope.” this is one way to understand that “back stairway” between our sufferings and our strengths. it is where suffering comes to be hope, where beliefs connect with experience. some people may find the image of the biological process of metamorphosis more helpful. figure 4 30 lunn may 2019. christian journal for global health 6(1) here an egg becomes a caterpillar becomes a chrysalis becomes a butterfly, changing from one stage to the next. in the biological metamorphosis, the progression seems foreseeable. in a spiritual metamorphosis, that path is far less predictable. there are so many variables, some understood, many not. it seems a contradiction, but many of our core beliefs have their beginning in such encounters with doubt, questioning, and anger. friedrich nietzsche said, “that which does not kill us makes us stronger.”7 viktor frankl said, “live as if you were living a second time, and as though you had acted wrongly the first time.”8 here are a few other thoughts in relation to this concept: doubt isn’t the opposite of faith; it is an element of faith. paul tillich god always answers in the deeps, never in the shallows of our soul. anonymous9 and from the scripture, “now faith is the assurance of things hoped for, the conviction of things not seen.” (hebrews 11:1) [fr. mark stelzer suggests taking] a different approach with our pain. what if instead of running from our pain, we paid attention to it? what if we listened to our pain “to know what god is saying to us?” what if we acknowledged that our pain, whatever its source, is not the final word? what if we trusted that even in the midst of our pain, god loves us and is working in us?10 essential principles in applying the ladder when we talk about pain management from the ladder, we also acknowledge five essential concepts in the who approach to drug therapy of cancer pain. i want to put them alongside five essential concepts to spiritual care (table 1): table 1. comparison of five essential concepts pain relief ladder (who) 11 spiritual care by the mouth by the ear – listen with a non-judgmental and open presence. by the clock throw out the clock. people need time. offer regularly by the ladder by the penrose stairs for the individual for the individual in the context of their community. (each person’s experience is unique.) with attention to detail with attention to strengths and resources spiritual listening is the key concept here. this listening can be aided by practice in this type of listening, reading, and study of various spiritual practices, tenets, and beliefs. it is important to have self-awareness, that is, being aware of what is important to you and your spiritual journey and/or practice. examples of assessment tools fica in palliative care, as in other areas of medicine, there are many different assessment tools. an early contribution to assessing the spiritual component was made by christina puchalski, george washington university, when she developed a questionnaire that she used to teach health care professionals how to obtain a spiritual history. the acronym she used is fica: 31 lunn may 2019. christian journal for global health 6(1) faith and belief “do you consider yourself spiritual or religious?” or “is spirituality something important to you,” or “do you have spiritual beliefs that help you cope with stress/difficult times?” (contextualize to reason for visit if it is not for a routine history). if the patient responds with “no,” the health care provider might ask, “what gives your life meaning?” sometimes patients respond with answers such as family, career, or nature. (the question of meaning should also be asked even if people answer “yes” to spirituality.) importance “what importance does your spirituality have in your life? has your spirituality influenced how you take care of yourself, your health? does your spirituality influence you in your healthcare decision making? (e.g., advance directives, treatment, etc.)” community “are you part of a spiritual community?” communities such as churches, temples, mosques, or a group of like-minded friends and family, or yoga can serve as strong support systems for some patients. this can be explored further: “is this of support to you and how? is there a group of people you really love or who are important to you?" address in care “how would you like me, your healthcare provider, to address these issues in your healthcare?” (with the newer models including diagnosis of spiritual distress, “a” also refers to the assessment and plan of patient spiritual distress or issues within a treatment or care plan.)12 this tool allows the health care provider to explore the spiritual aspect of a patient’s life and receive from the patient their desire for utilizing these resources through the assistance of the health care team. this is something that may need to be revisited from time to time to see if the person feels the same way about accessing these means. hope another tool, developed for medical doctors, is the hope questions for a formal spiritual assessment (table 2) in a medical interview. this was developed by gowri anandarajah and ellen hight of brown university.13 this tool helps identify spiritual resources that a patient could potentially access. the hope questions offer the person being interviewed an opportunity to comprehend what the questioner is trying to explore. this series of questions may work better with a person coming from a “traditional” faith group, e.g., buddhist, christian, hindu, jewish, etc. table 2. the hope questions h sources of hope, meaning, comfort, strength, peace, love and connection. o organized religion p personal spirituality and practices e effects on medical care and end-of-life issues three questions since simple is often a good place to start, let us look at the three questions developed by carolyn kinney to assist a nurse in assessing the spiritual aspect of a patient’s care. with practice, these three questions become the basis of an in-depth conversation about one’s spiritual nature, the foundation and the spiritual challenges. because kinney’s three questions are more open-ended they may prompt a person to answer with less traditional or conventional answers. in time, the questions can take on one’s personal flavor or character. 1. what helps you get through the tough time? 2. who do you turn to when you need support? 32 lunn may 2019. christian journal for global health 6(1) 3. what meaning does this experience have for you?14 these questions are meant to start a conversation, a conversation that is mostly listening on our part. these are open-ended questions where the “right answer” is their answer. it gives an opening, an opportunity for the person to explore these important areas of spirituality, of life. these questions, put in a language that may feel more natural for you, are basically an invitation. they are an invitation for that person to feel they are free to share their intimate struggles and burdens, and even their doubts with us. it is like saying, “you can talk to me. i’m a safe person with whom you can share your feelings.” be sure that you are a safe person, a non-judgmental and open presence, before making the offer. you may hear things that shock and distress you. your disapproval, displeasure, or condemnation will not be helpful here. in jesus’ ministry, he allowed people to come to him as they were and for whom they were. (sinner, tax collector, demon possessed, samaritan, canaanite, leper, or someone of questionable character.) he helped them make the changes they desired. the doctor tells us that we have cancer and only a few months to live. what do we make of jesus saying, “i came that they may have life, and have it abundantly,” (john 10:10b) in relation to that? do i understand this as a mistake made by the doctor? or, can this be seen as an invitation to live out my life fully and discover a richness in life i may not know? those working with people with terminal illnesses do see this response. brian white says, “it’s not the days in your life, but the life in your days that counts.”15 also, we are reminded that, “life is not measured by the number of breaths we take, but by the moments that take our breath away.” (anonymous16) context, meaning, and transcendence our deepest beliefs can offer suffering a context, meaning, and transcendence. viktor frankl, a psychiatrist and survivor of the holocaust, offers the following story of a client: a doctor whose wife had died, mourned her terribly. frankl asked him, “if you had died first, what would it have been like for her?” the doctor answered that it would have been incredibly difficult for her. frankl then pointed out that, by her dying first, she had been spared that suffering, but that now he had to pay the price by surviving and mourning her. in other words, grief is the price we pay for love. for the doctor, this thought gave his wife’s death and his own pain meaning, which in turn allowed him to deal with it. his suffering becomes something more: with meaning, suffering can be endured with dignity.17 with meaning—with someone (not feeling abandoned or all alone)—with a positive outcome, the worst things of life can be endured and even act as positive, life-changing experiences. once again, we are reminded that “we know that all things work together for good for those who love god, who are called according to his purpose.”(romans 8.28) in his 2003 ijpc article, coping with terminal illness: a spiritual perspective, sanjeev vasudevan puts forward the concept of transcendence. here he suggests that “transcendence can be described as a movement of the mind from the material plane, so full of pain and suffering, into a non-material plane.”18 that movement is spiritual liberation. it should be noted that transcendence is a notion that spans many religious traditions and philosophies. vasudevan also suggests that we must have an awareness of our own spirituality, not to offer as a solution or answer, but rather as a foundation for this often-difficult work. further, in this endeavor, we continually learn and grow from what our patients teach us. 33 lunn may 2019. christian journal for global health 6(1) conclusion life itself is a spiritual journey. it is a journey where our responses to challenges and happenstances serve as the building blocks for our resources and abilities to cope with and endure those things we encounter in life. this process, or course, is shaped by our faith, our community, and our spiritual and religious teaching. when we face our own mortality, this spiritual journey is quickened, it is accelerated. this spiritual care model is designed to help us understand how one can explore and encounter the spiritual issues, challenges, and problems from the platform which is created by summoning the depths of our own faith and/or belief. it is descriptive rather than prescriptive. it is conceptualized instead of substantiated in the future, i hope to flesh out assessment tools that would work within this framework. i would encourage others from various backgrounds, traditions, and settings to engage with this model and see what tools, techniques, and methods surface. references 1. world health organization [internet]. who's cancer pain ladder for adults [cited 2015 sep 1].2013 nov. 27. available from: http://www.who.int/cancer/palliative/painladder/en/ 2. deutsch d. the paradox of pitch circularity [pdf]. acoustics today. 2010;6(3):8–14. https://doi.org/10.1121/1.3488670. 3. national council of the churches of christ in the united states of america. new revised standard version bible, copyright © 1989, 1993 used by permission. all rights reserved worldwide. [all scripture references are from this source] 4. epictetus. symmetry counseling, 2017 [internet] [cited 2017 feb 5]. available from: https://www.symmetrycounseling.com/uncategorized/t wo-ears-one-mouth-art-active-listening/, 5. may gg. the dark night of the soul: a psychiatrist explores the connection between darkness and spiritual growth [epub]. harpercollins, 2005. 6. nouwen hjm. a soul searching [internet] [cited 2017 jan 25]. 2007. available from: http://acerminaro.blogspot.com/2006/01/quotes-fromhenri-jm-nouwen.html 7. nietzsche fw [1844-1900]. beyond good and evil: prelude to a philosophy of the future. ny, new york, usa: penguin books; 1990. 8. frankl ve. the will to meaning [internet] [cited 2017 jan 25]. panarchy. available from: https://www.panarchy.org/frankl/meaning.html 9. tentmaker ministries. faith and doubt quotes [internet] [cited 2017 jan 25]. available from: www.tentmaker.org/quotes/faithquotes.htm 10. fagnant-macarthur p. catholic exchange [internet] [cited 2017 jan 25] http://catholicexchange.com/2011/04/14/151309/ 11. world health organization [internet]. ho five principles, change pain [cited 2017 jan 25]. available from: http://www.change-pain.com/grtchange-pain-portal/change_pain_home/chronic_ pain/indication/cancer_pain/who_guidelines/en_en/3 10700135.jsp 12. puchalski cm. fica spiritual history tool [internet]. 1996 [cited 2017 jan 26]. the gw institute for spirituality & health, 1996. available from: https://smhs.gwu.edu/gwish/clinical/fica/spiritualhistory-tool 13. anandarajah g, hight e. spirituality and medical practice: using the hope questions as a practical tool for spiritual assessment. aafp home [internet]. 1 jan 2001 [cited 2017 jan 26]. available from: http://www.aafp.org/afp/2001/0101/p81.html 14. kinney c. spirituality and clinical care [internet]. 2010 [cited 2017 jan 25]. available from: http://inds.utmb.edu/spiritualityandclinicalcare/sylla bus.asp 15. white b. life coach inspirational quotes [internet]. 2011 [cited 2017 jan 35]. available from: http://www.mylifecoach.com/inspirationalquotes.htm 16. o’toole g. life is not measured by the number of breaths we take, but by the moments that take our breath away. quotes investigator [internet]. 2013 [cited 2017 jan 25]. available from: http://quoteinvestigator.com/2013/12/17/breaths/ 17. boeree cg. viktor frankl. plato's cave [internet] [cited 2017 jan 25]. 2006. available from: webspace.ship.edu/cgboer/frankl.html. 18. vasudevan s. coping with terminal illness: a spiritual perspective. indian j palliat care [serial online] [cited http://www.who.int/cancer/palliative/painladder/en/ https://doi.org/10.1121/1.3488670 http://acerminaro.blogspot.com/2006/01/quotes-from-henri-jm-nouwen.html http://acerminaro.blogspot.com/2006/01/quotes-from-henri-jm-nouwen.html https://www.panarchy.org/frankl/meaning.html file:///c:/users/dwone/downloads/www.tentmaker.org/quotes/faithquotes.htm http://catholicexchange.com/2011/04/14/151309/ http://www.change-pain.com/grt-change-pain-portal/change_pain_home/chronic_%20pain/indication/cancer_pain/who_guidelines/en_en/310700135.jsp http://www.change-pain.com/grt-change-pain-portal/change_pain_home/chronic_%20pain/indication/cancer_pain/who_guidelines/en_en/310700135.jsp http://www.change-pain.com/grt-change-pain-portal/change_pain_home/chronic_%20pain/indication/cancer_pain/who_guidelines/en_en/310700135.jsp http://www.change-pain.com/grt-change-pain-portal/change_pain_home/chronic_%20pain/indication/cancer_pain/who_guidelines/en_en/310700135.jsp https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool http://www.aafp.org/afp/2001/0101/p81.html http://inds.utmb.edu/spirituality_and_clinical_care/syllabus.asp http://inds.utmb.edu/spirituality_and_clinical_care/syllabus.asp http://www.mylifecoach.com/inspirationalquotes.htm http://quoteinvestigator.com/2013/12/17/breaths/ file:///c:/users/dwone/downloads/webspace.ship.edu/cgboer/frankl.html 34 lunn may 2019. christian journal for global health 6(1) 2017 feb 5]. 2003;9(1):19-24. available from: http://www.jpalliativecare.com/text.asp?2003/9/1/19/1 9873, peer reviewed: submitted 19 oct 2018, accepted 26 mar 2019, published 31 may 2019 competing interests: none declared. correspondence: john s. lunn, vicar, pastor, grace episcopal church; chaplain, hospice hawaii, united states of america. revlunn@gmail.com cite this article as: lunn js. spiritual care visualized. christian journal for global health. may 2019; 6(1):26-34. https://doi.org/10.15566/cjgh.v6i1.253 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.jpalliativecare.com/text.asp?2003/9/1/19/19873 http://www.jpalliativecare.com/text.asp?2003/9/1/19/19873 http://creativecommons.org/licenses/by/4.0/ poetry alone at christmas reena georgea a md, dnb, frcp edin., department of continuing medical education, christian medical college, vellore, india i longed to give you a gift, a pearl of great price. crafted within my wounds and nourished with body and blood, the pearl grew lovely and luminous. tenderly wrapped in gentle hues the lovely blues of sky and sea, it waited beneath the christmas tree. christmas came and went. you were busy. i understand. i always do. the tree and i continued sitting by the window with smiling fairy lights on. then it was lent, and i had to put away that old tree. the neighbours were sniggering you see. but the pearl and i, we sat waiting for you, my beloved, prodigal daughter. and then you came! and i ran, holding my walking stick and your gift. you opened the silken blue box, saying, “beautiful, thank you!” but then you saw that graceful glow and stopped, “no, i can’t take this.” “please,” i begged. “it was made for you with all that i am.” “but i am not worthy,” you whispered. only then, my heart broke, and i wept. george july 2021. christian journal for global health 8(1) peer reviewed: submitted 31 jan 2021, accepted 19 feb 2021, published __ july 2021 competing interests: none declared. correspondence: reena george, christian medical college, vellore, india. reena.vellore@gmail.com cite this article as: george r. alone at christmas. christ j global health. july 2021; 8(1):88-89. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank poetry july 2021. christian journal for global health 8(1) burnout reena georgea a md, dnb, frcp edin., department of continuing medical education, christian medical college vellore, india old easter lilies, leaves wilting, when all around grass gleams, palms dapple, trees fruit. one morn, they were shorn, chopped, bruised, green things, burnt out. “how will they survive?” i asked the gardener. “the bread-winner leaves cannot work.” “the bulbs will grow,” he said. “can bulbs grow without the leaves that fed them?” “the quiet womb of mother earth and safe sure arms of father heaven have food enough,” he said. un-knowing, un-doing, just being, seasons passed in moons and stars. then a brave shy flower, a babe in arms, heard the light, smiled colors bright, and christmas dawned on easter morn. peer reviewed: submitted 31 jan 2021, accepted 19 feb 2021, published 30 july 2021 competing interests: none declared. correspondence: reena george, christian medical college, vellore, india. reena.vellore@gmail.com cite this article as: george r. burnout. christian journal for global health. july 2021; 8(1):87. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank old easter lilies, one morn, “how will they survive?” i asked the gardener. “the bulbs will grow,” “the quiet womb un-knowing, then a brave shy flower, christmas dawned case study forging relationships between faith-based and secular organizations to address the global water crisis: a case study from liberia kristin r alforda and jamison l koemanb a phd, mph, msw, assistant professor of social work, calvin college, usa b student, calvin college, usa abstract it is imperative to engage in interdisciplinary and multisector partnerships as we seek to develop and deliver effective solutions to address the global water crisis. these partnerships allow us to live out our christian charge to demand justice for the vulnerable and promote human flourishing. this case study reviews the benefits and challenges of multisector partnerships between faith-based and secular organizations using the example of a multi-year water filter distribution project in liberia. benefits of the partnership include shared expertise, investment in students and liberians, and results-driven research. challenges include differing sub-goals, logistical challenges, communication difficulties, and different ways of communicating results. intentional program planning, avoiding preferential treatment, and engagement in process evaluation are all suggestions for mitigating the potentially harmful effects of these challenges. key words: partnerships, faith-based organizations, sustainable development, multi-sectorial, clean water introduction and literature review in 2008, a christian young adult group in washington, dc, asked two questions: 1. what is the greatest need in the world? and 2. where is the most challenging place in the world?1 out of these two questions, along with a commitment by the group to address them, emerged the goal to bring the gospel and clean water to all liberians by 2020. this article will discuss this effort and the need for strong, multisector partnerships between faith-based and secular organizations to achieve global health goals, and the benefits and challenges of working between sectors. where is the most challenging place? the nation of liberia was identified as an area of need due to its history and context. the history of liberia is wrought with conflict, which has served as a major barrier to development. liberia was colonized by freed american slaves in 1820 and eventually gained independence from the united states in 1847.2 the freed slaves, titled americoliberians, established a government under which native liberians were oppressed. as a result, nine major civil conflicts, which impeded development, resulted between 1847 and 1931. following a short 2 alford & koeman time of peace, civil unrest emerged again beginning with a coup d’etat in 1980 and resulting in multiple civil wars until relative peace was assumed again in 2003.3 the country experienced further tragedy during the ebola epidemic that raged in the country between 2014 and early 2016. during this outbreak, over 10,500 liberians contracted ebola of which nearly 5,000 liberians died.4 this epidemic exposed the inadequacy of the health care delivery system and health workforce capacity in liberia. today, liberia is known as one of the poorest countries in the world. of its 4 million inhabitants, 54 percent are impoverished and 45 percent experience food poverty.5 these needs are even greater in rural areas where 70 percent of rural liberians are impoverished and 53 percent experience food poverty. what is the greatest need? access to clean drinking water was identified as the greatest need in liberia as only 70 percent of the country has access to improved sources of drinking water within a 30-minute walk from their residence.6 not surprisingly, only 60 percent of rural liberians, compared to 80 percent of urban liberians, have access to these sources. unfortunately, improved sources of drinking water does not mean the water is, or remains, contaminantfree. many factors can compromise the safety of drinking water, including the source of piped water, water storage practices, and whether households choose to consistently use the improved sources versus unimproved sources of water.7 access to and consistent use of clean drinking water is integral to health. contaminated drinking water can transmit many diseases, such as diarrhea. according to the world health organization (who), diarrheal disease is the 6th leading cause of death for children under the age of five in liberia, accounting for 560 deaths per 100,000 live births.8 diarrheal disease is closely associated with malnutrition in children leading to impairments in physical growth, cognition, and immune strength.9,10,11 diarrheal disease has been effectively reduced in developing countries through interventions focused on increasing access to improved sources of drinking water, sanitation, and hygiene.12,13,14 our christian call to justice the discussion around our christian call to justice is often limited to the pentateuch and the old testament prophets. new testament writings, however, reflect the commitment of jesus to proclaiming and practicing justice. in the great assize in matthew 24, jesus calls us to feed the hungry, give drink to the thirsty, be hospitable to the stranger, and visit those who are sick or imprisoned. this passage, along with references to isaiah in the book of luke urging the undoing of injustice, demonstrates the importance jesus places on lifting up those who are downtrodden and promoting justice.15 the character of god, as revealed in jesus, emphasizes the value of human life and the promotion of human flourishing.16 the universal church proclaims the kingship of christ, and thus, has a prophetic role to preach justice in a broken world and to demonstrate both stewardship and servanthood as modeled for us through jesus christ.17 the apostle paul in ii corinthians identifies the church as ambassadors of christ, rooting our identity in christ’s work and teaching.18 this then serves as a context for promoting justice and engaging in efforts to serve those who are vulnerable. our efforts to address inequalities should be done in cooperation with others, as daniel o’neill aptly reminds us “though the church is designed to embody the fullness of truth, she does not have a monopoly on the truth.”16 while the church, through faith-based organizations and local faith communities, play an important role in global public health efforts, we are called to work cooperatively with other people of all faiths.16 multisector partnerships lofty population health goals often miss their mark, as demonstrated by the incomplete 3 alford & koeman implementation of the united states healthy people 2010 goals and the world health organization’s millennium development goals. this lack of success can be attributed to fragmentation across sectors, lack of collaboration, and no entity taking primary ownership of the goal.19 with the introduction of the united nations sustainable development goals (sdg) in 2016, the need for multisector partnerships was outlined in the seventeenth goal, noting that partnerships are vital to successfully achieving the other goals.20 the creation of partnerships across sectors to promote global health is fundamental.21 effective multisector partnerships are integral for comprehensive and sustainable public health efforts.22 the advantage of collaboration has been attributed to the concept of synergy, “the power to combine the perspectives, resources, and skills of a group of people and organizations.”23 synergy within partnerships can generate more creative, comprehensive, practical, and transformative thinking.23 multisector partnerships have demonstrated success in several global health efforts including increased health care utilization in odisha, india, and reduction of under-5 mortality by 69 percent in ethiopia.24,25 however, partnerships can also hinder these efforts. poor performance in population health goals has been attributed to poor partnership quality which can result from lack of strong cooperation, lack of individual responsibility by partnering organizations, and an imbalance or misuse of power.19,26 faith-based organizations have a record of success in global health efforts. several studies have explored the importance and successful efforts of faith-based organizations in partnership with the public and private sectors.27,28,29 however, collaborative efforts between faith-based and secular organizations can be hindered by differing goals and challenges in sacrificing aspects of autonomy.30 in order to ensure continued effectiveness and synergy, multi-sectoral partnerships need to engage in a process of continuous improvement, considering the work as a learning process rather than an organizational structure.31 this case study of water filter distribution in liberia has brought together a christian non-governmental organization (ngo), a christian liberal arts college, and a private, for-profit organization. while the process of filter distribution seems relatively straightforward, the implementation and evaluation of the effectiveness is quite complex and requires a variety of expertise. as the project developed, a core team composed of three sectors emerged as leaders. the last well, a faith-based ngo, established in 2008 to address the needs addressed in this project, coordinates the implementation of the project and oversees filter distribution and data collection. sawyer international, a us-based company, donates the filter systems, trains and equips partners on how to use their point-of-use filters in the field, and trains and equips partners on the gis data collection. calvin college, a christian liberal arts college, cleans and analyzes data and reports on filter use and the effects of filter distribution on health and wellbeing in liberia. this partnership benefits from collective expertise and is driven by a common goal to address the global water crisis in an efficient and cost-effective manner. the case study utilizes results from an internal mid-project process evaluation conducted among the key project leaders to assess the partnership. the evaluation seeks to understand the benefits and challenges of such partnerships as identified through the core leadership team. method the primary purpose of the process evaluation is to determine the strengths and challenges of the partnership in order to make mid-project modifications to further strengthen the work of the project going forward. secondarily, the process evaluation will inform future multi-sectoral partnerships. participant characteristics 4 alford & koeman in order to evaluate the partnership process, six core leaders emerged from the three different organizations. the leaders included the field operations coordinator at the last well, the international director from sawyer, inc., and faculty members from the geography, mathematics and statistics, and public health departments at calvin college, including the authors of this publication. sampling procedure and measures the core leadership team were invited via email to participate in the process evaluation in july and august of 2018. each of the six members answered five, open-ended evaluative questions: 1) what do you perceive to be your organization’s role in the project? 2) what do you perceive to be your organization’s goals in this project? 3) what does your organization hope to see as results from this project? 4) what do you perceive to be the advantages/benefits of completing this project with multiple sectors/organizations? please be specific. 5) what have been the challenges of completing this project with multiple sectors/organizations? please be specific. the answers to the open-ended questions were combined and categorized by themes. these themes were presented in the results as benefits and challenges of engaging in this partnership. results benefits of the approach the goal of bringing water to all liberians by 2020 requires a broad swath of expertise and community trust. engaging in these collaborative partnerships was described as vital for solving global, regional, and local challenges. this multisector partnership has allowed each partner to contribute meaningfully and within their scope of knowledge. for instance, the last well understands the cultural context and has a strong relational presence in liberia, while sawyer international provides state-of-the-art water filters and develops and maintains the gis-based data collection software. calvin college provides expertise in analyzing and communicating results of large-scale, data-driven projects. by partnering, each organization focuses on areas of expertise which also can contribute to better outcomes. the approach also allows each organization to further develop sustainable efforts by investing in both local community members and student researchers. partnering organizations have more time to invest in others as their time is only focused on their areas of expertise. this investment is primarily seen in the development of a public health workforce as local liberians are called upon to distribute filters and collect data, and students are involved in the data analysis and communication of results. unlike many other public health partnerships, this partnership engages the corporate sector. this sector is largely results driven, pushing other partners to complete the work in a timely fashion. furthermore, this sector introduces a business and marketing model into public health practice, emphasizing the potential for the project to be replicated and advertising the work to a variety of audiences. by utilizing academia in the research, the data are analyzed, and statistically significant results are identified and communicated. challenges of the approach working in a global, multi-sector partnership also presents challenges including differing subgoals, logistical challenges, communication difficulties, and different ways of communicating results. in this case study, partners discovered each organization had other priorities in addition to the main goal of creating access to clean water in liberia and, ultimately, to more people worldwide. for example, as a business, sawyer international wants to see other ngos use their product to provide clean water to other areas of the world, even if it means foregoing some profit in selling their product at a discounted rate. the last well aims to preach the gospel throughout all of liberia. calvin college researchers seek to publish and provide a way for 5 alford & koeman students to gain research experience and to quantify effectiveness of filter distribution in a variety of ways. while the existence of different sub-goals presents advantages in the scope of work being done, it unfortunately causes differential prioritization by each partner. logistical challenges also have affected the timeliness and quality of the partnership. the data collection method relies on local lay people in liberia, which builds local capacity but requires long-term training, monitoring, and evaluation. the collected data often requires additional cleaning before it is ready for analysis, resulting in longer lagtimes between data collection and dissemination of results. the process of getting the filters from manufacturing through customs in liberia has been a challenge and, additionally, the geography and climate of liberia slow distribution and data collection as many villages are very inaccessible, particularly during the rainy season. communication can also be a challenge as the partners are stationed in different parts of the world, resulting in most decisions being made via phone or e-mail. even in times of limitless access to phone or e-mail, these mediums can contribute to confusion. different ways of expressing ideas or different priorities due to differing professional backgrounds also can hinder communication. for instance, those on the academic end often become too absorbed in minor dataset issues while those on the corporate or ngo end often rely on anecdotal stories or observations. furthermore, it is a challenge to communicate with those who are collecting data as they are often undereducated due to war and poor educational systems in liberia. finally, different backgrounds and goals often require different final products, ways of communicating information, and various response times. for example, while academic publications often are overly detailed and rigorous, marketing materials need to convey the story concisely and effectively to a lay person. for organizations like sawyer international, timeliness is critical as they need to demonstrate results to make the case that this approach is a viable solution and can be adopted by other ngos and aid organizations. this quick turnaround time is relatively foreign in the academic setting and requires increased nimbleness and responsiveness to data requests. discussion the development of a common framework for global health, as articulated in the sdgs, necessitate the forging of new collaborations.30 neither faithbased organizations nor governmental agencies are equipped to solely reach global public health goals, and must rely on the expertise and experience of each other along with other players in civil society.29,32 inclusion of multiple disciplines among multiple sectors provides a holistic approach to addressing community health.33 continued commitment from “multiple agents of change working across sectors over time across ecological levels” is needed to continue to improve population health outcomes.19 these partnerships promote access to new resources and skills, capacity-building, have extensive reach globally, and often can reach the most vulnerable populations.32,34 faith-based partnerships have a large presence and potential in public and global health.29 for instance, in this case study, inclusive partnerships can implement and assess large-scale public health projects, such as bringing clean water to an entire nation. more efficient and streamlined service delivery is possible by streamlining processes and maximizing the skillset of each partner. several of the challenges we faced in our partnership are inevitable due to the nature of multisector partnerships and interdisciplinary work. however, the negative effects of these challenges can be mitigated by taking an intentional approach to planning and communication throughout the process. prior to work beginning, it is imperative that a comprehensive plan for action and the partnership structure be clearly articulated. previous work has highlighted the need for defining governance and management processes along with 6 alford & koeman detailed timelines and work plans.19,35 additionally, common goals, as well as individual partner subgoals and priorities, should be laid out prior to the commencement of the project. in partnerships, it is a delicate balance to allow each partner to contribute to the project while also seeking to further their own goals—whether those be evangelical, marketing, or publication goals in our case. the potential contributions of each partner should be identified along with their values, commitments and motivations.27 these conversations are necessary for building trust, a key element in multisector partnerships between faith-based and secular organizations.33,35 communication is a challenge in global health partnerships and poses additional difficulties when the work is interdisciplinary and multisector. these challenges call for increased attention to ensuring understanding and using care in communicating ideas and messages.21,27 rather than expressing frustration at the differing ways of communication, each perspective should be valued. engaging multiple ways of looking at a problem and discussing solutions provide a richer, more complex narrative of the success and failures of a project. giving voice to all partners, rather than relying heavily on one voice can lead to stronger collaborations. relationshipbuilding is critical for partnership synergy.23 emphasis on building trust, fostering respect, addressing conflict, and acknowledging and addressing power differentials in the partnership leads to better communication and effectiveness.23 the emphasis on the importance of partnerships in the sdgs necessitates process evaluations to better understand the nature of these partnerships and identify common ways to work more effectively. the establishment of evaluation systems to measure the effectiveness of multi-sector partnerships is integral to determine if these arrangements are merely a fad or if they, in fact, truly enhance global health efforts.30,36 using process evaluations throughout project implementation allows participants to build on strengths and address challenges moving forward. this case study has limitations, namely that it covers only one multi-sectoral partnership and thus the generalizability may be limited. furthermore, there may be bias as the authors are members of the project team. however, the case study provides lessons learned for future endeavors and encourages the exploration of partnerships between faith-based and secular organizations as we seek to be agents of renewal in god’s kingdom. conclusion multi-sectoral partnerships can provide increased means to optimize the use of each partner’s gifts, combine resources to more efficiently address global health needs, and use the partnership to invest in others. it is imperative to articulate communication needs, desired outcomes and expectations, and program plans throughout the process to promote thriving. as we follow christ’s model of a life of servanthood and his call to justice, we must engage in these effective strategies to address the needs of those who are most vulnerable. we have a sacred charge to do justice, love mercy, and to walk humbly with our god. in considering the global water crisis and other major global health challenges, we must seek opportunities to work alongside those who are best equipped and to identify strategies to promote flourishing in those partnerships to best fulfill our calling here on earth. references 1. thelastwell.org [internet]. rockwall, texas: our history [2018]. available from: https://thelastwell.org/why-liberia/ 2. shick tw. behold the promised land: a history of afro-american settlers in nineteenth-century liberia. baltimore, md: the johns hopkins university press;1980. 3. levitt ji. evolution of deadly conflict in liberia. durham, north carolina: carolina academic press; 2005. 4. centers for disease control and prevention. 20142016 ebola outbreak in west africa [internet]. atlanta, georgia: cdc; 2017. available from: https://thelastwell.org/why-liberia/ 7 alford & koeman https://www.cdc.gov/vhf/ebola/history/2014-2016outbreak/index.html 5. liberia institute of statistics and geo-informational services (lisgis). household income and expenditure survey 2014: statistical abstract [internet]. liberia: lisgis; 2016 mar. available from: https://www.lisgis.net/pg_img/liberia%20statistical %20abstract%20final.pdf 6. the who/unicef joint monitoring programme for water supply, sanitation and hygiene [internet]. new york, ny: united nations children’s fund (unicef) and world health organization; 2015. available from: https://washdata.org/data#!/lbr 7. shaheed a, orgill j, montgomery ma, jeuland ma, brown j. why “improved” water sources are not always safe. bulletin of the world health organization. 2014; 92:283-89. available from: http://dx.doi.org/10.2471/blt.13.119594 8. world health organization. liberia who statistical profile [internet]. 2015 jan. available from: / https://www.who.int/gho/countries/lbr/country_profile s/en 9. checkley w, buckley g, gilman rh, et al. childhood malnutrition and infection network. multi-country analysis of the effects of diarrhoea on childhood stunting. int j epidemiol. 2008 jun 20;37(4):816-30. https://doi.org/10.1093/ije/dyn099 10. guerrant rl, oriá rb, moore sr, oriá mo, lima aa. malnutrition as an enteric infectious disease with long-term effects on child development. nutr rev. 2008 sep 1;66(9):487-505. https://dx.doi.org/10.1111%2fj.17534887.2008.00082.x 11. kotloff kl, nataro jp, blackwelder wc, et al. burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the global enteric multicenter study, gems): a prospective, case-control study. lancet. 2013 jul 20;382(9888):209-22. https://doi.org/10.1016/s01406736(13)60844-2 12. fewtrell l, kaufmann rb, kay d, enanoria w, haller l, colford jr jm. water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and metaanalysis. lancet infect disease. 2005 jan 1;5(1):4252. https://doi.org/10.1016/s1473-3099(04)01253-8 13. cairncross s, hunt c, boisson s, et al. water, sanitation and hygiene for the prevention of diarrhoea. int j epidemiol. 2010 mar 23;39(suppl_1):i193-205. https://doi.org/10.1093/ije/dyq035 14. prüss‐ustün a, bartram j, clasen t, et al. burden of disease from inadequate water, sanitation and hygiene in low‐and middle‐income settings: a retrospective analysis of data from 145 countries. trop med int health. 2014 aug;19(8):894-905. https://doi.org/10.1111/tmi.12329 15. wolterstorff n. justice, not charity: social work through the eyes of faith. soc work christ. 2006;33(2):123-40. 16. o'neill dw. theological foundations for an effective christian response to the global disease burden in resource-constrained regions. christ j global health. 2016 may 15;3(1):3-10. https://doi.org/10.15566/cjgh.v3i1.112 17. vorster k. kingdom, covenant, and human rights. in die skriflig. 2017;51(2):1-8. http://dx.doi.org/10.4102/ids.v51i2.2257 18. davis r. what about justice? toward an evangelical perspective on advocacy in development. transformation. 2009 apr;26(2):89-103. https://doi.org/10.1177%2f0265378809103385 19. fawcett s, schultz j, watson-thompson j, fox m, bremby r. building multisector partnerships for population health and health equity. prev chronic dis. 2010 nov;7(6). 20. united nations. about the sustainable development goals [2018] [internet]. available from: https://www.un.org/sustainabledevelopment/sustainab le-development-goals/ 21. corbin jh. health promotion, partnership and intersectoral action. health promot int. 2017 dec 1;32(6):923-9. https://doi.org/10.1093/heapro/dax084 22. frieden tr. six components necessary for effective public health program implementation. am j public health. 2014;104:17-22. https://doi.org/10.2105/ajph.2013.301608 lasker rd, weiss es, miller r. partnership synergy: a practical framework for studying and strengthening the collaborative advantage. milbank q. 2001;79(2):179-205. https://doi.org/10.1111/14680009.00203 23. kandamuthan s, madhireddi r. equity in health care: lessons from public-private partnership initiatives in tribal health from odisha, india. bmj global health 2016;1:a25. http://dx.doi.org/10.1136/bmjgh-2016ephpabstracts.33 https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html https://www.lisgis.net/pg_img/liberia%20statistical%20abstract%20final.pdf https://www.lisgis.net/pg_img/liberia%20statistical%20abstract%20final.pdf https://washdata.org/data#!/lbr http://dx.doi.org/10.2471/blt.13.119594 https://www.who.int/gho/countries/lbr/country_profiles/en https://www.who.int/gho/countries/lbr/country_profiles/en https://doi.org/10.1093/ije/dyn099 https://dx.doi.org/10.1111%2fj.1753-4887.2008.00082.x https://dx.doi.org/10.1111%2fj.1753-4887.2008.00082.x https://doi.org/10.1016/s0140-6736(13)60844-2 https://doi.org/10.1016/s0140-6736(13)60844-2 https://doi.org/10.1016/s1473-3099(04)01253-8 https://doi.org/10.1093/ije/dyq035 https://doi.org/10.1111/tmi.12329 https://doi.org/10.15566/cjgh.v3i1.112 http://dx.doi.org/10.4102/ids.v51i2.2257 https://doi.org/10.1177%2f0265378809103385 https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://doi.org/10.1093/heapro/dax084 https://doi.org/10.2105/ajph.2013.301608 https://doi.org/10.1111/1468-0009.00203 https://doi.org/10.1111/1468-0009.00203 http://dx.doi.org/10.1136/bmjgh-2016-ephpabstracts.33 http://dx.doi.org/10.1136/bmjgh-2016-ephpabstracts.33 8 alford & koeman 24. ruducha j, mann c, singh ns, et al. how ethiopia achieved millennium development goal 4 through multisector interventions: a countdown to 2015 case study. lancet global health. 2017 nov 30;5(11):e1142-51. https://doi.org/10.1016/s2214109x(17)30331-5 25. faul mv. multi-sectoral partnerships and power. background paper prepared for unrisd flagship report [internet]. geneva, switzerland. united nations research institute for social development; 2016 august. available from: http://www.unrisd.org/80256b3c005bccf9/(httpau xpages)/ca910973b03cb947c1258061006504bb/$ file/faul%20bp.pdf 26. duff jf, buckingham ww. strengthening of partnerships between the public sector and faith-based groups. lancet. 2015 oct 31;386(10005):1786-94. https://doi.org/10.1016/s0140-6736(15)60250-1 27. levin j. partnerships between the faith-based and medical sectors: implications for preventive medicine and public health. preventive medicine reports. 2016 dec 1;4:344-50. https://doi.org/10.1016/j.pmedr.2016.07.009 28. levin j. faith-based partnerships for population health: challenges, initiatives, and prospects. public health rep. 2014 mar;129(2):127-31. https://doi.org/10.1177%2f003335491412900205 29. duff j, battcock m, karam a, taylor ar. high-level collaboration between the public sector and religious and faith-based organizations: fad or trend? rev faith int aff. 2016 jul 2;14(3):95-100. https://doi.org/10.1080/15570274.2016.1215819 30. buse k, tanaka s. global public-private health partnerships: lessons learned from ten years of experience and evaluation. int dent j. 2011;61:2-10. https://doi.org/10.1111/j.1875-595x.2011.00034.x 31. davie g, ammerman nt, huq s, et al. religions and social progress: critical assessments and creative partnerships. in rethinking society for the 21st century: report of the international panel for social progress. cambridge university press; 2018. 32. safe m, grills n, wainwright e, lankester t. community health global network: “clustering” together to increase the impact of community led health and development. christ j global health. 2014 nov 6;1(2). https://doi.org/10.15566/cjgh.v1i2.9 33. willis cd, corrigan c, stockton l, greene jk, riley bl. exploring the unanticipated effects of multisectoral partnerships in chronic disease prevention. health policy. 2017 feb 1;121(2):158-68. https://doi.org/10.1016/j.healthpol.2016.11.019 34. kamya c, shearer j, asiimwe g, et al. evaluating global health partnerships: a case study of a gavi hpv vaccine application process in uganda. int j health policy manag. 2017 jun;6(6):327. https://dx.doi.org/10.15171%2fijhpm.2016.137 35. brinkerhoff jm. assessing and improving partnership relationships and outcomes: a proposed framework. eval program plan. 2002 aug 1;25(3):215-31. https://doi.org/10.1016/s0149-7189(02)00017-4 peer reviewed: submitted 14 sept 2018, accepted with revisions 16 march 2019, published 31 may 2019 competing interests: none declared. correspondence: dr. kristen r alford, calvin college, usa. kadmir42@calvin.edu cite this article as: alford kr, koeman jl. forging relationships between faith-based and secular organizations to address the global water crisis. christian journal for global health. may 2019; 6(1):35-42. https://doi.org/10.15566/cjgh.v6i1.243 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1016/s2214-109x(17)30331-5 https://doi.org/10.1016/s2214-109x(17)30331-5 http://www.unrisd.org/80256b3c005bccf9/(httpauxpages)/ca910973b03cb947c1258061006504bb/$file/faul%20bp.pdf http://www.unrisd.org/80256b3c005bccf9/(httpauxpages)/ca910973b03cb947c1258061006504bb/$file/faul%20bp.pdf http://www.unrisd.org/80256b3c005bccf9/(httpauxpages)/ca910973b03cb947c1258061006504bb/$file/faul%20bp.pdf https://doi.org/10.1016/s0140-6736(15)60250-1 https://doi.org/10.1016/j.pmedr.2016.07.009 https://doi.org/10.1177%2f003335491412900205 https://doi.org/10.1080/15570274.2016.1215819 https://doi.org/10.1111/j.1875-595x.2011.00034.x https://doi.org/10.15566/cjgh.v1i2.9 https://doi.org/10.1016/j.healthpol.2016.11.019 https://dx.doi.org/10.15171%2fijhpm.2016.137 https://doi.org/10.1016/s0149-7189(02)00017-4 http://creativecommons.org/licenses/by/4.0/ a phd, mph, msw, assistant professor of social work, calvin college, usa introduction and literature review method results discussion conclusion references historical review article april 2020. christian journal for global health 7(1) historic plagues and christian responses: lessons for the church today? bryan justa a ma(th), event & executive services manager, center for bioethics and human dignity abstract the covid-19 pandemic has led to unprecedented upheaval throughout the world, especially for christians who have had to drastically alter their practices in light of the disease. this review will examine how christians throughout history have dealt with times of plague through several case studies, including the cyprian plague and the response of geneva’s pastors to several plagues in the mid-sixteenth century. it will consider some of the lessons we can draw from these examples and conclude with practical considerations for how the church can respond to the covid-19 pandemic. key words: plagues. pandemics, christian response. introduction the covid-19 pandemic has disrupted life for millions around the globe. for those with religious affiliation, this disruption has extended to their gatherings and has affected those of all religions, not just christians.1 in the midst of this global crisis, many are wondering what it looks like to live out their faith under restrictions regarding close personal contact and large group gatherings. christians especially have many activities that have had to change, from their regular sunday morning gatherings to the practice of sacraments. though the global scope of the current pandemic is unprecedented in the modern world, it is helpful to remember that plagues and disease are not. since its inception, the church has dealt with times of plague, and these examples can and should inform the ways in which we formulate our own response. in what follows, i will present a summary of some of the ways christians have approached plagues throughout history and conclude that while we have much to learn from their examples, many of their specific activities will need to be changed to account for modern scientific knowledge and advances. i believe that if christians can do this, they will be able to stay true to their faith while also reaching a world that increasingly views religious belief with suspicion or disdain. review plagues in the ancient world during the early years of the roman empire, the way in which societies dealt with the sick was very different than it is today. there were no hospitals as we now know them. additionally, “in the classical world there was little recognition of social responsibilities on the part of the individual. before the advent of christianity, moreover, there was no concept of the responsibility of public 8 just april 2020. christian journal for global health 7(1). officials to prevent disease or to treat those who suffered from it.”2 this meant that when a plague struck, it was devastating. the horror of plagues in the ancient world, as well as the increased mortality caused by a lack of caregivers, was famously written about by thucydides. describing a plague in athens around 430 b.c., he writes: . . . they became infected by nursing one another and died like sheep. and this caused the heaviest mortality; for if, on the one hand, they were restrained by fear from visiting one another, the sick perished uncared for, so that many houses were left empty through lack of anyone to do the nursing; or if, on the other hand, they visited the sick, they perished . . . they perished in wild disorder. bodies of dying men lay one upon another, and half-dead people rolled about in the streets and, in their longing for water, near all the fountains. the temples, too, in which they had quartered themselves were full of the corpses of those who had died in them.3 as thucydides makes clear, plagues in the ancient world were nothing to be trifled with. fear often kept people from providing any kind of care to the suffering and resulted in total neglect of the bodies of those who died. in this context, christian care for the sick was distinctly counter-cultural. a prime example comes from the plague of cyprian. cyprian was a bishop in the city of carthage during the time of the decian persecution of christians. in 252 a.d., a plague hit the city, and once again the reaction of the inhabitants was much like that thucydides has described — the sick and dying were neglected while bodies began to pile up in the streets with no one to bury them.2 cyprian chose not to ignore the crisis and encouraged the christians to risk their own lives to care for the sick and dying. from the rich, he asked for funds; from the poor he requested service. he organized the christian response and encouraged believers not to make any distinction between caring for fellow christians and caring for pagans. all were to receive care, even those who were actively persecuting the church.2 though the efforts of cyprian were perhaps the most well-known, christians elsewhere provided similar responses. thus, dionysius, writing from alexandria, tells us: most of our brother christians showed unbounded love and loyalty, never sparing themselves and thinking only of one another. heedless of danger, they took charge of the sick, attending to their every need and ministering to them in christ . . . many, in nursing and curing others, transferred their deaths to themselves and died in their stead.4 he goes on to say that this service was provided by both church leaders and laypersons, and he connects their service to martyrdom. though it was a revolutionary concept in the ancient world, care for the sick and the dying became characteristic of christians. this demonstration of care was not limited to the cyprian plague. an epidemic lasting from 312– 313 a.d. is described by eusebius, who wrote: for they alone [christians] in the midst of such ills showed their sympathy and humanity by their deeds. every day some continued caring for and burying the dead, for there were multitudes who had no one to care for them; others collected in one place those who were afflicted by the famine, throughout the entire city, and gave bread to them all; so that the thing became reported abroad among all men, and they glorified the god of the christians.5 once again, christians were unique in caring for those struck by an epidemic, and their service was noted by those outside of the faith. it has been argued that this care became the basis for our modern 9 just april 2020. christian journal for global health 7(1). hospital system: “when the concept of a hospital began to emerge in the mid-fourth century, it owed much to the church’s long experience for caring for the ill . . . without [it] the immediate success of the hospital, i believe, would have been impossible.”2 plagues in geneva christian care for those suffering from plagues was not limited to its early centuries. another example comes from geneva in the mid-sixteenth century, although this time the response was somewhat more cautious. at this time, john calvin headed a large group of pastors in charge of the spiritual health of the city and surrounding areas, and one of their tasks was providing visitation and care to those who were sick. in 1542, geneva was struck by a plague. one of the pastors, pierre blanchet, volunteered to minister to those who had been moved to the plague hospital outside the city. though he ministered bravely, it was not long before he contracted the disease and died. geneva’s pastors took some time in filling blanchet’s post. though several were appointed, all refused to go, as they were fearful of contracting the plague themselves. finally, after a week of deliberation, matthieu de geneston volunteered; he too died from the plague.6 this experience set the stage for later plague responses in geneva. when a plague hit the city a few decades later, the pastors were more prepared to follow a lottery system to choose one man out of their group to minister at the plague hospital and a second to visit those quarantined in their homes. they took new precautions, however, such as having the minister remain outside and speak with patients through a window.6 when the plague returned to geneva a third time, between 1568 and 1571, the pastors had become further convinced of their duty. this time, they rejected the lottery system, and each pastor became responsible to providing spiritual care to plague victims within his congregation. all of the pastors, not just one, took turns visiting the plague hospital, and this became the model followed during future epidemics.6 the experience of the genevan pastors demonstrates several things. though initially hesitant regarding their pastoral duty, successive plagues only strengthened these pastors’ resolve to care for the sick and dying in their congregations without regard for their own health or safety. by this point, they were not needed as much to provide basic medical care, but were instead providing spiritual care and comfort at the end of life.6 we can also see in these episodes a burgeoning awareness of the need to temper duty with wisdom and caution. though the pastors eventually placed duty above caution, this did not hold true for laypeople. in fact, theodore beza (one of the most prominent of geneva’s pastors and john calvin’s successor) wrote that it was perfectly acceptable for christians to flee from cities in times of plague provided they did not neglect their duties to god, family, or neighbor.7 this represents something of a turn from the early church; while once all christians, from bishops down to laypeople, were responsible for caring for plague victims, in geneva the duty was seen as falling squarely on the shoulders of pastors. discussion how can we apply these examples from early christianity to our experience of epidemics in the twenty-first century and to the covid-19 outbreak specifically? one point should be abundantly clear: christians have long held that believers have a duty to minister to the sick and vulnerable, and while the means may have changed over time, the mandate has not. going beyond this, however, is more difficult. clearly, early christians, as well as the pastors in geneva, saw it as their duty to risk their own lives for the sake of those suffering. at the time, this was viewed with wonder and appreciation. rodney stark and gary ferngren have both demonstrated that the ancient world held little regard for those infected with plagues, making the christian response stand 10 just april 2020. christian journal for global health 7(1). out.2,8 today, however, the situation is much more complicated. many religious groups, including christians, have come under fire for continuing in their standard practices despite recommendations that they cancel services, avoid large gatherings, etc.9 in south korea, the shincheonji church of jesus became an epicenter for the spread of the virus and “the most vilified church in south korea.”10 although the church is more like a cult than a branch of orthodox christianity, the distinction is easily lost by those without religious experience, casting a negative pall on anyone associated with a church. how then should the church respond during times of pandemic? for many, this question has been centered in the realm of church practices. should we continue to hold worship services? what about smaller groups? what does worship look like, or sacraments like baptism or communion, when the church cannot gather in person? as important as these questions are for the life of the church, however, they are all inward focused. part of the reason people have viewed the church with disdain at this time is that its activities appear mostly selfish. while gathering for worship or engaging in communion make perfect sense to the believer, they do nothing for a watching world that is fearful and looking to contain the virus by any means necessary. if we truly wish to engage the world by following the example of the christians who have come before us, we must not look solely at what they did, but also why they did it. though this may seem counterintuitive, part of ministering to the world today is contextualization; it is foolish to think that we can take examples from 2,000 years ago and uncritically apply them to today’s problems. in treating those stricken with the plague, early christians were attempting to live out jesus’ commands to love their neighbor, to care for the sick and vulnerable, and to follow the “golden rule” of doing to others as you would have done to you. this means that we must determine what “loving our neighbor” looks like today. though there is disagreement among christians,11 i have argued elsewhere that during this time of pandemic, the most loving thing that the church can do is suspend services for the sake of the most vulnerable among us.12 by following physical distancing guidelines, we can show that we wish to put others before our own religious interests. while a good first step, however, this is not exactly the radical, self-sacrificial love shown by early christians in times of plague. for them, that meant going and physically being with and caring for those stricken by plague. how does that part of their response apply to us? today, care may look very different depending on where we are. in places where medical care is not adequate, this may still be the best way to show the love of christ to the world. however, in many other parts of the world, due in large part to the influence of christianity, there is a robust medical system in place for ministering to those who have contracted covid-19. no longer are christian laypeople necessary for making sure these victims receive care and attempting to provide it could, in many cases, cause more harm than good, either through substandard care or through unintentionally spreading the virus. in these places, christian care is going to have to look different. the same is also true of spiritual care. the genevan pastors were not wrong in thinking that they had a duty to minister spiritually to the sick and especially those at the end of life. now, however, the means by which this is done have evolved. in my own church, it has grieved the pastors and elders that we cannot be present with those in our congregation who have tested positive for the virus; it was heart wrenching to stand by as one of our members worsened and succumbed without being able to be physically present. however, we were (and continue to be) bound by the rules of the government and the hospital. thus, alternatives to in-person care must be found. we are fortunate to live in an age of technology, and while screens are a poor substitute for embodied presence, they do serve as a temporary solution, a prudent compromise in extraordinary 11 just april 2020. christian journal for global health 7(1). times. through phone calls, texts, and video messaging, we can do our best to continue the work of the church even during times when physical presence is not allowed. demonstrating christian care is not limited to the clergy. christian laypersons can show their care in a variety of ways while adhering to physical distancing guidelines. many of these can be simple and relatively safe, such as going shopping for others so they can remain safe at home or offering to pray over the phone or by video call with friends, family, and neighbors. christians can make themselves available to provide help, comfort, prayer, or just a listening ear through forums such as a community facebook group. they can lead through example by following guidelines regarding distancing, physical contact, and wearing masks. they can also provide positive examples by refusing to hoard resources or give in to fear or hysteria. and, christians can contribute financially to individuals and organizations who are hurting during this time. these are all good things, but it can also be argued that they are also the things everyone should be doing, not things that set christians apart. thus, i wish to conclude with a few thoughts on what radical christian love could look like in our present circumstances. what are the things that could make the world sit up and take notice? one that comes to mind is the need for volunteers. from food banks to elder care facilities to homeless shelters, there is a desperate need for people to provide services for the vulnerable in society who are the most easily overlooked in times of crisis. what kind of example would it set if christians were to volunteer for these opportunities en masse? if churches were to fill food banks and individuals were to open their homes to the homeless? if the elderly never had to worry about isolation because there were constantly those who would check in with them? these activities may seem simple — far too simple to be considered “radical christian love” or not risky enough to live up to the example set by our predecessors. and yet, one could also say that feeding someone broth, digging a grave, or reading someone a passage from scripture were also simple. it was not the risk that made the ancients take note of the christians, but the care that they provided, and this care is something that we can still offer today. . references 1. robinson k. how are the major religions responding to the coronavirus? council on foreign relations; 2020 mar 19. available from: https://www.cfr.org/in-brief/how-are-majorreligions-responding-coronavirus. 2. ferngren gb. medicine & health care in early christianity. baltimore: johns hopkins university press; 2009. 3. thucydides. history of the peloponnesian war, volume i: books 1-2. [translated by cf smith]. loeb classical library 108. cambridge, ma: harvard university press; 1919. p. 349–51. 4. dionysius. festival letters. in: stark r. the rise of christianity: how the obscure, marginal jesus movement became the dominant force in the western world in a few centuries. san francisco: harpercollins; 1997. p. 82. 5. eusebius. church history, book ix. [translated by mcgiffert ac]. in: schaff p, wace h, editors. nicene and post-nicene fathers, second series, vol. 1 [cited 2020 apr 13]. buffalo, ny: christian literature publishing; 1890. [rev. and ed. for new advent by knight k]. available from: http://www.newadvent.org/fathers/250109.htm. 6. manetsch s. calvin’s company of pastors. new york: oxford university press; 2013. 7. beza t. questions regarding the plague. in: manetsch s. calvin’s company of pastors. new york: oxford university press; 2013. 8. stark r. the rise of christianity: how the obscure, marginal jesus movement became the dominant force in the western world in a few centuries. san francisco: harpercollins; 1997. 9. yee v. in a pandemic, religion can be a balm and a risk. new york times; 2020 mar 22. available from: https://www.nytimes.com/2020/03/22/world/middle east/coronavirus-religion.html. https://www.cfr.org/in-brief/how-are-major-religions-responding-coronavirus https://www.cfr.org/in-brief/how-are-major-religions-responding-coronavirus http://www.newadvent.org/fathers/250109.htm https://www.nytimes.com/2020/03/22/world/middleeast/coronavirus-religion.html https://www.nytimes.com/2020/03/22/world/middleeast/coronavirus-religion.html 12 just april 2020. christian journal for global health 7(1). 10. sang-hun c. ‘proselytizing robots’: inside south korean church at outbreak’s center. new york times; 2020 mar 10. available from: https://www.nytimes.com/2020/03/10/world/asia/so uth-korea-coronavirus-shincheonji.html. 11. stone l. christianity has been handling epidemics for 2000 years [internet]. foreignpolicy.com; 2020 mar 13. available from: https://foreignpolicy.com/2020/03/13/christianityepidemics-2000-years-should-i-still-go-to-churchcoronavirus/. 12. just b. biblical exhortation in a time of crisis, part 3 [internet]. intersections. everydaybioethics.com. publication pending may 2020. available from: https://everydaybioethics.org/intersections competing interests: none declared. correspondence: bryan just. bajust@cbhd.org cite this article as: just b. historic plagues and christian responses: lessons for the church today? christian journal for global health. april 2020;7(1):7-12. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.nytimes.com/2020/03/10/world/asia/south-korea-coronavirus-shincheonji.html https://www.nytimes.com/2020/03/10/world/asia/south-korea-coronavirus-shincheonji.html https://foreignpolicy.com/2020/03/13/christianity-epidemics-2000-years-should-i-still-go-to-church-coronavirus/ https://foreignpolicy.com/2020/03/13/christianity-epidemics-2000-years-should-i-still-go-to-church-coronavirus/ https://foreignpolicy.com/2020/03/13/christianity-epidemics-2000-years-should-i-still-go-to-church-coronavirus/ https://everydaybioethics.org/intersections mailto:bajust@cbhd.org http://creativecommons.org/licenses/by/4.0/ discussion references short communication november 2020. christian journal for global health 7(4) the time to begin plans for covid-19 eradication is now t jacob johna, dhanya dharmapalanb a phd (virology), frcp (paediatrics), former professor & head, department of clinical virology, christian medical college, vellore, india b mbbs, md, consultant, paediatric infectious diseases at apollo hospitals, navi mumbai, india abstract after the world recovers from the pandemic of sars-cov-2, it is most likely to stabilise as endemic and seasonal, deserving/demanding control efforts perpetually in all countries, unless it can be eradicated. the risk of mortality is high among those above 65 years and those with chronic “lifestyle” diseases. endemic circulation will, therefore, take a heavy toll on life annually. eradication is an extreme form of control, eliminating the disease permanently and globally. effective vaccines are expected in the near future. as the pandemic abates, herd immunity will be very high, enabling early eradication by additional build-up of a vaccine-induced herd immunity. public memory of the pandemic will be fresh, which will assist in social mobilisation and fund raising towards eradication. if time is lost, the infection is likely to become non-eradicable as domestic/farmed animals may become fresh reservoirs. resolve to eradicate and designing its road-map must be made at the earliest. key words: covid-19, pandemics, vaccines, global health “we cannot solve our problems with the same thinking we used when we created them.” (einstein) the covid-19 pandemic, a veritable nightmare the pandemic of the coronavirus disease2019 (covid-19), caused by an infection with severe acute respiratory syndrome coronavirus type 2 (sars-cov-2), has sowed disease, death, and devastation in its path across all countries of the world. by the end of june 2020, it has caused over 9.4 million cases and over 480,000 deaths globally.1 risks of severe disease and death are high in those above 65 years and those with chronic non-communicable diseases (co-morbidities).2 children, adolescents, and young healthy adults tend to develop asymptomatic infection or only mild symptoms and are at low risk of death. the mode and speed of the spread of sarscov-2 resembles that of influenza viruses. the 1918 influenza pandemic (causative virus identified by paleo-virology as a h1n1) had three successive waves in march, september– november, and early 1919.3 h1n1 virus was replaced by h2n2 when it became a pandemic in 1957, which was then replaced by the h3n2 48 john & dharmapalan november 2020. christian journal for global health 7(4) pandemic virus of 1968,4 but the 2009 pandemic h1n1 virus did not replace h3n2, and since then, both h1n1 and h3n2 are endemic globally. each pandemic virus became globally endemic unless replaced by another influenza virus, and sarscov-2 will most likely emerge as globally endemic.5 we have no reason to expect a less virulent beta coronavirus to emerge and replace this highly virulent pandemic virus. two other coronaviruses have emerged as zoonosis first and then human-to-human transmission continued: the sars-cov-1 and the mers-cov, causing severe acute respiratory syndrome (sars) and the middle-eastern respiratory syndrome, respectively. the former did become a pandemic involving 27 countries, resulting in 8,096 cases and 774 deaths.6 by diligently case diagnosing, contact tracing, and quarantining, sars was eradicated within one year without a vaccine or anti-viral drug. this approach failed with sars-cov-2 because of greater transmission efficiency and the fact that infected asymptomatic and presymptomatic (during incubation period) individuals transmitted infection, whereas sars virus was transmitted only after a fever developed, allowing case detection and breaking of transmission chains. fortunately, it has not reappeared as zoonosis in the country of origin as precautions were taken. mers-cov has appeared several times as a zoonosis, often resulting in limited person-toperson transmission. further spread could be interrupted so that it has neither persisted as anthroponosis nor became a pandemic. however, when imported into the korean republic, it caused a major epidemic, but once detected and when nonpharmacological interventions were applied, it could be eliminated.7 sars-cov-2 is a highly efficient person-to-person transmitter and, within a span of 4 months from first recognition in china, it has reached all united nations member countries. it is now fully entrenched globally as anthroponosis and it would be naive and foolhardy to expect that its transmission could be interrupted everywhere using non-pharmacological interventions. to presume it will die out will turn out to be a huge risk if it does not. the world will be safer if we presume the opposite—that it will become pan-endemic when herd immunity grows sufficiently high.5 in the medium term, as the disease remains endemic with annual seasonal prevalence, senior citizens and those with comorbidities will have to live in fear of infection and its consequences, unless effective anti-viral therapy is developed or at least one safe and effective vaccine becomes available, accessible, and affordable even in low income countries, or unless the disease is eradicated. can covid-19 be eradicated? disease eradication is defined as permanent reduction to zero of the worldwide incidence of the causative infection, with deliberate efforts.8 for covid-19 eradication, the coronavirus transmission must be interrupted globally. three biomedical criteria determine if a disease can be eradicated: i) availability of vaccine for primary prevention; ii) availability of a diagnostic tool to reliably detect infection; iii) absence of extra-human reservoir of the agent.8 although sars-cov-2 only recently jumped species from bats to humans as a zoonosis, it is now an anthroponosis, meaning efficiently spreading person-to-person, hence theoretically eradicable.8 the presumptive parent virus in the bat is a millennia old. its emergence as an emerging anthroponosis of zoonotic origin had not happened before 2019, so we have to presume it is a one-off event. as an anthroponosis, it is eradicable, in spite of its original reservoir remaining in nature. however, constant vigilance and escalated surveillance for any new zoonotic to human introduction is needed. if such re-introductions recur, eradication may have setbacks, but we will know if reintroduction, if any, since surveillance will be of eradication quality. thus, if we fear reintroduction of either the same or another coronavirus capable of easy/rapid spread, we must eradicate the current 49 john & dharmapalan november 2020. christian journal for global health 7(4) one, instead of remaining unprepared for such eventualities. diagnostic tests like reverse transcription polymerase chain reaction (rt-pcr) and antibody tests are already available. sars-cov-2 is excreted in the faeces and found in sewage. environmental surveillance of sewage for sarscov-2 can, therefore, be used to detect infection if during the eradication programme it silently reemerges in the community. this is a lesson we have learned from environmental surveillance of the polio eradication programme. the critical intervention tools are vaccines to build herd immunity sufficient to interrupt transmission. currently several vaccine candidates are in the pipeline. we expect more than one vaccine to be on the market by 2021. since infection and transmission are based on upper respiratory mucosal infection, the best vaccine that offers upper respiratory mucosal protection should be used for eradication. since basic reproduction number ro is below 4, theoretically the herd immunity threshold for interruption of transmission would be about 75%.9 vaccination coverage has to top up the existing herd immunity due to natural infection. vaccine efficacy will determine the coverage needed: the higher the efficacy, the lower the coverage needed. why think of eradication when the pandemic is still on? wisdom calls for early eradication of the virus without providing it time and opportunity to better adapt to human hosts and alter behaviour, antigenicity, or virulence. we must pre-empt the virus from adapting itself to non-human vertebrates, potentially allowing them to become non-human reservoirs. if that happens, covid-19 will become theoretically non-eradicable. already canines, felines, and fur animals (mink and fox) are found to be susceptible to infection—we must not allow time for virus adaptation to any domestic, farm, or wild animals. as mink-to-human transmission has already occurred on limited occasions, no doubt there will be strict infection control in mink farms, but leaks are always possible.10 although such infections have been stray instances of reverse zoonosis (human-to-vertebrate transmission), the natural extension of transmissibility is continued enzootic transmission. non-pharmacological deterrents of transmission require social distancing. humans need social interactions from the cradle to the deathbed. economic reconstruction and administrative, health management, recreational, educational, and religious activities require social interactions. however, social interactions will promote virus transmission when it is endemic, a potential catch-22. most important, we must galvanize the world to prepare for eradication while the memory of the nightmare of the pandemic remains fresh in the public’s mind and when public cooperation can readily be solicited. technically, the best opportunity to eradicate the coronavirus will be in the near-term, when herd immunity will be extremely high as the pandemic peaks and evolves as pan-endemic. what will it take to develop a global agenda for eradication? eradication becomes a global agenda only when the world health assembly passes a resolution to commit the world health organisation and its member nations to join in partnership to achieve this goal. for the reasons argued above, eradication must be achieved in the shortest possible time—ideally as short as five years or perhaps a little longer, according to practicality and our collective wisdom. eradication has to be formally certified, which will take one or two more years. an innovative immunisation platform will have to be imaginatively created as the existing ones, such as the expanded programme on immunisation, will be insufficient for eradication. the majority of infections are asymptomatic, hence invisible and silent. children must be vaccinated in spite of low risk of disease; adolescents and adults, young and old, must be vaccinated although individually they may feel no 50 john & dharmapalan november 2020. christian journal for global health 7(4) reason for it. herd immunity must be rapidly built up through high vaccination coverage. the pandemic has taught us a new way of looking at human health problems—and that innovative solutions must be developed. eradication, as an inevitably gargantuan project, will require a huge commitment of human and financial resources across the globe. implementation will require innovative financial design and must be faster than our past performances addressing global public health problems, including polio eradication. scepticism from strong quarters is to be expected and must be countered through persuasive thought leadership and a concerted global educational campaign. the interventions for effective control of the pandemic or country-level epidemics, and for eradication, should not be conceived of as sequential but as simultaneous or overlapping as necessary. we should be ready to implement the eradication programme as soon as a primary prevention tool becomes available. all the deliberations needed and the resolve and resolutions commensurate with the enormity of the challenges should be ready to be in fast-forward gear. “everything is created twice — once in the mind and then in reality” (robin sharma). let us get the first part done by the time reality opens its door for us. references 1. world health organisation. coronavirus disease (covid-19) situation report–158, 2020 june 26 [cited 2020 june 27]. available from: https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200626covid-19-sitrep-158.pdf?sfvrsn=1d1aae8a_2 2. cdc covid-19 response team. severe outcomes among patients with coronavirus disease 2019 (covid-19) united states, february.12march 16, 2020. mmwr morb mortal wkly rep 2020;69(12):343-6. http://dx.doi.org/10.15585/mmwr.mm6912e2 3. taubenberger jk, morens dm. 1918 influenza: the mother of all pandemics. emerg infect dis. 2006;12(1):15-22. http://dx.doi.org/10.3201/eid1201.050979 4. dharmapalan d. influenza [published online ahead of print, 2020 feb 11]. indian j pediatr. 2020;1‐5. http://dx.doi.org/10.1007/s12098-02003214-1 5. john tj. will coronavirus pandemic eventually evolve as pan-endemic? current science. 2020;118(6):855-6. available from: https://www.scopus.com/record/display.uri?eid=2 -s2.085085976260&origin=inward&txgid=e1083edc3 cb277e3b8a1bcdfbcca8e84 6. cherry jd. the chronology of the 20022003 sars mini pandemic. paediatr respir rev. 2004;5(4):262-9. http://dx.doi.org/10.1016/j.prrv.2004.07.0 09 7. al-omari a, rabaan aa, salih s, altawfiq ja, memish za. mers coronavirus outbreak: implications for emerging viral infections. diagn microbiol infect dis. 2019;93(3):265285. http://dx.doi.org/10.1016/j.diagmicrobio. 2018.10.011 8. dowdle wr. the principles of disease elimination and eradication. morb mortal wkly rep 1999;48(su01):23-7. available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/s u48a7.htm 9. liu y, gayle aa, wilder-smith a, rocklöv j. the reproductive number of covid-19 is higher compared to sars coronavirus. j travel med; 2020;27(2):1-4. http://dx.doi.org/10.1093/jtm/taaa021 10. mink infected two humans with coronavirus: dutch government. health. 2020 may 25[cited 2020 may 27]. available from: https://www.usnews.com/news/world/articles/202 0-05-25/dutch-government-second-case-of-minktransmitting-coronavirus-to-human about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 51 john & dharmapalan november 2020. christian journal for global health 7(4) submitted 11 june 2020, accepted 13 aug 2020, published 9 nov 2020 competing interests: none declared. correspondence: dhanya dharmapalan, apollo hospitals, navi mumbai, india. drdhanyaroshan@gmail.com cite this article as: john jt, dharmapalan d. the time to begin plans for covid-19 eradication is now. christ j global health. november 2020; 7(4):47-51 https://doi.org/10.15566/cjgh.v7i4.481 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank https://doi.org/10.15566/cjgh.v7i4.481 http://creativecommons.org/licenses/by/4.0/ the covid-19 pandemic, a veritable nightmare can covid-19 be eradicated? why think of eradication when the pandemic is still on? what will it take to develop a global agenda for eradication? references guest editorial mission hospitals as vital capacity builders in the majority world bruce dahlmana a md, mshpe, faafp, christian academy of african physicians, former head, department of family medicine and community care, school of medicine and health sciences, kabarak university, kenya this christian journal for global health issue (june 2020) gives us a broad spectrum of insights into both the past and the present of how healthcare and medical missions have made an impact in our world. in the commentary elsewhere in this issue, i propose that for the mission of the church to be fulfilled, “healthcare mission” is the responsible party to engage the mainstream mission enterprise to bring about an integral approach, “ . . . as the father sent me . . . [jesus]” (john 20:21). but for there to be greater collaboration of healthcare in mission, capacity must be built to, “ . . . send out more laborers.” (luke 10:12). this must come in many forms — community health, transformational development, and also more locally discipled medical “boots on the ground” in the majority world who can also engage crossculturally. engaging a medical education and discipling agenda when our family arrived in kenya in 1992, i joined three other missionary family physicians, two general surgeons, two nurse anesthetists, and a dozen nurses as the expatriate contingent serving with a staff of 300 at a 220-bed church-owned hospital. we family doctors took first call at night with an occasional western medical student. the nursing school that had started in 1980 still had all missionary tutors who mentored well-trained and caring kenyan nurses. when the lord moved our family on in 2006, specialty physicians, business management, and nursing tutors were nearly all transitioned to kenyan leadership. by then, the hospital mission statement had clearly incorporated the desire to excel in education as well as its traditional clinical and chaplaincy services. the hospital became the focus of the training for hiv workers for the church-based, aids relief pepfar program. the hospital has now grown to a 340-bed capacity, served by 30+ interns and residency trainees in four specialties spanning the breadth from family medicine to pediatric surgery. the majority of the nearly 30 physicians and surgeons are kenyan, supplemented by missionary faculty and shortterm, sub-specialty, teaching staff. this transformation from an expatriate missionary-managed, secondary-care hospital to a tertiary level, teaching and referral hospital is one model of a mission hospital’s future in the majority world setting — embracing specialization with a blended faculty to fill unmet needs in the larger healthcare system. it follows the trajectory of dr. philip woods's forecast in his third decennial review (2011) of a sample of african church hospitals.1 most hospitals within church health systems that had a majority of local doctors had transitioned to national ownership and leadership, and some had started formal residency training programs. do church hospitals in majority world settings need to be involved in residency-level education into the future? and are western medical educators needed? the short answer is, “yes:” 1) there are not enough positions for postgraduate training overall and few in family medicine and other primary care specialties; 2) what programs that do exist are not easy for church hospital junior staff to join; and 3) there is something important about being mentored within a wholistic approach that includes the spiritual dimension of healing. 4 dahlman the “brain push” compounds the brain drain although resources have been invested to rapidly grow the number of medical schools in majority world settings, post-graduate educational opportunities have not kept pace in africa, and likely other areas.2 most african countries have from zero to 30% capacity for their graduates to follow on to specialty residency training, and what is available is mostly in large, big-city, national, referral hospitals. what happens when you are not the one in three or four to find a residency placement? i call it the “push factor” to add to the “brain drain,” which is a “pull factor” that empties the brightest from their countries to seek after specialty training where it can be found. most never return.3 the disproportion in the raw numbers of available residency positions is magnified by the huge disparity of their distribution. when moi university began planning for its first family medicine residency in 2000, the statistics showed less than 25% of the district hospitals in kenya had any specialists, even though the staffing plan intended each to have surgery, obstetrics & gynecology, pediatrics, and medicine specialists.4 over these past twenty years, this proportion has improved as the number of medical school graduates has increased, but long-term commitment to these district facilities by even the “core specialists” is still not the norm. most move on to “greener pastures.” another key need across all countries and sectors is the importance of professionalizing the broad generalist by providing a pathway for an internship-trained “medical officer/general practice doctor” to aspire to an equivalent specialty training. when a small group of family physicians come together, they can rotate the main call responsibilities in a small district hospital, something that cannot be done with single specialists in each of the other primary care specialties. opportunities for primary care specialty training, especially family medicine, outside of the inappropriate huge tertiary referral hospitals, are few. disparity of opportunities unlike most western countries, funding for post-graduate resident salaries in specialty training in most majority world countries is not channeled directly through training hospitals but catered for directly from the central ministry of health human resource system. therefore, the salary follows the government-sponsored resident wherever they serve, district hospital or residency teaching position. therefore, when the mission hospital wants to sponsor their bright and enterprising medical officer, they must pay both the resident to go off to training and the salary of the doctor that must fill the now vacant position. for mission hospitals that operate on whisker-thin financial margins with (rarely subsidized) patient fees being their only source of revenue, it is difficult to attract the national doctors. because of the additional financial burden, the mission hospital finds it doubly difficult to offer a path for professional advancement like the government ministry of health can do with the exchequer to finance the bursaries. when they do return to serve in underserved areas with their often under-resourced (primary and secondary) schools, how will their children receive the same educational opportunity as their parents to follow in their footsteps at the top of the national exams? wholistic care must be modeled caring in christ’s name has a long legacy across the centuries. coincident with the rise of scientific understanding over the last 150 years of how our bodies are fearfully and wonderfully made, missionary nurses, doctors and many other cadres established hundreds of hospitals, health centers, and dispensaries across latin america, south and east asia, africa, and many other places. the number of these facilities has diminished in most countries as the responsibility for health care has been taken up by governments such as the uk’s national health service or african countries’ ministries of health. but the names of the hospital facilities they operate from (e.g., the st. luke’s and baptist hospitals in the us), and the continued presence of church5 dahlman sponsored health ministries started by missionaries across the world reflect the largely christian heritage of providing healing and care to the sick from earliest times. church-sponsored health systems may seem anachronistic to some. but in a kenyan study of how the poor try to pay for their healthcare, the rural church hospital outranked all others, even though the costs were higher.5 clearly, when the poorest vote with their feet to use a churchsponsored health facility, it speaks to something in the care that is worth preserving and growing.6 one of my career-long mentors and colleagues is dr. samuel mwenda, general secretary of the christian health association of kenya (chak) and founding ceo of the african christian health associations platform (achap).7 i once asked him, “is there a continued role for health care in the mission of the church?” there was a long pause and a quizzical look. he answered and in characteristically christological form, responded with another question. “what would jesus do? how would the church not be intimately involved in showing the love of jesus in this way? shouldn’t the church everywhere be directly involved in healing ministries across all domains; the physical, emotional, and spiritual?” if mission hospitals are to continue, one important need is the training and discipling of national consultants who will themselves continue to model wholistic care and the humble service that patients are drawn to and which meets the healthcare needs of underserved areas. although christian faculty and residents within government medical education systems can and do emulate this care, i believe it can best be done within residency programs where faculty are unencumbered to integrate the skills of modern science and technology with mental health and spiritual healing that comes with ministering freely in the spirit’s power. standing on shoulders of giants many might be surprised to learn that starting medical schools and providing specialty physician education is not a new trajectory of medical missions. christian medical schools have been producing national graduates that serve the underdeveloped and underserved areas of their countries and beyond as far back as the founding of che jung wan medical school (now yonsei university) in seoul, korea in 1886.8 similar schools founded before 1920 are found in china, india, and uganda (see jansen’s article in this issue). india’s christian medical centre vellore (1900) 9 and tanzania’s kilimanjaro christian medical centre (1971, now tumaini university) 10 are examples of health care leadership and education in their respective countries. in more recent times, the pan-african academy of christian surgeons11 has trained over 100 surgeons in twelve programs since 2000 who are technically excellent, yes, but who are also serving in under-resourced church and other hospitals for extended years where their skills are needed most. similarly, the christian academy of african physicians12 is being formed to complement what paacs has pioneered in surgery so that more mission hospitals can be supported to also train the primary care specialties; especially family medicine, which started in nigeria in the 1980s. african mission healthcare13 has gathered the alliance; a group of organizations focused on expanding teaching centers of excellence in mission hospitals across africa. the distinct legacy of missionaries starting mission hospitals over the last 150 years is that they gravitated to the poorer, more rural areas where the majority (70 – 90% in most african countries) live and where health disparities are still the greatest. the paacs experience is already showing that graduate physicians are staying to serve in these areas. if excellent training for a complementary specialty such as family medicine can also expand in these mission hospitals, their graduates also will be able to build capacity and continually improve services for the underserved populations who need it most; while also ministering to their spiritual needs and concerns.14 looking forward as we look forward, we need to embrace a great hallmark of jesus’ ministry, both then and now — bringing together skills and gifts from 6 dahlman across the global body of christ to teach and disciple those who will facilitate the wholistic healing that only he can give. in the majority world, and especially in the areas outside the capital cities, the disparities are stark. expanded educational and discipling capacity of church health systems and ministries in these areas can lead to not only “better outcomes.” we can, in the spirit’s power, and as a united, collaborative, mission enterprise, expect to fulfill christ’s charge to, “ . . . do even greater things than these.” (john 14:12). references 1. wood p. the evolution of church mission hospitals in africa. evang missions quart online. july 1 2011 [cited 2020 june 10]. available from: https://missionexus.org/theevolution-of-church-mission-hospitals-in-africa/ 2. rigby p, ranarayan g. world medical schools: the sum also rises. jrsm. 2017 jun;5;8(6): 2054270417698631. https://doi.org/10.1177/2054270417698631 3. crisp n, chen l. global supply of health professionals. new eng j med 2014;370(10):950-6. http://dx.doi.org/10.1056/nejmra1111610 4. schwarz r. the health sector in kenya: health personnel, facilities, education and training. development solutions for africa. nairobi, kenya: kenya ministry of health [internal report]. 1995. 5. zollman j, ravishankar n. struggling to thrive: how kenya’s low-income families (try to) pay for healthcare [internet]. fsd kenya. 2016 [cited 2020 june 10]. available from: https://fsdkenya.org/publication/struggling-tothrive-how-kenyas-low-income-families-try-topay-for-healthcare 6. fort al. the quantitative and qualitative contributions of faith-based organizations to healthcare: the kenya case. christ j global health. 2017 nov;4(3):60-71. https://doi.org/10.15566/cjgh.v4i3.191 7. african christian health association platform. [internet] available from: https://africachap.org/ 8. yonsei university college of medicine. [internet] available from: https://medicine.yonsei.ac.kr/en/index.asp 9. christian medical college vellore. [internet] available from: https://www.cmch-vellore.edu/ 10. kilimanjaro christian medical centre. [internet] available from: http://kcmc.ac.tz/ 11. pan-african academy of christian surgeons. [internet] available from: http://www.paacs.org/ 12. christian academy of african physicians. [internet] available from: http://www.caaphome.org/ 13. african mission healthcare. [internet] available from https://africanmissionhealthcare.org/ 14. van essen c, steffes b, thelander k, akinyi b, li h, tarpley m. increasing and retaining african surgeons working in rural hospitals: an analysis of paacs surgeons with twenty-year program follow-up. world j surg. 2018 sep;43:75–86. https://doi.org/10.1007/s00268018-4781-9 submitted 20 june 2020, accepted 23 june 2020, published 29 june 2020 competing interests: none declared. correspondence settings: bruce dahlman, minnesota, usa bruce.dahlman@aimint.org cite this article as: dahlman b. mission hospitals as vital capacity builders in the majority world. christian journal for global health. june 2020; 7(1):3-6. https://doi.org/10.15566/cjgh.v6i1.413 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://missionexus.org/the-evolution-of-church-mission-hospitals-in-africa/ https://missionexus.org/the-evolution-of-church-mission-hospitals-in-africa/ https://doi.org/10.1177/2054270417698631 http://dx.doi.org/10.1056/nejmra1111610 https://fsdkenya.org/publication/struggling-to-thrive-how-kenyas-low-income-families-try-to-pay-for-healthcare https://fsdkenya.org/publication/struggling-to-thrive-how-kenyas-low-income-families-try-to-pay-for-healthcare https://fsdkenya.org/publication/struggling-to-thrive-how-kenyas-low-income-families-try-to-pay-for-healthcare https://doi.org/10.15566/cjgh.v4i3.191 https://medicine.yonsei.ac.kr/en/index.asp https://www.cmch-vellore.edu/ http://kcmc.ac.tz/ http://www.paacs.org/ http://www.caaphome.org/ https://africanmissionhealthcare.org/ https://doi.org/10.1007/s00268-018-4781-9 https://doi.org/10.1007/s00268-018-4781-9 mailto:bruce.dahlman@aimint.org https://doi.org/10.15566/cjgh.v6i1.413 http://creativecommons.org/licenses/by/4.0/ book review dec 2019. christian journal for global health 6(2) disability in mission – the church’s hidden treasure, eds. david c deuel and nathan g john. hendrickson, 2019. neville howard carra a phd, ma, bd, ba hons, member, australian college of educational leaders and former cms missionary in the philippines and tanzania disability is often viewed as a reason for disqualification or a cause for attrition in crosscultural missionary service. in addition, some theological views may lead to non-inclusive approaches to persons with disabilities, which is being challenged in the twenty-first century.1 there is little in the literature on living with disability as a redemptive part of effective and sustainable missionary service. this book seeks to address that gap in the literature. a co-editor (n. john) asserts that “disabilityinclusive missions provide major opportunities for ministry in the twenty-first century.” he defines disability as “impairments, activity limitations and participation restrictions from various physical and non-physical causes... various weaknesses, emotional issues and vulnerabilities” (p.6). the “success-oriented approach” of mission agencies, he says, squeezes missionary candidates “into rigid molds in which they have to be intelligent, strong, agile, and have high energy: the type a personality.[w]e therefore discount people who are different” (p.3, 4). he and his wife faced challenges raising a severely disabled daughter in a mission context. he argues that many case studies in the book “outline a similar pattern whereby god has worked powerfully in missions through disability, and not just in spite of disability” (p.5). the specific focus on cross-cultural missions and disability is because “international mission is typically out of bounds for people with disability.” rarely do books “explore the role of people with disability in global missions” (p.7). deuel (ch.1) suggests that “god uses disability and any resultant weakness as part of our growth.” weakness in others “is our opportunity to serve them and to help them grow” (p.12). god “chose moses, isaiah and paul in weakness and disability, then sent them on their missions.” he challenges christians to “pray for a greater presence of disability and weakness in the church” (p.17). the man closest to god was the “least able to communicate his experience to others. moses’ disability did not prevent god from using him. this is weakness pressed into service” (p.24). subsequent chapters explore some of the dilemmas and heartaches missionary parents face with the responsibility of caring for a disabled child in a non-western context. bonnie baker, who had a breakdown described as post-partum depression after the birth of her down syndrome daughter (ch.3) asks, “would it be responsible for us as parents to take a cognitively disabled child away from all the resources available in the united states (therapies, special education, etc.) and bring her to a developing country where there was no guarantee that any resources would be available?” (p.33). through the struggles, her daughter (anna) came to be seen as a “leavening agent” of the kingdom, in whom “something of the work of god was going to go on display in anna’s life that would bless indonesian families” (p.41). anna changed several things for bonnie (worldview, calling, and a sense of god’s sovereign purposes in special needs): make no mistake: raising a child with disabilities on the field may be one of the hardest investments you will ever make in your life, but it holds great potential for kingdom impact on the people around you, and it brings glory and pleasure to god (p.44). 58 carr dec 2019. christian journal for global health 6(2) chapter 4 tells how a missionary couple became foster parents of an indian baby born with “no eyelids, no fingers, severely webbed legs, a cleft palate and lip, as well as an absent nose” (p.46). this involved surgeries in the united states, a journey through which god taught them how to love and redefine missions—“a life laid down... adam transformed both my husband’s and my heart and mission to look away from ourselves and our short-sighted views of changing the world” (p.53, 58). barry funnell (ch.5) relates how his paraplegia drew him closer to god, becoming involved through the use of a wheelchair in bible translation work in malawi and tanzania: “my disability has taught me how insignificant working legs are in the light of souls and their eternal wellbeing” (p.73). the story is told, in chapter 6, of paul kasonga, a gifted preacher and leader in zambia, whose leprosy “gave him ministry integrity among his peers and valuable spiritual insight for preaching and counselling” (p.81). justin reimer (ch.10) raises some considerations that parents of children with a disability need to make regarding applying for mission work: [w]e must be careful about our questioning of the missional ability of a friend with a disability and their fitness for ministry... taking your child with special needs out of a culture that provides some of the best disabilityrelated resources in the world and moving them to a country with nearly none of these resources requires a creative approach (p.127, 128). the emphasis in chapter 11 turns to member care. many who approach mission agencies suffer from “physical illness (e.g., food allergies), mental health issues and relational dysfunction,” yet “mission policies and practices still seem unwilling to look past a perceived risk and fully embrace workers with disabilities. there is a near absence within the member care literature regarding the management of those with disabilities. however, there is hope for change as we continue to move forward... [especially] when it comes to disability inclusion” (p.138). the capacity to deal with autism is mentioned: the “more a disability is understood, and the more clearly the needs of the individual or family are made known, the better the risk can be managed” (p.144). four main areas of concern for mission agencies are listed: “(1) the nature and extent of the disability; (2) the parents’ ability to cope; (3) the planned place of service and receiving team; and (4) the suitability of schools and health care in that place” (p.144). some very practical guidelines for sending and supporting agencies come in the penultimate chapter (p.148). the conclusion offers further wisdom: “missionaries with disability can vividly understand the grief and struggles that others with disability feel. they can share deeply in a place of trust that is unique to them” (p.153). it reminds the reader how the “pain and suffering is very real” for each of the contributors and editors of this book (p.155). the mission movement “should focus more on how to enable those with disability to serve, and to continue serving” (p.158). it offers a warning: “if we do exclude people with disability from missions, then the mission movement is missing part of the body. the mission is itself disabled. and that’s not god’s plan” (p.160). reviewer comments pre-field preparation is touched on with reference to a writing project to “teach and train others in how to engage effectively” with disabled children (p.120). mission agencies vary considerably in preparing missionaries for service—from three-week intensives to programs lasting months. whatever unresolved problems beset an individual, couple, or family (e.g., relational, theological, psychological, health, familial), unless addressed rigorously, they will be exacerbated in any cross-cultural context. the editors might have given more thought to this in an otherwise thought-provoking volume. the suggestion that there was “no screening process” in the case of moses (p.21) sends a wrong message. chapter 10 fortunately does note strategies for parents taking a disabled child to the field. there is some problematic speculation that moses, gideon, and paul suffered from a “speech 59 carr dec 2019. christian journal for global health 6(2) disability” or impediment (p.9, 12, 17, 20–22, 24– 25, 87, 88), when “slow of speech” or “thorn in the flesh” may allow other interpretations—for example, in the case of moses, that “he had forgotten egyptian!”2 if god is “the cause of disability,” why is it a “serious error” to blame him (p.22) for a natural response with which god can surely cope? it’s unwise to build a case on scripture that is unclear.3 undoubtedly, the stories in this inspiring book testify of the sovereign grace of god in testing, strengthening, and mobilising the faith and loyalty to him of missionaries living with disability. perhaps further study might be informative about cases with more sinister trajectories (e.g., divorce, apostasy, sibling resentment, or “emotional, physical and relational health breakdown” [p.141]), such as the recent articles in this journal on treatment-resistant depression.4,5 for every “success” story, how many “failures?” what lessons could be learned by mission agencies from such comparative and/or longitudinal studies? chapter 11 deals with member care and provides some good wisdom and guidelines for mission agencies dealing with disability (p.147). a strength and weakness of the book is its reliance on personal stories—powerful and heartwrenching, displaying remarkable resilience and courage; yet prone to a certain sameness. the stories are moving, but perhaps more rigorous editing might have helped. finally, the traditional understanding of mission as sending folks to less developed countries or different people groups is still dominant among agencies and churches. this book is no exception, though clearly testifying to the brokenness and humility of each missionary’s life. the danger is that it elevates the missionary to an elite status among ordinary christians, called by god to engage in mission everywhere. crosscultural mission can take different forms in secular and multicultural societies, like europe or australia. equipping both able and disabled believers for mission in such contexts may have different challenges from those outlined here. this stimulating book calls for a sequel, perhaps entitled disability in mission at home and abroad! i recommend it heartily to any reader with an interest in missions. references 1. otieno pa. biblical and theological perspectives on disability: implications on the rights of persons with disability in kenya. dis studies q. 2009. 29(4). available from http://dsqsds.org/article/view/988/1164 2. chavalas mw. moses. dictionary of the old testament pentateuch. td alexander, baker dw, editors. downers grove, illinois: ivp; 2003. [p.574]. 3. note: abraham’s argument with god about sodom, the many psalms of complaint, or jeremiah’s accusation of god’s deception [jer 15:18; 20:7]. 4. york h. understanding treatment-resistant depression: a missionary’s autobiographical case report. christ j global health. may 2019;6(1):4350. https://doi.org/10.15566/cjgh.v6i1.275 5. york h. biblical reflection on the passion of jesus christ as it relates to 20 years of treatment resistant depression. christ j global health. 2019;6(1):518. https://doi.org/10.15566/cjgh.v6i1.279 peer reviewed: submitted 25 june 2019, accepted 29 aug 2019, published 23 dec 2019 competing interests: none declared. correspondence: neville carr. ebedyah45@gmail.com cite this article as: carr nh. disability in mission – the church’s hidden treasure, eds. david c deuel and nathan g john. hendrickson, 2019. christ jrl global health. dec 2019; 6(2):57-59. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://dsq-sds.org/article/view/988/1164 http://dsq-sds.org/article/view/988/1164 https://doi.org/10.15566/cjgh.v6i1.275 https://doi.org/10.15566/cjgh.v6i1.279 mailto:ebedyah45@gmail.com http://creativecommons.org/licenses/by/4.0/ reviewer comments references case studies nov 2020. christian journal for global health 7(4) frugal innovations that helped mission hospitals manage during the pandemic and further suggestions gnanaraj jesudian a, kevin gnanaraj b, biju islaryc, botoho sumid, george mathewe a ms (gen), mch (urology), fics, fiages, farsi, international federation of rural surgeons, adjunct professor (biomedical engineering), karunya university, and director medical services, seesha, coimbatore, tamil nadu, india b b.tech (mechanical) c ms (gen), crofts memorial christian hospital, assam d mbbs, dnb (rural surgery), medzhiphema community health center, nagaland e ms, md, shanthi bhavan medical center, jharkhand abstract the covid-19 pandemic with the suddenly announced lockdown in india caused great stress to already resource-constrained rural mission hospitals. frugal innovations helped some of the mission hospitals cope with the lockdown and resume regular work. personal protective equipment was made locally and staff were trained to take care of the infected patients. cell phones and the zoom app helped them with communications. the gas insufflation less laparoscopic surgical technique helped them perform safe surgeries and allow quicker turnover of patients. the innovative laptop cystoscope helped in follow up treatment of patients treated earlier by specialists and for emergency treatment. empowering local mission hospital doctors and modern communication methods helped these hospitals maintain services during the pandemic. key words: covid-19, gills, laptop cystoscope, personal protective equipment introduction the christian coalition for heath reported that currently there are 70,000 inpatient beds in the catholic and protestant mission hospitals in india.1 these facilities are the major non-profit providers of health care for the rural population. in india, the pandemic has lowered the utilization of services ranging from 30% to 69%.2 since the beginning of 2020, the number of deaths due to covid-19 is only a tiny portion of the total number of deaths due to any cause.2 most of the hospitals under stress are in remote locations, do not have significant fund reserves, and need to send employees out for supplies.3 we describe some of the frugal innovations that helped the rural mission hospitals survive during the pandemic. materials and methods innovations were collected from three rural hospitals where the association of rural surgeons of india have training programs for rural surgeons. the shanthi bhavan medical center [sbmc] is situated about 150 kilometres from the nearest town, ranchi, from where they need to get supplies. it is the only hospital with facilities for intensive care in the entire 34 gnanaraj, gnanaraj, islary, sumi, mathew nov 2020. christian journal for global health 7(4) district of simdega, which is the most rural district of jharkhand. the crofts memorial christian hospital with 60 beds is at tukrajhar in assam, near india’s border with bhutan. the third hospital is in nagaland, in a small village called medzhiphema, and has 20 beds. the innovations involved making local personal protective equipment [ppe] rather than depending on donations or purchases, conducting consultations using zoom meeting software, performing minor surgical procedures under supervision using the zoom meeting software, limiting surgeries to the more relevant and less expensive, and caring with compassion, a hall mark of mission hospital care. results the following are the innovative ways that were followed at these mission hospitals. personal protective equipment sbmc first made a prototype from the locally available materials as shown in figure 1. figure 1: locally made ppe prototype after using it a few times, the hospital then produced them in bulk as shown in figure 2. figure 2: production of local ppe figure 3 shows a training session. training started many days before the first suspected covid19 patient came to the hospital. figure 3: training the staff further innovations were needed for examining and treating patients. to start with, they did not have a non-touch thermometer. hence, a 2meter long handle with a tray held the usual thermometer which the patient took and used to measure temperature. figure 4 shows the equipment for examining the patient and figure 5 for admitting the patients. 35 gnanaraj, gnanaraj, islary, sumi, mathew nov 2020. christian journal for global health 7(4) figure 4: local patient examination set figure 5: apparatus for admitting the patients patient consultation once the hospital was identified as a covid care hospital, it became difficult to separate the regular patients from those suspected of having covid-19 infections. another problem was that many consultants from other hospitals and medical colleges visited the hospital to help. many patients had double “j” stents [dj stents] placed after urology treatment. they were told to report for stent removals within 3 months of placement. with the lockdown extending for more than 3 months, these patients needed consultations and advice. the zoom application was used for consultations. the zoom meeting links were sent to the patients, their relatives, the hospital staff, and the doctors involved along with the reports of the patients. written advice was sent following the zoom consultation. the feedback from the patients was that zoom consultations were much better than telephone calls that had been used earlier. zoom supervised surgical procedures the camera of the cell phone was used to share the screen using the zoom software so that the specialist from a remote location could guide the local surgeon during procedures like dj stent removals and dj stent placements. figure 6 shows the picture of one surgery in progress. figure 6: zoom supervised dj stenting 36 gnanaraj, gnanaraj, islary, sumi, mathew nov 2020. christian journal for global health 7(4) gas insufflation less laparoscopic surgeries (gills) laparoscopic surgery carries the highest risk of aerosols due to pneumoperitoneum with co2.4 also, sars cov 2 is detected in peritoneal fluid in concentrations higher than in the respiratory tract.5 the use of gills is recognized by the who compendium of innovative health technologies in lowand middle-income countries and makes laparoscopic surgeries possible under spinal anaesthesia.6 in rural areas, the technique offers advantages such as shorter hospital stay, lower chances of contamination, and fewer persons required in the operating room.7 it is recommended by the association of rural surgeons of india, the international federation of rural surgeons, and the association of surgeons of india.8 figure 7 shows the gills device in use. figure 7: the stan laparoscopy position-er tm in use the crofts memorial christian hospital started gills surgeries with zoom supervision after isolating pre-operative patients who had no symptoms of covid-19 or any contact with covid-19 positive areas for 7 days. the laptop cystoscope two of the hospitals were able to use the lowcost laptop cystoscope shown in figure 8 to remove and insert dj stents using the zoom meeting software for supervision and guidance during the procedure. figure 8: the laptop cystoscope this is an innovative device that has a camera instead of a telescope and connects to the laptop computer. prior dj stenting and ureterorenoscopy are innovative methods for treating renal and ureteric stones in rural areas.9 the use of the zoom app helped with supervision of the surgery from a remote location. the cell phone camera’s pictures could be shared through zoom using the screen share facility and remote guidance in pointing out the orifice and monitoring the progress was possible. ongoing innovations the time available due to the lockdown was used to work on research projects that would be useful in the future. comfortable ppe currently available ppe were not comfortable to wear and health care workers were eager to take them off after their use. skin injuries and complications were common. in one of the studies, they found that “soaked skin combined with pressure increased the friction coefficient between the ppe and skin, and when masks and goggles were removed quickly, skin tears happened.”10 the authors designed a prototype shown in figure 9 that makes ppe comfortable to wear. 37 gnanaraj, gnanaraj, islary, sumi, mathew nov 2020. christian journal for global health 7(4) figure 9: prototype for comfortable ppe it has cooled, filtered air pumped in so that there is some positive pressure for safety and cool air inside for comfort. the peltier thermo-cooler effect could be used for cooling, and a special coating and passing electric current could prevent fogging. special powerful led lights could help too. robotic remote consultation unit the authors are also working on a remotely controlled robotic unit that has facilities for measuring pulse rate, oxygen saturation, and blood pressure in addition to transmitting voice and pictures. height, weight, and body mass index, blood sugar, and haemoglobin are possible additional non-invasive measurements we are considering for future addition.11 we are also working on a remote controlled robotic unit with a camera that could allow a closer look at areas of interest. later, these arms could be used for holding ultrasound probes, camera, or instrument while helping with surgical procedures from a remote location. figure 10 shows the base model on which these additions are planned. figure 10: remote controlled robotic assistant discussion caring for the sick has long been considered a hallmark of christianity. christian health care workers cite biblical references of the call to medical missions as an example of god’s unconditional love (matthew 10:8; luke 10:8–9, 25–34). although christians have been involved in medical missions throughout history, participation in short-term medical missions (stmms) has grown dramatically in the past few years.12 the pandemic highlights the problem with the stmm when the local doctors are not able to do the work of the visiting faculty. however, empowering local surgeons helps them to continue to work to the best of their ability.13 thanks to the training by the association of rural surgeons of india, the local surgeons were able to carry on the surgeries with gills and laptop cystoscope. the visitors to the mission hospital were able to support the hospitals by donating to the hospital which paid for the ppe and the staff’s salaries. the staff also contributed to mitigate the crisis by offering to take payment only for their needs during the pandemic rather than taking their full salaries. the staff also participated in the zoom lectures on gills so that the surgeons in other low and middle-income countries (lmics) in africa could 38 gnanaraj, gnanaraj, islary, sumi, mathew nov 2020. christian journal for global health 7(4) benefit from their experience. the patients appreciated the efforts of the staff. summary the pandemic forced the local lmic hospitals to be more autonomous and to problem solve rather than relying on help from outside. the rural surgery associations played an important part in supporting these hospitals with necessary guidance and innovations. references 1. christian coalition for health. cchi | health care movement in india [internet]. ccih. 2018. available from: http://shalinimembership.wixsite.com/cchi/healthcare-movement-in-india 2. cash r, patel v. has covid-19 subverted global health? lancet. 2020;395:1687-8. https://doi.org/10.1016/s0140-6736(20)31089-8 3. anderson da. the future of christian mission hospitals in india. j christ med assoc india. 1958;33(5):246-9. 4. shinde dp. covid-19: guidelines for surgeons for use after lockdown is withdrawn [internet]. [cited 2020 jun 29]. available from: www.awrsurgeons.com 5. coccolini f, tartaglia d, puglisi a, giordano c, pistello m, lodato m, et al. sars-cov-2 is present in peritoneal fluid in covid-19 patients. ann surg. 2020 sep; 272(3): e240–e242. https://doi.org/10.1097/sla.0000000000004030 6. world health organization. who compendium of innovative health technologies for low resource setting [internet]. 2017. available from: https://www.who.int/medical_devices/innovation/co mpendium/en/ 7. gnanaraj j, rhodes m. laparoscopic surgeries in middle and low income countries. gasless lift laparoscopic surgeries. surg. endosc. 2016 may;30(5):2151-4 http://dx.doi.org/ 10.1007/s00464-015-4433-1 8. gnanaraj j, aruparayil n, reemst p. revisiting gasless laparoscopic surgeries for possible benefits during and after the covid-19 pandemic. trop doct. first published 2020 aug 6. http://dx.doi.org/10.1177/0049475520945444 9. gnanaraj j, ellapan b. ureterorenoscopic removal of renal stones: cost-effective patient friendly method in rural areas. trop doct. 2011 apr;41(2):102. http://dx.doi.org/10.1258/td.2010.090318 10. chadha s. rash, sweat, bruises: wearing ppe for hours causing skin infection [internet]. fit. 2020 may 7. available from: https://fit.thequint.com/coronavirus/ppe-causesrashes-sweat-and-discomfort-doctors-shareexperiences-during-coronavirus-care 11. gnanaraj j, rajasekaran, rekh s, jyothi j, mary a. non-invasive haemoglobin measurement: a great blessing to the rural community [internet]. md current. n.d. available from: http://mdcurrent.in/primary-care/non-invasivehemoglobin-measurement-a-great-blessing-to-therural-community/ 12. grundmann gh. mission and healing in historical perspective. int b of mission research. 2008;32(4):185-8. http://dx.doi.org/10.1177/239693930803200404 13. gnanaraj j. working holidays for overseas doctors: host perspective in mission hospitals in rural india. christ j global health. 2015 may;2(1):35-42. http://dx.doi.org/ 10.15566/cjgh.v2i1.53 peer reviewed: submitted 1 july 2020, accepted 10 sept 2020, published 9 nov 2020 competing interests: none declared. correspondence: dr. gnanaraj jesudian, tamil nadu, india. jgnanaraj@gmail.com cite this article as: gnanaraj j, gnanaraj k, islary b, sumi b, mathew g. frugal innovations that helped mission hospitals manage during the pandemic and further suggestions. christ j for global health. november 2020; 7(4):33-38. https://doi.org/10.15566/cjgh.v7i4.419 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted us distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank introduction materials and methods results references commentary nov 2014. christian journal for global health, 1(2):16-18. shalom & eirene: fully caring for the afflicted person apolos landa a a md, msc chdc of lshtm , mth regional coordinator for south america, luke society, moyobamba, peru the biblical concepts and categories relating to the person portray the individual as a multidimensional relational totality. to be fully human is to be a constitutive part of the whole creation in an enhancing relationship with god, with others made in his image and likeness, and with the rest of god’s creation. the ecosystem, cultureeducation, family, and friends unavoidably influence the individual, as do the choices he or she has already made. thus to be “a responsible partner” with god in the creative process of becoming and making shalom, a person needs to be selfreconciled and then become reconciled one with another, in family, in community, and in all other spheres of their immediate and cosmic context. it is this that proves a person to be truly reconciled with god and thus enables him or her to become fully human. the creation narratives give us an understanding of what god’s ideal is for human wholeness in regard to physical and social health. in genesis 1 and 2, god’s creative project is pronounced good and finished, up to the stage at which humanity had been created. from there, male and female, as a human partnership, are commanded to subdue and rule the creation and the powers of creation with a view to the fullness of god’s cosmic intention, even in the aftermath of the fall. 1 yet, due to disobedience and rebellion, there is a dramatic failure and the task of establishing shalom ( ), health and wholeness remains far from being completed. the good news is that god has not given up on his creation. in the pentateuch (torah), we gain understanding of how god chooses and calls from fallen humanity those with whom he will work. moreover, god restores and saves, prepares, and involves this people in his ongoing quest to bring back his humanity and creation to completion. goldingay agrees with juergen moltmann and concludes that “genesis does recognize that creation was the beginning of a project, not the end of one.” in fact, he goes further, asserting that . . . the statement that god’s relationship with the world involves “creation, conservation, and transformation” does not say quite enough. even before it went wrong and needed restoration, it was a project still on the way . . . god would hardly have given humanity the task not merely of maintaining it but of subduing the world. so the renewed world is not merely a world restored to its edenic state, but one taken to the destiny god intended when creating it. god’s creation commission was that humanity should subdue the earth (gen 1:28), win it to the internal harmony that was apparently not built into it even though it could be described as “good,” and god is still committed to the fulfilling of that creation project. there will come a day [as isaiah 11 and 65 envisions, in which there will be total harmony] . . . without human beings or animals eating one another [and that] is part of the dream vision of genesis 1, of a world that reflects yhvh’s abode in heaven . . . a new creation in which the great limitation of the old, the reality of death, is overcome. 2 paul tillich calls this process “cosmic healing” and states that “when salvation has cosmic significance, healing is not only included in it, but salvation can be described as the act of cosmic healing.” in a person, the cosmos converges and 17 landa nov 2014. christian journal for global health, 1(2):16-18. is united, and, therefore, in a person, it has to be reconciled, healed, saved, and subjected again. he says: [not to see salvation and healing related] . . . implies a conscious or unconscious rejection of the idea of cosmic disease, the universal fall, and of cosmic healing, the universal redemption. it does not see that the eternal fulfilment is actual in the fragmentary fulfilment in time and space. healing as well as salvation are temporal and, at the same time, are eternal. healing acquires the significance of the eternal, and salvation the actuality of the temporal. 3 the new testament greek lexicon and the nuevo diccionario bíblico español certeza (ndbc) informs us that the meaning of healing is closely related to salvation, as the meaning of the greek word soteria, sozo (to save, to heal) in the nt parallels the meaning of the hebrew yasha´ (from which the words moshiah–messiah and yeshua–jesus derive) in the ot. 4 this hebrew verb, according to the old testament hebrew lexicon, means to save, be saved, and be delivered. salvation, known as the greek word soteria, is merely a derivative noun from sozo, which is the verb form, and derives in turn from a primitive sos (contracted for the now obsolete word saos, “safe”). it has also been found that the root of the word “salvation” in many languages indicates healing, as paul tillich illustrates: thus, the greek word soteria is derived from saos (sic); the latin word salvatio from salvus; the german word heiland from heil, which is akin to the english word “healing.” saos, salvus, heil, mean whole, not yet split, not disrupted, not disintegrated, and therefore healthy and sane . . . the english translation of sesoken se [“has saved thee,” referring to an act of healing by jesus in mat 9:12] reads: “made thee whole.” salvation is basically and essentially healing, the re-establishment of a whole that was broken, disrupted, disintegrated . 3 both, in the bible and in the mythological narrative of many non-biblical witnesses, tillich finds a basis for saying that salvation, in the sense of making whole or healing, equally applies to the physical, psychological, and social dimensions of human life. he explains that . . . every specific state of health or salvation represents the cosmic wholeness in a being which is a fragment of the whole, and whose wholeness is, therefore, always conditioned, threatened, imperfect, and pointing beyond itself. 3 a vision of the kingdom of god is a vision of a creation brought to wholeness, that is, to a state of shalom ( ). it is also a vision of a society in which the values of justice, peace, and joy in relationship prevail without exclusion. therefore, healing also “involves a struggle against injustice by making the necessary resources available to the poor,” the agents of healing –themselves risking poverty. 5 this is the attitude in which the mission for salvation or healing must be forwarded in the world. the journey towards shalom and wholeness includes pain and suffering. these are not realities that can be ignored. health is not simply the absence of illness. if it were so, then the chronically sick, the disabled, and the frail elderly would be discounted from a healthy society, a reality which, though unacceptable and reproachable, is never far away in our western lifestyle. therefore, there is no guarantee that the healing agents will not be wounded in the process of fulfilling their mission. the recent experience of many health agents both secular and religious with ebola epidemics in liberia speaks a great deal about this. sometimes, the healing that deals also with values and relationships includes breaking, wounding, and even permanent scars for those seeking healing and wholeness. as in the case of jacob, after healing his relationship with his brother esau, he walks away to a full life with a conquered blessing from god, with a dignifying new name, but with a permanent limp. thus, for caring and healing, tillich concludes: this is the function of reconciliation, to make whole the man who struggles against himself. it reaches the centre of personality, and unites man not only with his god and with himself, but also with other men and 18 landa nov 2014. christian journal for global health, 1(2):16-18. nature. reconciliation in the centre of personality results in reconciliation in all directions, and he who is reconciled is able to love. salvation is the healing of the cosmic disease which prevents love. 3 such are the powerful values and insights that the biblical shalom ( ) and eirene (εἰρήνη) shed for our health care concerns and practices of today. to recover them provides reasons to reject the “patent-evergreening” 6 free-market deformation of pharmaceutical, medical, and health developments 7 for commercial profit. 8 conversely, it provides reasons to equally reject the abuse of users and beneficiaries of the blessings of health and care by running senseless risks, by carelessness, and by negligence that overload the health systems unnecessarily, revealing no personal or collective concern for those in real need. 9 it leads also to the rejection of all egotism in people, companies, and states that impose endeavours with negative impacts for nature, society, and life. anything less than an integrated approach to health and healing in the search for wholeness for the human person and creation will result in mere patchwork efforts and disillusionment. it can also wound and corrupt the healers. as those in mission, sent to heal in the comprehensive approach of god’s intention, healers need to rediscover the biblical view of the person, as well as of health and healing. references 1. gen. 1:26, 28c; psalms 8:3-8; heb. 2:6-9. 2. goldingay j. old testament theology: israel’s faith, vol. 2. downers grove, illinois: ivp academic; 2006. [p.728-9] 3. tillich p. the meaning of health. the relation of religion and health historical considerations and theoretical questions. in palmer m, editor. writings in the philosophy of culture, vol 2. new york: walter de gruyter & co.;1990. [p 211-6] 4. bruce ff, marshall ih, millard ar, packer ji, wiseman dj, powell dr. el nuevo diccionario bíblico certeza, 2nd ed. buenos aires: ediciones certeza unida; 2003. [1220 p.] [author’s free translations] 5. allen ea. the church’s ministry of healing: the challenges to commitment. in allen ea, luscombe k, myers bl, et al, editors. health, healing and transformation. california: mark/world vision international; 1991. [p 23] 6. a full new patent for the same slightly modified product, to avoid patent expiration, and to extend profiting monopoly for the pharmaceutical products at the expense of excluding generic drugs from the market. 7. mudur g. msf challenges novartis's action over indian patent for imatinib. brit med j. 2007; 334: 172. http://dx.doi.org/10.1136/bmj.39104.718380.ab 8. blech j. inventing diseases and pushing pills: pharmaceutical companies and the medicalization of normal life. new york: routledge; 2006. [p 17, 21-3, 66-8] 9. lessig l. free culture: how big media uses technology and law to lock down culture and control creativity. ny: penguin press; 2004. [p 211-3] _____________________________________________________________________________ this is part ii of a two-part series. portions of this paper were previously published in the lausanne world pulse, february 2009 http://www.lausanneworldpulse.com/themedarticles.php/1090?pg=all competing interests: none declared. correspondence: dr. apolos landa. luke society, moyobamba, peru panluk@usa.net cite this article as: landa, a. shalom & eirene: the full framework for health care. christian journal for global health (november 2014), 1(2):16-18. http://dx.doi.org/10.15566/cjgh.v1i2.39 © landa, a. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ _______________________________________________________________________________ www.cjgh.org http://dx.doi.org/10.1136/bmj.39104.718380.ab http://www.lausanneworldpulse.com/themedarticles.php/1090?pg=all mailto:panluk@usa.net http://dx.doi.org/10.15566/cjgh.v1i2.39 http://creativecommons.org/licenses/by/4.0/ short communications april 2020. christian journal for global health, 7(1) the real hero and the real challenge in the covid-19 era apolos b. landaa a md, msc, mth, past regional coordinator for south america, luke society, moyobamba, peru we are going through a truly historic event — memorable for generations to come. us old doctors, separated from the service due to precautions for covid-19, had, in our time, cholera, malaria, yellow fever, and guerrillas (mrta, sendero, etc., in peru), but those are nothing compared to the challenge for this generation of health workers (hws). my young colleagues have a leading role to play — a priestly role like aaron, the brother of moses, when they came out of the oppression of egypt (numbers 16: 45-49), who interposed between the living and those who died in the plague of core, datan, and abyran — and the plague stopped! we offer prayers for you and your families! the real hero is not the celebrity from sports, hollywood, politics, or the ceo of pharmaceutical or biotechnology corporations, but the hard-working and dedicated health professional – those who serve in markets, farmers, bank employees, police, and workers of municipal cleaning that are exposed every day, so that every country remains standing and the nation does not collapse. the coronavirus is showing us how absurd it is to try to live with our backs to each other, without wanting to recognize that we are all, in everything, interdependent and co-responsible. the materialistic system based on receiving for oneself, dehumanized us and made us depend on individualistic profit and consumption, without responsibility for each other, and even less for the creation/nature of which we are part. we evaded our part and passed our responsibility onto others. and now nature/creation sends us a virus that shows us how vulnerable we really are. we pretend to be cordial and affectionate, when in reality we are not concerned about the well-being of others. this vulnerability shows us that in this way we may never become part of the mutuality system for which we were created, in which the law of mutual responsibility and guarantee governs. that is, we all give the best of our abilities for the greatest well-being of all, and we do not worry about ourselves because we have everyone worried about us too (2 corinthians 8:12-15). so, nobody lacks because nobody accumulates too much for himself. that law is as old as creation itself: "love your neighbor as yourself" (leviticus 19:18; luke 10:27). hopefully, this time we do not ignore that ancient directive. as in exodus, before sinai, it is only in obeying it that we will understand. as rabbi dr. michael laitman would say it: in fact, this virus is a remedy for my ego and it comes to show me that i must rise above my ego and connect with others and in this i find the remedy, the correction for our situation. let's try to realize that running away, that my selfish "i" towards the common point between us, in this connection is the upper world, the upper force, the main dimension, a higher level than mine, this is what is called israel (right / yashar / אל–ישר g-d / el / אל) right to g-d, and there we will be directed towards the creator and there is our eternal, spiritual life in the connection between us.1 31 landa april 2020. christian journal for global health, 7(1) even the meaning of professional and personal success seems to have changed in our times. success was usually defined or perceived as a feeling of fulfillment by fitting into a role, which in turn confers value and meaning to the very existence within a system. much more than in all history, in the last two generations, the current socio-economic system linked success to monetary gratification, to wealth or material attainment, to the level of power, control and influence that one exerts on others; and to the unlimited satisfaction of our desires, making them insatiable. health professionals have not been immune to this distortion, which has led to perceiving health as a commodity, the health system as a profit industry, and illness as a recyclable condition that gives us the opportunity to achieve professional or personal "success". this is the reason why at the same time that humanity has reached the maximum capacity to generate wealth and welfare of all kinds; along with the greater technological development to prevent, early-diagnose and eradicate diseases, there is more soul impoverishment, misery and disease than at all times in the world's history. true, health is the most complete state of physical, mental, social and spiritual well-being -ie. shalom, and not only the absence of disease. however, to achieve this we need to postpone money, prestige and power as satisfying determinants of success in our doctorpatient/community relationships and we must recover the value of the total person; the significance of the human connection and social, emotional, and spiritual unconditional reciprocity as the basis and guarantee of personal and collective well-being. how do we achieve this? such is the challenge and the task that we have before all the health professionals and society, who awoke to what this coronavirus is making us conscious of. a virus is a message, a piece of information, a string of precise rna commands or instructions, but a message nevertheless. maybe, then, the sars-cov-2 virus is a message from our damaged world – from nature, be it nonhumanor human-manipulated – a message from our damaged system of life due to our materialism and our attitude of receiving insatiably for ourselves without considering others. this dehumanizes us, when we depend on an individualistic profit and consumption, and disregard the other — including all of creation/ nature. like when our computer systems get hung up when the software is contaminated by a distorted message from an extraneous virus, our systems of life in the world get hung up until we scrutinize and discover the errors and correct the software. our ego was created as a recipient, always desiring to receive; we are not guilty of that. however, the final purpose of our creation was to be conformed to the image and likeness of our creator. but the one who created all was never lacking anything. in fact, he is the source, the eternal bestower, the one who is good and doer of good. his glorious nature is just being the source, the existence, and end of everything (rom 11:36), never lacking, never wanting, and complete in himself. how could we ever become like him, for everything we are has been received and so does proceed from him. we start to resemble him when we acknowledge him, turn towards him, and want to be like him in all his communicable attributes, above all the attribute of bestowing. hence, this changes the intention from receiving for ourselves to receiving only for the good of his creatures (humanity) and creation. so, we give delight to the creator when we also want to give what we have received and so fulfill the desire of our creator for his creation, which is to be good 32 landa april 2020. christian journal for global health, 7(1) and do good to all, which will bring about total well-being, which is health for all! 2(ein 'od m'lvado) אין עוד מלבדו references: 1. laitman m. from the morning lesson. destacados seleccionados. 2020 apr 1. cabalá media. petak tikva, israel. available from: https://kabbalahmedia.info/es/lessons/cu/xva3jw c9?sstart=0m54s&send=4m41s 2. deuteronomy 4:35c "אין עוד מלבדו","ein 'od m'lvadoh" is the transliteration of the hebrew text which literally means "there is no one (nothing) but him alone" from whom all things proceed. competing interests: none declared. correspondence: dr. apolos landa, san martin, peru. apoloslanda@gmail.com cite this article as: landa ab. the real hero and the real challenge in the covid-19 era. christian journal for global health. april 2020;7(1):30-32. https://doi.org/10.15566/cjgh.v7i1.383 © author this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://kabbalahmedia.info/es/lessons/cu/xva3jwc9?sstart=0m54s&send=4m41s https://kabbalahmedia.info/es/lessons/cu/xva3jwc9?sstart=0m54s&send=4m41s mailto:apoloslanda@gmail.com https://doi.org/10.15566/cjgh.v7i1.383 http://creativecommons.org/licenses/by/4.0/ references: commentary april 2020. christian journal for global health 7(1) when demand outstrips supply: a christian view of the ethics of healthcare resource allocation during the covid-19 pandemic james haslama and melody redmanb a mbbs, consultant in anaesthesia & intensive care medicine at salisbury nhs foundation trust, wiltshire, uk b mbbs, paediatric trainee & leadership fellow, sheffield, uk abstract the coronavirus (covid-19) pandemic presents the greatest challenge to global healthcare systems in living memory. this article deals with the ethics of rationing the supply of scarce healthcare resources, such as ventilators, during periods of high demand, such as the current pandemic. existing ethical guidelines and commentaries are cited and critiqued from a christian ethics viewpoint. key words: coronavirus, covid-19, pandemic, bioethics, christian ethics, rationing. introduction as doctors working in the united kingdom’s national health service (nhs), a well-resourced and integrated european healthcare system, we approach the subject of healthcare rationing with a degree of humility. we are yet to work in a healthcare setting in a developing nation, where agonising decisions around resource allocation can be a daily occurrence. on one level, we have minimal experience of rationing essential resources for our patients. but, after deeper reflection, perhaps those of us who work as doctors in the nhs do have at least some expertise in resource allocation? we may not sit on the donation ethics committee, deciding which patient on the transplant list is most deserving of the latest precious organ: … the single mother? … the recovering alcoholic with liver disease? … the university student? … the doctor? we do, however, triage patients all the time. the word triage is derived from the 14th-century french verb trier, which means to pick or sort.1 when we are deciding which patient to see next on our list of referrals, do we decide purely on a “first-come, firstserved” basis, or do we prioritise on the basis of need? when the crash bleep goes off for a bleeding periarrest patient, do we leave them to exsanguinate whilst we continue our clinic, or do we prioritise on the basis of urgency? when we apply for funding to give a novel treatment, we do so on the basis we believe a particular patient in our care meets the criteria to benefit from that treatment and that such benefit will offset the substantial cost. if resources were truly unlimited, perhaps all patients admitted to hospital would have a nurse:patient ratio of 1:1, as guidelines state level 3 patients should on the intensive care unit (icu). the reality is that resources are routinely allocated to different patients variably. the question is: on what basis should limited healthcare resources be allocated? when asked, what is the greatest commandment: jesus replied: “‘love the lord your god with all your heart and with all your soul and with all your mind.’ this is the first and greatest commandment. and the second is like it: ‘love your neighbour as yourself.’” (mt. 22:37-39)2 these are fundamental truths by which we make our day-to-day decisions, trivial or important. loving our neighbour may look quite different from one 14 haslam & redman april 2020. christian journal for global health 7(1) person to the next, based on clinical need and health status. yet love must remain at the heart of all our decisions. what does this look like in practice? the covid-19 coronavirus pandemic brings this question into sharp focus. the demand for intensive life-saving resources from seriously unwell, and even critically ill, patients is rising rapidly in countries all around the world. managing this demand has involved measures such as testing, contact tracing, quarantining, and social distancing to “flatten the curve.” there are many examples in scripture of increasing resources in times of challenge through faith and prayer (mt. 14:19; 2 ki. 4:1-7), recruiting more workers (mt. 9:37-38), and training and releasing new leaders (nu. 11:16-17; lk. 10:1). on the healthcare supply side of the covid-19 response, there has been a commendable concerted effort from the uk government to delay elective activity and increase capacity, including staff measures such as: 1. bringing back retired doctors and nurses. 2. recruiting final year medical and nursing students. 3. diverting staff from other specialities, often by closing or delaying non-essential activities. infrastructure and equipment supply side capacity increases include: 1. building or converting new hospitals such as the excel nightingale hospital. 2. creating more high care capacity, for example by increasing use of continuous positive airway pressure (cpap) devices. 3. re-deploying ventilators from the operating theatre and commissioning new ventilators to provide more ventilated icu beds.3 4. increasing financial and other resources. despite these admirable efforts, our supply of healthcare resources is being outstripped in certain locations and may yet be even more dramatically so.4 this will inevitably result in some very challenging decisions around rationing, involving serious ethical dilemmas. the british medical association (bma) has recently produced guidance around the ethical issues presented by the covid-19 pandemic.5 the national institute for health and care excellence (nice) has also produced a rapid guideline for adult critical care during the pandemic, which includes guidance for decision-making around escalation.6 in addition, the royal college of physicians (rcp) has issued guidance, in conjunction with other stakeholders such as the general medical council, the faculty of intensive care medicine, the intensive care society, and royal colleges and faculties.7 as christian doctors, we must consider how we can respond to the ethical challenges posed. here we will attempt to consider some of the issues involved and how to think about them biblically, using beauchamp and childress’ widely recognised four pillars of medical ethics as a framework.8 respect for patient autonomy it is clear that if a patient has capacity and refuses escalation in care, even life-sustaining treatments, these cannot be forced on them, even if this seems unwise.9 however, if a patient insists they should be for full escalation, that does not necessarily mean they are a suitable candidate or that they should be offered all potentially available treatments. doctors are not obliged to offer treatments that they consider are not in their patient’s best interests. it can be clinically appropriate to withhold certain treatments that are unlikely to be of benefit.10 unfortunately, in some cases, intensive treatment may convert what could be a “good death” into a “bad death.” dying in the more impersonal context of an icu, or even in hospital at all, is an outcome that many patients would wish to avoid. with this in mind, some patients, particularly those frail and elderly, might choose not to be treated in hospital but to stay at home with their family with the support of high-quality palliative care or “hospice at home” teams. this may allow patients a more natural death, in the comfort of their own home, and in the company of those they love. beneficence — maximising benefit with good stewardship of resources as christian healthcare workers, we are called to be good stewards of our resources – see, for example, the parable of the talents (mt. 25:14-30). however, utilitarianism11 — “the greatest good for the greatest number” — often makes us deeply uncomfortable. the ends do not necessarily justify the means; motives, 15 haslam & redman april 2020. christian journal for global health 7(1) virtue, and other moral principles can be neglected12 in this approach to ethics that often emphasizes the value to society over the paramount value of each individual human life (“ends in themselves” — immanuel kant). yet, the covid-19 crisis is an example of an extreme circumstance with an overwhelming need and limited resources where a utilitarian ethic may be justified. dr david stephens is helpful here: you are forced into using a utilitarian ethic decision-making process under these conditions: • there are limited resources. • there are no moral absolutes for or against an action . . . • you know your moral duty but are not sure how to fulfil it . . . • there is a conflict between two moral duties and both cannot be fulfilled . . . • you must prioritize duties . . . when you are forced to employ a utilitarian ethic, you constantly re-evaluate your allocation decisions based on changing circumstances.13 we know that we have limited and finite resources, and healthcare has to be rationed to some extent; we have seen in many areas already the postponement of many routine and elective services. therefore, it seems reasonable where resources are insufficient, to prioritise access to intensive interventions for those who are more likely to benefit. ultimately, it is the application of this principle which is most challenging; as our knowledge about covid19 is patchy but expanding, we may find ourselves making decisions about prognoses without feeling we have the full information at our disposal. yet making no decisions at all carries even greater potential for harm. it is important to clarify here that we are only endorsing a form of “soft” utilitarianism in these extreme circumstances — what we might consider an emergency stewardship ethic in these extraordinary times. we are not, however, endorsing the “hard” form of classic utilitarianism which depends on a “hedonic calculus” where a summation is made of the positive benefits of an action and then a subtraction of all the negative consequences. this mathematical approach to ethics can lead to all kinds of abhorrent acts, such as organ donation euthanasia, which is anathema to us as christians. there are drawbacks with even this “soft” form utilitarianism: although relevant, this specification of doing the greatest good for the greatest number is inadequate because it ignores other ethically relevant considerations. for example, it is also relevant to consider the number of years of life saved. the moral intuition of many people would support prioritizing a patient who stands to otherwise lose 40 years of life, compared with one with a chronic illness that will in all likelihood result in death within a few years . . . persons who have essential responsibilities in saving lives during the pandemic, such as health care workers and first responders, also deserve heightened priority. the prioritization is not because these individuals are more intrinsically worthy but because of their instrumental value in saving others.14 we will address the prioritisation of certain categories of people later on. the authors of this article go on to advocate an ethical approach which incorporates multiple criteria into a single integrated framework . . . . . . based on (1) patients’ likelihood of surviving to hospital discharge, assessed with an objective measure of acute illness severity; and (2) patients’ likelihood of achieving longer-term survival based on the presence or absence of comorbid conditions that influence survival.14 this framework could be adapted over time, depending on the resource capacity, shifting evidence base, and the context in question.15 to summarise, the overarching priority when making a decision about who should receive treatment during this crisis is: how likely a person is to survive and the speed of anticipated benefit. relevant factors include: 16 haslam & redman april 2020. christian journal for global health 7(1) • severity of acute illness • presence and severity of comorbidity • frailty or, where clinically relevant, age16 this brings us to prognostication and certainty. doctors vary in their ability to prognosticate likely outcomes; achieving a high degree of certainty in prognostication is fraught with difficulty. we must approach this with humility, using robust tools to help us identify disease severity (such as the sequential organ failure assessment (sofa) score) with an extensive evidence base17 to assist us. tools also exist to help us recognise when our patients are nearing the end of their lives.18 the word of god repeatedly commands us to be compassionate, just as our heavenly father is compassionate: finally, all of you, be like-minded, be sympathetic, love one another, be compassionate and humble. (1 pt. 3:8) we know that healthcare workers are particularly susceptible to “compassion fatigue,”19 and some of us may have seen this in ourselves or others. but despite increasing stress and pressure in this time, the command remains. as christians, now is a time to receive the compassion and comfort of the lord so that we may pass it on to those around us (2 co. 1:3-4). from that starting point, how can we identify ways to help prevent compassion fatigue in ourselves and those around us during this time of crisis? we should acknowledge the moral distress that rationing in the context of a pandemic will cause healthcare teams and should look to model what it means to promote wellbeing in our colleagues, as well as our patients. this is a complex area and we recommend spending some time reading20 and praying around this topic. distributive justice — ensuring impartiality, equality and fairness fairness in healthcare resource allocation could be achieved by random selection, such as a lottery, or by “first-come, first-served” allocation, but would mean that people who happen to get sick later on (perhaps because of their strict adherence to public health recommendations) are excluded from treatment, worsening outcomes without improving fairness.15 as christians, we affirm that all people have intrinsic value and significance, being made in the very image of god (gn. 1:27), and are equally worthy of care. one of the greatest pleasures of being part of team nhs is that this truth is widely celebrated — three of the six values in the nhs constitution are “everyone counts,” “compassion,” and “respect and dignity.”21 the government introduced an ethical framework for decision making for pandemic influenza, which was revised in 2017.22 it is a respectable framework and appropriately recognises: “everyone matters equally” and “people with an equal chance of benefiting from health or social care resources should have an equal chance of receiving them.” however, equality is not the same as uniformity; that all patients are equal does not mean they should all be treated the same. hippocrates’ ancient adage comes to mind: cure sometimes, treat often, comfort always. in our view, the most controversial aspect of the bma guidance is the section entitled, “maintaining essential services.”5 it argues for prioritising certain groups of people according to their utility to society, for example those who work in essential services. rather than doctors making these decisions, it argues this is a role for government. how about this thought experiment? three patients are in need of the last ventilator: one is a government minister; one is an experienced critical care nurse; and the other is a prisoner, a convicted paedophile. who would you choose? the nhs depends on an unwritten social contract between the population and the service. every year the population provides a large sum from general taxation in the understanding that the service will provide care in a fair, just, and non-discriminatory way. to give preferential care to those with higher status, whether vips or key workers, would prove intensely unpopular and socially destabilising. the long-term damage to the public’s attitude and trust in the nhs may be far worse than the short-term benefit in saving the lives of a small number of prioritised individuals. the bma guidance even recognises that, “decision-makers could face criticism for discriminating between individuals on the basis of social, rather than solely medical, factors.”5 17 haslam & redman april 2020. christian journal for global health 7(1) so, is the answer simply not to discriminate in this way at all? god’s creation blessings are given indiscriminately, to the “just” and the “unjust:” but i tell you, love your enemies and pray for those who persecute you, that you may be the children of your father in heaven. he causes his sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous. (mt. 5:44-45) this ethic is the underpinning of conceptions of justice within all societies based on the judaeochristian tradition. justice becomes corrupted if it discriminates in favour of some lives over other lives. throughout scripture, in different contexts, we see that all people are of equal worth, and we should not favour individuals based on their social (ga. 3:28), financial (jm. 2:1-9), or other status — our god abhors favouritism and loves impartiality (pr. 24:23; rm. 2:11; lk 14:12-14). indeed, we are called to be advocates of the vulnerable (pr. 31:8-9). the rcp ethical guidance, reassuringly, makes this anti-discriminatory approach more explicit: treatment should be provided, irrespective of the individual’s background (e.g. disability), where it is considered that it will help the patient survive and not harm their long-term health and wellbeing.7 consideration also needs to be made for access of non-covid-19 patients to scarce healthcare resources. for example, how do we care for those requiring urgent and risky cancer treatments when our hospital resources are close to exhaustion? these are very difficult challenges and we need to pray for wisdom. non-maleficence — minimising harm consideration of when it may be appropriate to withdraw life-sustaining treatments, including invasive ventilation, in those who deteriorate despite it or have failed to respond, will also be important during this crisis. decisions around withdrawal of life-sustaining treatments are made frequently in an icu setting on clinical grounds of futility. withdrawal of treatment is not morally equivalent to intentional killing.10 in those circumstances, death is already in the room, and allowing a death to take place is not the same as causing death. perhaps, during this covid-19 crisis, decisions around withdrawal may, out of necessity, occur sooner than would happen under normal circumstances and on grounds of resources if there is ongoing demand for scarce lifesaving assets such as ventilators for use in patients who are more likely to benefit. bma guidance states: health professionals may be obliged to withdraw treatment from some patients to enable treatment of other patients with a higher survival probability. this may involve withdrawing treatment from an individual who is stable or even improving but whose objective assessment indicates a worse prognosis than another patient who requires the same resource.5 these kinds of existentially burdensome decisions are fairly unprecedented in well-resourced healthcare systems and, in addition to potential legal ramifications,23 will be emotionally, morally, and spiritually distressing for those clinicians having to make and be made accountable for them. as a consequence of this, it has been advocated that complex decisions around rationing should be made in discussion with a second opinion and even by committee: [w]hen a hospital is placed in the unavoidable but tragic role of making decisions that may harm some patients, the use of a committee removes the weight of these choices from any one individual, spreading the burden among all members of the committee, whose broader responsibility is to save the most lives.24 one of our institutions has convened a clinical ethics committee which will meet regularly to aid clinicians with these more complex and burdensome decisions. we are planning a 24/7 on-call clinical ethics rota for telephone support during this current crisis. is this something you could initiate or engage with in your institution? 18 haslam & redman april 2020. christian journal for global health 7(1) conclusion this covid-19 pandemic provides a clarion call to pray for clinicians, managers, politicians, and all involved in the response. we should pray for new solutions, innovations, and technologies to support healthcare delivery and an end to this challenging crisis. ultimately, we should seek wisdom from the lord (jm. 1:5). we want you to know that we, our families, and our wider church family all across the world are praying for you and other healthcare professionals all around the globe. we must endeavour to be good stewards whilst also lobbying for sufficient resources. throughout, we must strive to affirm that compassion is key, all people are equal, and all are worthy of care. further thought-provoking resources are available from the royal college of physicians: https://www.criticalcarenice.org.uk/clinicalguidelines references 1. edwards m. triage. lancet. 2009;373(9674):1515. https://doi.org/10.1016/s0140-6736(09)60843-6. 2. all scripture passages quoted from the new international version (niv), 2011. 3. as we write, national guidance is to double and plan to more than quadruple intensive care bed capacity. 4. ives j. coronavirus may force uk doctors to decide who they’ll save [internet]. the guardian. 2020 mar 14. available from: https://www.theguardian.com/commentisfree/2020/m ar/14/coronavirus-outbreak-older-people-doctorstreatment-ethics. 5. covid-19 — ethical issues. a guidance note [internet]. british medical association. 2020 apr 1. available from: https://www.bma.org.uk/media/2226/bma-covid-19ethics-guidance.pdf. 6. covid-19 rapid guideline: critical care in adults [internet]. national institute for health and care excellence. 2020 mar 20. available from: https://www.nice.org.uk/guidance/ng159. 7. ethical dimensions of covid-19 for frontline staff [internet]. royal college of physicians. 2020 apr 2. available from: https://www.rcplondon.ac.uk/news/ethical-guidancepublished-frontline-staff-dealing-pandemic. 8. beauchamp tl, childress jf. principles of biomedical ethics. 5th rev. ed. new york: oxford university press; 2001. 9. treatment and care towards the end of life: good practice in decision making [internet]. general medical council. 2010 jul 1. available from: https://www.gmc-uk.org/ethical-guidance/ethicalguidance-for-doctors/treatment-and-care-towards-theend-of-life/principles. 10. haslam j. cmf file 62: withholding and withdrawing medical treatment [internet]. christian medical fellowship. 2017. available from: https://admin.cmf.org.uk/pdf/cmffiles/62_withholdin g_medical_treatment.pdf. 11. bentham j. an introduction to the principles of morals and legislation (1789). garden city, nj: doubleday; 1961. 12. response from cmf to nice on their draft guidelines on social value judgements [internet]. christian medical fellowship. 2005 jun 30. available from: https://www.cmf.org.uk/advocacy/submissions/?id=3 8. 13. stevens d. the ethical approach to limited resources. in: a christian healthcare worker’s response to covid-19 [internet]. medical missions. 2020. available from: https://www.medicalmissions.com/coronavirus. 14. white db, lo b. a framework for rationing ventilators and critical care beds during the covid19 pandemic. jama [internet]. 2020 mar 27. https://doi.org/10.1001/jama.2020.5046. 15. emanuel ej, persad g, upshur r, thome b, parker m, glickman a, et al. fair allocation of scarce medical resources in the time of covid-19. nejm [internet]. 2020 mar 23. https://doi.org/10.1056/nejmsb2005114. 16. coulson-smith p, lucassen a. clinical ethics guidance during the covid-19 pandemic. paper presented at: university hospital southampton clinical ethics committee. 2020 mar 30; southampton, uk. 17. for example, report on 775 patients critically ill with covid-19 [internet]. intensive care national audit & research centre. 2020 mar 27. available from: https://www.icnarc.org/about/latestnews/2020/03/27/report-on-775-patients-criticallyill-with-covid-19. 18. see https://www.goldstandardsframework.org.uk/ or https://www.spict.org.uk/. 19. cocker f, joss n. compassion fatigue among healthcare, emergency and community service workers: a systematic review. int j environ res public health. 2016;13(6):618. https://doi.org/10.3390/ijerph13060618. https://www.criticalcarenice.org.uk/clinical-guidelines https://www.criticalcarenice.org.uk/clinical-guidelines https://doi.org/10.1016/s0140-6736(09)60843-6 https://www.theguardian.com/commentisfree/2020/mar/14/coronavirus-outbreak-older-people-doctors-treatment-ethics https://www.theguardian.com/commentisfree/2020/mar/14/coronavirus-outbreak-older-people-doctors-treatment-ethics https://www.theguardian.com/commentisfree/2020/mar/14/coronavirus-outbreak-older-people-doctors-treatment-ethics https://www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf https://www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf https://www.nice.org.uk/guidance/ng159 https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/principles https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/principles https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/principles https://admin.cmf.org.uk/pdf/cmffiles/62_withholding_medical_treatment.pdf https://admin.cmf.org.uk/pdf/cmffiles/62_withholding_medical_treatment.pdf https://www.cmf.org.uk/advocacy/submissions/?id=38 https://www.cmf.org.uk/advocacy/submissions/?id=38 https://www.medicalmissions.com/coronavirus https://doi.org/10.1001/jama.2020.5046 https://doi.org/10.1056/nejmsb2005114 https://www.icnarc.org/about/latest-news/2020/03/27/report-on-775-patients-critically-ill-with-covid-19 https://www.icnarc.org/about/latest-news/2020/03/27/report-on-775-patients-critically-ill-with-covid-19 https://www.icnarc.org/about/latest-news/2020/03/27/report-on-775-patients-critically-ill-with-covid-19 https://www.goldstandardsframework.org.uk/ https://www.spict.org.uk/ https://doi.org/10.3390/ijerph13060618 19 haslam & redman april 2020. christian journal for global health 7(1) 20. peppiatt p. too tired to care. in: spotlight [internet]. christian medical fellowship. 2018 spring. available from: https://www.cmf.org.uk/resources/publications/conte nt/?context=article&id=26779. 21. uk government [internet]. the nhs constitution for england [updated 2015 oct 14; cited 2020 apr 3]. available from: https://www.gov.uk/government/publications/thenhs-constitution-for-england/the-nhs-constitution-forengland. 22. uk government [internet]. pandemic flu: ethical framework [cited 2020 apr 3]. 2013 feb 20 [updated 2017 nov 24]. available from: https://www.gov.uk/guidance/pandemic-flu#ethicalframework. 23. intensive care society. legal and ethical advisory group (leag) statement: statement on legal liabilities of clinicians as individuals during coronavirus pandemic [internet]. 2020 mar 31 [cited 2020 apr 3]. available from: http://ics.informz.net/z/cjuucd9tat03ody4nzm0jn a9msz1ptgwotm0mdc4oczsat02ndqwmzc3 oa/index.html. 24. truog rd, et al. the toughest triage — allocating ventilators in a pandemic. nejm [internet]. 2020 mar 23. https://doi.org/10.1056/nejmp2005689. competing interests: none declared. acknowledgements: this paper has been previously published as a briefing paper by christian medical fellowship (cmf), uk. 3 april 2020. correspondence: dr. james haslam, wiltshire, uk. james.haslam@nhs.net cite this article as: haslam j, redman m. when demand outstrips supply: a christian view of the ethics of healthcare resource allocation during the covid-19 pandemic. christian journal for global health. april 2020; 7(1):13-19. https://doi.org/10.15566/cjgh.v7i1.369 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.cmf.org.uk/resources/publications/content/?context=article&id=26779 https://www.cmf.org.uk/resources/publications/content/?context=article&id=26779 https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england https://www.gov.uk/guidance/pandemic-flu#ethical-framework https://www.gov.uk/guidance/pandemic-flu#ethical-framework http://ics.informz.net/z/cjuucd9tat03ody4nzm0jna9msz1ptgwotm0mdc4oczsat02ndqwmzc3oa/index.html http://ics.informz.net/z/cjuucd9tat03ody4nzm0jna9msz1ptgwotm0mdc4oczsat02ndqwmzc3oa/index.html http://ics.informz.net/z/cjuucd9tat03ody4nzm0jna9msz1ptgwotm0mdc4oczsat02ndqwmzc3oa/index.html https://doi.org/10.1056/nejmp2005689 mailto:james.haslam@nhs.net https://doi.org/10.15566/cjgh.v7i1.369 http://creativecommons.org/licenses/by/4.0/ introduction references original article the local church and the first thousand days of a child’s life: a mixed methods study from south africa ruth edith lundiea, deborah merle hancoxb a sikunye programme manager, common good, cape town, south africa b phd candidate and research associate, department of practical theology and missiology, faculty of theology, university of stellenbosch, south africa abstract background: whilst there is a growing body of research indicating the life-long significance of the first thousand days (f1000d) in a person’s life, there is currently limited research regarding the church’s understanding and support of this critical period for human health and wellbeing. exploratory research was therefore conducted by a cape town faith-based organization seeking preliminary answers to the question: what is the specific contribution a local church can make in support of the first thousand days (conception to 2 years) of a child’s life in cape town, south africa? methods: a mixed-method study was conducted with 194 respondents, seeking to understand knowledge and attitudes of church leaders towards f1000d, current church responses, existing f1000d models and approaches that may be suited to the church, the role that respondents see for the church in f1000d, and barriers to mothers accessing f1000d services. results: the research showed that although there is limited knowledge and engagement with f1000d by church leaders, there is broad consensus that the church does have a significant role to play in this life stage. the church has many assets that can be mobilised in support of f1000d and doing so will also serve the church’s missional purpose. discussion: key recommendations include the following: f1000d should be included and normalised across all church activities; programmatic responses to f1000d that use the assets of a local church should be developed; the collective voice of the church for advocacy for f1000d support and services within society should be harnessed. key words: first thousand days, early childhood development, nurturing care, church, missional, social development introduction a growing body of evidence supports the thinking that one of the most effective ways to assist human flourishing is to ensure “a good start in life” through the provision of the basic building blocks of love, nutrition, stimulation, health, and safety to children during their first thousand days (f1000d) from conception to two years. whilst the importance of the f1000d of life is broadly accepted by government, civil society organisations, and 7 lundie & hancox august 2020. christian journal for global health 7(3) academia, the understanding and contribution of the local church to this important life stage is not well understood or researched. hence, a cape town based non-profit organisation, common good, conducted exploratory research to understand the specific contribution a local church can make in support of the f1000d of a child’s life.1 first thousand days overview the f1000d offers a “unique and invaluable window of opportunity to secure the optimal development of the child, and by extension, the positive developmental trajectory of a country”.2 central to the importance of f1000d is the rapid development of the brain which grows up to 80% of its adult size during this period.3–6 this “once in a lifetime” opportunity of optimal brain development is dependent on the availability of supportive and nurturing environments that have a lifelong impact on the infant’s future physical, mental, and emotional health.2,3,7 the lancet early childhood development (ecd) series and subsequent nurturing care framework emphasise that all children need and have the right to receive the essential factors of nurturing care, defined as “a stable environment that is sensitive to children’s health and nutritional needs, with protection from threats, opportunities for early learning, and interactions that are responsive, emotionally supportive, and developmentally stimulating.”8,9 around the world, an estimated 250 million children younger than 5 years in low-income and middle-income countries are born into environments that place them at risk of not reaching their developmental potential.10,11 research has identified multiple risk factors predictive of poor early childhood development including, poverty, poor nutrition, infectious diseases, environmental toxins (especially drugs and alcohol), stress (toxic stress), exposure to violence, psychosocial risk (mental health), disrupted caregiving, and disabilities.2,11 poverty has been shown to be a crucial risk factor which increases the likelihood of exposure to multiple adversities, including undermining the capacity of families to provide their children with the required nurturing care.7,11,12 there is an urgent call for all relevant stakeholders to prioritize and invest early in interventions aimed at reducing the risks and adversities confronting children to ensure their optimal development.3 this investment, which can yield positive lifetime developmental returns for the child, is a key lever to improving the socio-economic development of a country, benefiting the whole of society.13,14 church and f1000d two factors motivate for seeking the involvement of the local church in f1000d. firstly, the church is an important social actor in social development.15 ter haar and ellis state, regarding the development sector, that “one of the greatest surprises in recent decades has been the resilience of religion”.16 religion, they maintain, provides a powerful motivation for how many people choose to act; therefore, the worldviews of the people that social development seeks to benefit ought to be engaged. using korten’s typography of four social development generations gives a framework for understanding the types of social development activities in which churches engage.17 churches are better suited to relief and charity activities (type 1) and to discipling and developing their own congregants who then go on to be change agents (type 2). the church may also serve as an activist organisation and leader in social movements for wide-scale change (type 4). in seeking the church’s engagement in social development, a religious health assets approach may be adopted, using the assets normally found within a church community.18,19 secondly, speaking to the theological motivation for the church’s involvement, f1000d may be positioned within a framework of the mission of god — the missio dei — and the consequent mission of the church — the missio ecclesiae. christian mission is god's mission in which the church participates and “to participate in mission is to participate in the movement of god’s love toward 8 lundie & hancox august 2020. christian journal for global health 7(3) people, since god is a fountain of sending love” (see john 3:16).20 god's mission is one of holistic (both spiritual and material) liberation and restoration as he seeks to bring about his kingdom, his reign, for the whole world. churches are to “renounce an introverted concern for their own life, and recognize that they exist for the sake of those who are not members, as sign, instrument, and foretaste of god's redeeming grace for the whole life of society.”20 it is worth noting there is currently very little literature that considers the intersection of f1000d and mission. in addition, churches often struggle to implement and sustain social development programmes.21 other barriers to the church playing a more active role in f1000d include theological frameworks that mitigate against the church’s role as a social actor,22 inadequate theological conceptualisation about f1000d, and poor engagement with issues of power and gender within the church. methods the research sought to answer the question: “what is the specific contribution a local church can make in support of the first thousand days (conception to 2 years) of a child’s life in cape town, south africa?”1 in answering this question, three of the areas probed were: 1. knowledge and attitudes of church leaders towards f1000d 2. barriers in the use of f1000d services by mothers and primary carers 3. current church responses to f1000d the research was exploratory and mixed methods including a survey, one-on-one interviews and workshops. key informants in the research were church leaders, laity, denominational leaders, practitioners, and experts in the field of f1000d. all informants were based in cape town except for denominational leaders positioned nationally within south africa. informants were drawn from across the socio-economic spectrum of the city, but with a greater emphasis on those working in high-risk areas. informants were purposively sampled, guided by the knowledge and connections of the research team, and was, therefore, non-probability sampling (meaning that not everyone within the research profile had an equal chance of being selected for the survey). thematic analysis was used when analysing data. initial coding was open, but a standard list of codes was later compiled according to emerging themes and f1000d literature, and as far as possible, this was used to classify the empirical research findings. survey from a list of 150 church leader, 71 church leaders completed the survey of which 53 (75%) were male and 18 were female. forty-five of the respondents (63%) were between the age of 41-60 years; 13 church leaders were over 60 years; 13 were under 40 years. interviews semi-structured one-on-one interviews were used to collect in-depth qualitative data. interviews were conducted with 12 denominational leaders, 11 experts in f1000d, 8 pastors, and 4 practitioners. table 1. numbers of interviewees interviews n interviews n female interviewees n male interviewees total interviewees experts in field 11 10 2 12 denominational leaders 12 3 10 13 pastors 8 6 4 10 practitioners 4 5 0 5 totals 35 24 16 40 gender by percent 60% 40% 9 lundie & hancox august 2020. christian journal for global health 7(3) workshops with mothers and carers to gain insights from mothers and primary carers of young children, two workshops were held in high-risk areas of cape town (khayelitsha and vrygrond). the majority of attendees (70% +) were unemployed which reflects the high unemployment rates in these areas; the majority receive a south african government support grant. table 2: participants of mothers/carers workshop vrygrond khayelitsha n participants: 17 23 average age (in yrs): 29.6 34.2 age of youngest participant: 17 23 age of oldest participant: 57 52 average n of children: 2.1 2.3 most n of children: 7 5 workshop with church laity the researchers sought to gain insights from church laity who were either vocationally or voluntarily engaged with children and their parents/carers in their f1000d. participants were asked about the current and potential role of the local church to promote the wellbeing of children in f1000d. there were 40 workshop attendees from 26 different churches. only 3 participants were men. the researchers the research team were either employed parttime or contracted by the organisation conducting the research. all were regular and involved members at churches in cape town that may be described as “evangelical/charismatic.” the research team had one man (who helped with computerising the online survey) whilst the rest were women, the majority of whom are themselves mothers. research ethics the research was carried out in line with standards for ethical research. the researchers set up their own methods for ensuring factors, such as informant anonymity, voluntary participation, nonpayment of informants, the right of informants to withdraw at any time, and a complaints and ethics oversight mechanism. the board of the non-profit organisation conducting the research agreed to act as an appeal board in case of any complaints or issues related to the research. during the research, no ethical issues arose. results the knowledge and attitudes of church leaders towards f1000d the interviews with denominational leaders explored their comprehension around the subject of f1000d. the data below in figure 1 indicates the answers given: 10 lundie & hancox august 2020. christian journal for global health 7(3) figure 1. interview findings of denominational leaders’ awareness and understanding of f1000d the findings indicated almost 42% of the denominational leaders had not heard of f1000d before the interview and about half recognised f1000d as starting in the womb, while more than half were not aware of the critical development that happens in the womb. similarly, the findings from the survey of church leaders indicated a lack of awareness about f1000d among church leaders. the survey also explored attitudes around pregnancy, showing that church leaders recognised the prevalence of stigma, judgement, and lack of community support for teenage pregnancy and pregnancy outside of marriage. positively, the importance of fathers’ involvement in f1000d caregiving, both towards the child and mother, was recognised. barriers in the use of f1000d services by mothers and other carers multiple sources of empirical data were used to investigate “what are the barriers to mothers and other carers providing what is needed and accessing services during f1000d?” the interviews with experts, pastors, and practitioners were analysed thematically and responses coded. the table below denominational leaders heard of term 'first thousand days' (n=12) denominational leaders understanding of 'first thousand days' (n=12) denominational leaders understanding of when faith begins (n=12) denominational leaders understanding of when learning begins (n=12) 11 lundie & hancox august 2020. christian journal for global health 7(3) shows the results using a heat map format. in the heat map, the darkest colour is used to indicate the barrier most mentioned, and the lightest colour indicates the barrier least mentioned for each group of respondents. the table itself is sorted to show the barriers most frequently mentioned across all respondent groups at the top of the table. table 3. interview findings of barriers to mothers and carers obtaining services during f1000d barrier code comments experts (n=11) pastors (n=8) practitioners (n=4) total poverty unemployment; if employed — mother is absent (returned to work asap); no money for transport to services; food insecurity; no vitamins; no books / toys 6 5 2 13 knowledge lack of, or no access to knowledge about: when life begins; available services; parenting skills; importance of stimulation, verbalisation, toys (can be improvised). lack of confidence 6 4 2 12 services not enough, not coordinated; long waits; not accessible; poor referral systems; target the child and not the mother; unfriendly and judgmental; results in feeling fearful; distrustful; overwhelmed — don't report pregnancies 5 1 5 11 depression 5 1 1 7 family breakdown no support; grannies caring for children; young girls evicted by parents 3 2 1 6 substance abuse addictions 1 2 2 5 nutrition malnutrition; hunger; poor distribution of food; lack of nutrition in pregnancy; 2 0 2 4 attitudes low morals; lazy; rebellious 0 2 1 3 shame on drugs; not coping; 'just a mom' 2 1 0 3 violence in home; in community; prevents access to services; stress 2 0 1 3 isolation need social network 2 0 0 2 12 lundie & hancox august 2020. christian journal for global health 7(3) the qualitative data indicates four key barriers to mothers/carers accessing services and support within f1000d. firstly, poverty presents multiple barriers including, among other things, a lack of safe transport to service facilities, food insecurity, unemployment, or return to work shortly after birth. secondly, a paucity of knowledge and access to information also pose barriers. these include knowledge on f1000d, available services, optimal parenting skills, and nurturing care. thirdly, inadequate services and poor quality of accessible services, especially within the health sector, present as barriers, with mothers reportedly experiencing unfriendly and judgemental service delivery from healthcare and social-welfare professionals. fourthly, maternal mental health, especially depression, is a critical barrier to mothers providing the nurturing care required in f1000d. this is in line with literature that shows that maternal mental health has an impact on mothers’ ability to access service and results in the “lower uptake of available services.”23 the current church responses to f1000d interviews with denominational leaders asked if their denomination offered services or programmes in f1000d. analyses of their responses were grouped across 5 target audiences and classified as either no services, congregation-based services, or a more widely targeted programme. figure 2. denominations (n=12) offering f1000d services. length of bar indicates the number of leaders who indicated their denomination does or does not conduct services or programmes for the target group the formal programmes of denominations are generally specialised and professionally run by organisations (such as diaconic services) that play a statutory role in child protection services, as well as early childhood development centres for children 36 years. in a few of the denominations, these are large organisations or non-profit organisations that have been in existence for a long time and are not necessarily directly working into f1000d or with a local congregation. none of the denominations mentioned a formal programme for expectant fathers. the survey of church pastors asked questions to explore the level of engagement with the topic of f1000d and services offered by these churches. as most participants did not provide answers to these open-ended questions, it is reasonable to conclude their church does not provide any services to pregnant mothers, expectant fathers, parents or caregivers, and babies (0-2years). 13 lundie & hancox august 2020. christian journal for global health 7(3) over half of the surveyed participants indicated they had services for children (3-6years). similarly, the interviews with pastors found that churches are more actively and intentionally involved with children aged 3 6 years, with this engagement predominately anchored in sunday school programs. additionally, expectant fathers and fathers of little children were found to be underserved within local churches. the services most offered to pregnant mothers and expectant fathers are of a supportive nature, with some offering capacity development workshops and training. respondents also mentioned general congregational support. survey respondents were asked who they thought should be providing services to these target groups — they could indicate any one or all of the following as service providers. the results to this question are depicted in the chart below. figure 3. survey finding for who should be providing services in f1000d these findings indicate that survey participants believe that churches are a major roleplayer in the provision of services, particularly to parents/caregivers within f1000d. the role of the church in f1000d firstly, the pastors surveyed were asked, in an open-ended question, to describe the role in f1000d of a well-resourced church and a church in a vulnerable area. the responses were analysed thematically, and the results are depicted using a “heat map” format. 14 lundie & hancox august 2020. christian journal for global health 7(3) table 3. survey results for what is the role of church in f1000d intervention category comments church in high risk area church in low risk area total support love; congregational support; help each other; support groups; counselling; mentoring; babysitting services; support for single parents, young mothers, grandmothers; encouragement; emotional support; inclusion. making space available, safe spaces, safe homes. 25 20 45 capacity development antenatal classes; parenting skills; how to keep kids safe; health & safety; 13 19 32 resources food, books, bibles, toys, clothes, nappies, transport 15 15 30 education for children: stimulation; after care; day care; crèche; playgroup; early learning; free childcare; build centres for games 19 9 28 spiritual sunday school; preaching importance of women & children; family model 8 10 28 community involvement, training community workers, awareness progs, well-resourced churches to assist / work with community church, work with npos, work with doh, dsd 7 9 16 health drugs, abuse, home visits, immunisation & feeding, clinic, encourage breastfeeding, report abuse 6 6 12 advocacy govt red tape 1 1 2 job support cvs, interviews, skills 1 1 2 adolescent programmes for teenagers 0 1 1 no more progs parents too busy to spend time with children 0 1 1 the role of providing support, especially as it pertains to providing a “safe space” in the community for mothers and children (in both a physical and emotional sense) is seen as important for all churches, as well as capacity building and providing material resources. within vulnerable areas, the church is seen to have an added role in providing educational services for children. in the interviews, experts, denominational leaders, pastors, and practitioners were asked to give their opinions on the role of the church in f1000d. they were specifically asked to differentiate between the role of a church in a high-risk area and a church in low risk area; the two heat maps below show the analysis of these responses. 15 lundie & hancox august 2020. christian journal for global health 7(3) table 4: interview results for what is the role of church in high risk area in f1000d intervention category comments experts (n=11) denom leaders (n=12) pastors (n=8) practitioners (n=4) total support sharing, listening & relationships alleviates depression, mother-child bonding & attachment, loving baby vs. violence, involve fathers, groups for pregnant mothers, moms & tots groups, mom's groups, mother-to-mother peer support, social networks prevent isolation & depression, available safe spaces, church as place of safety, mentoring, counselling, referral to services, childcare (for working parents), home visits, include divorcees, single parents, children born out of wedlock 8 8 6 3 25 capacity building when getting married, antenatal classes when pregnant, positive parenting, preparation for parenting, knowing rights breastfeeding at work & uif, developmental stages, first aid, how to wean your child, breastfeeding support, equip parents to spiritually nurture children, parents' role as educator, fathers to be present, mothers to be godly mothers 4 3 4 1 12 resources nutritional stunting, access to food, nutrition for babies & moms, soup kitchens, toys, clothes, accommodation 4 2 3 1 10 education education & stimulation of child: early storytelling, reading, stimulate through play & talking, ecd 3 5 1 1 10 change within church leaders trusted source of information about: accessing services, role of father, involve fathers in childcare, perceptions of breastfeeding, intimate partner violence, reduce stigma about mental health, stop hitting children, sex & health education, teach about consequences of sex, re-instil godly family values in non-judgmental way, accept unmarried mother, no shaming, judging, condemning mothers 5 4 0 1 10 spiritual prayer, discipleship 1 3 1 1 6 health home visiting, community health workers, health education for parents, clinics 3 2 0 1 6 social services connect people to services, child grants, clinic cards, referrals 3 0 1 0 4 community education/awareness fas, immunisation. seminars with mothers to give awareness and give love. 0 1 0 2 3 advocacy 0 1 0 1 2 job support income generating skills 1 0 0 0 1 adolescence responsibility of parenting 1 0 0 0 1 across all interviewee groups there was consensus that the most important role of the church in a vulnerable area is to provide support to parents. these churches are also seen to have a role in building the capacity of parents, especially around parenting skills, providing resources to vulnerable families, providing educational/stimulation services for children, and then effecting changes within the church, especially around delivering factual 16 lundie & hancox august 2020. christian journal for global health 7(3) information to overcome misconceptions or lack of knowledge. table 5. interview results for what is the role of church in low risk area in f1000d intervention category comments experts (n=11) denom leaders (n=12) pastors (n=8) practitioners (n=4) total support loneliness, breakdown of families can lead to depression, stress, anxiety, pressure, spend time with kids, support groups for mothers, mentoring fathers, parents working with other parents, home visits, economically comfortable parents still vulnerable emotionally 7 4 4 2 17 connect create connections with marginalised communities, greater awareness of needs, develop relationships, partner/twin well-resourced church with under-resourced church and financially assist them, share skills (doctors, social workers), train locals, pastors come together, provide volunteers, provide educational material. create networks support with local service providers, networks of resources & information, connect with government, match moms from 2 communities 4 4 6 2 16 resources channel money, gifts, skills to vulnerable, nutrition packs, vitamins, knitting blankets, making preschool play equipment, food, clothing, transport money to clinics, baby boxes 3 5 1 1 10 capacity development parenting classes, self-worth, faith formation in children, make info available: dvds, access to mobile apps 2 2 2 0 6 education for children: limit screen stimulation, nursery schools, ecds (esp. for parents can't afford fees) 1 2 3 0 6 ngo support support existing organisations, fund project staff, provide skills, collaborate, take to scale, make them more sustainable, don't reinvent wheel, volunteers from church, financial support, local congregations support children's homes, refugee care 3 2 1 0 6 job income generating skills, work opportunities 0 0 1 1 2 advocacy to employers: keeping mother & child together 0 0 0 1 1 change within fathers involvement 1 0 0 0 1 health harmful effects substance abuse, alcohol abuse, smoking during pregnancy 1 0 0 0 1 spiritual 0 1 0 0 1 17 lundie & hancox august 2020. christian journal for global health 7(3) according to those interviewed, churches in low risk areas also have a key role in providing support to parents. however, there is a definite expectation from both those interviewed and surveyed that churches in low risk areas need to be connecting and partnering with churches in vulnerable areas in ways that are more intentional and relational, as opposed to merely passing on material resources. church in low risk areas can also play a role in financially supporting non-profit organisations (including faith-based organisations) working with families in f1000d in vulnerable areas. discussion this research sought to explore “the specific contribution a local church can make in support of the first thousand days (conception to 2 years) of a child’s life in cape town.” all the results point to consensus amongst clergy, laity, experts, and practitioners that the church does have a specific and influential role to play in supporting f1000d. at the same time though for the church to contribute effectively, the one key finding points to low awareness and knowledge within church leadership around f1000d issues and the importance of the church’s involvement. this finding is supported by a report delineating the gap between what experts know about early childhood development from science and what public understanding is.3 this is a key barrier for church involvement and would need to be addressed. a model for church and f1000d there are multiple levels of engagement for churches, dependent on the context, assets, and strengths of the local church. a model for church and f1000d is to integrate the finding with two existing models, namely church strengths, drawn from the religious health assets literature and the social ecological model (sem).18,24 when examining the many roles that the church can play in support of f1000d, and looking at the various risk factors and protective factors as well as the barriers to accessing services for carers in f1000d, the researchers identified that the sem gives a helpful framework to bring all of these parts together. the sem is “a theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviours and for identifying behavioural and organizational leverage points and intermediaries for health promotion within organizations”.24 the church is well positioned within the sem to play an influential role into all five hierarchical levels of the sem, namely, individual, interpersonal, community, organizational, and policy/enabling environment.24 the christian faith is present across all levels of the sem through individual christians seeking to live out their faith at these various levels. the opportunity exists, therefore, for the organised church, through its members and its individual and collective organisational forms, to support f1000d. in south africa, the church is still one of the most trusted institutions that convenes a substantial proportion of the population on a regular basis.25 therefore, the church has leverage in all of the areas within the sem. gary gunderson proposes eight inherent strengths of local churches which can, should, and do shape communities. these include strengths to accompany, convene, connect, tell stories, give sanctuary, bless, pray, and endure.18 the following discussion presents some preliminary ideas of how the church can interact with f1000d based on the findings in this research and bringing the strengths of the church and all the levels of the sem together: 1. at the primary level, that of the individual, the church should strengthen the capacity of the individual (primary carer responsible for the child’s care) by supporting and influencing the knowledge, attitude, behaviour, and skills of the individual to provide responsive nurturing care. the findings show that capacity 18 lundie & hancox august 2020. christian journal for global health 7(3) development can be conducted through initiatives such as anteand post-natal classes, positive parenting programmes, pre-marriage classes and early learning information, as well as home visiting which was found to be an indispensable intervention.2,11,26 this can be also be accomplished by highlighting the importance of f1000d and available services (through story-telling, connection); the promotion of breastfeeding8 (give sanctuary); and importantly by encouraging father involvement (give sanctuary, connect). the finding highlighted that churches can play a key influential role in strengthening father engagement in f1000d. this is in line with literature that shows that the role of fathers is significant and should be encouraged.27 2. at the interpersonal level (family, friends, peers, social networks), the church can provide ongoing social and spiritual support and encouragement to various groups, by building relationship and community amongst congregants. this can include creating safe spaces (emotional and physical) to enable nurturing care and supportive groups for all parents, especially those facing multiple adversities (give sanctuary, convene, connect). 3. at the community level, the church can constitute part of the network of resources and support available to parents within f1000d. at this level, the church can advocate, collaborate, connect, and partner with organisations. the church is recognised as having a trusted voice of influence in society to which people still listen; therefore, the church can utilise its trusted and powerful voice to influence, raise awareness and knowledge, and change attitudes within the community for positive social development within f1000d (tell stories, convene). 4. at the institutional/organisational level, at which the church organisation is itself located, the church can provide organisational resources and support; promote f1000d services; and address any organisational barriers to f1000d. at this level the church can acknowledge that it does have a role and a missional imperative to promote the well-being of children to engage meaningfully and intentionally with f1000d to secure the optimal development of children and transform the whole of society. as an organisation, the church can enhance and deepen theology, knowledge, and awareness on the crucial opportunity of f1000d and through a targeted communication campaign raise conviction and motivation for involvement and action. 5. at the public policy level, the church should familiarise itself with the laws and regulations affecting f1000d; the organisational resources and support needed to lobby at this level; the government programmes that exist to support f1000d; policy barriers; and relevant stakeholders. the church can advocate for the rights of financial support and rights in the workplace to improve mother/father-child dyad and increase income, decrease stress, and increase nutrition in the home. the experts indicated that the church has a voice to advocate into broader systemic issues, for example, stigma, shame, lack of awareness, gender issues, intimate partner violence, corporal punishment, and inequality, that all impact on f1000d. recommendations to interpret the multiple levels of engagement for the church in f1000d, three approaches are recommended linked to korten’s generations of social development.17 approach 1: f1000d included and normalised across all church activities in this approach, korten’s first generation (type 1),17 ways would be sought to encourage and assist a local church (and wider church bodies, such as denominational structures, ministers’ fraternals, 19 lundie & hancox august 2020. christian journal for global health 7(3) and training institutions) to grow in their knowledge and awareness of f1000d issues and the support of f1000d activities within the local church. this would involve moving f1000d people (infants, parents, etc.) and topics (conception, pregnancy, fatherhood, etc.) from the periphery of church activity into the mainstream activities of a church. it could also include some relief activity in the wider community but would be predominantly focused on the well-being of f1000d people within their own church community. church based responses should also include the everyday activities of church members, like visiting people in their homes. churches should start by developing interventions that assist their own members in f1000d and then move outwards into the community. churches should seek “church-suited” existing initiatives and look at their current responses and see if they can be more coordinated, strategic, and informed by science to make an even bigger impact. as discussed in the lancet ecd series, emphasis should be placed on interventions that enable caregivers to provide “nurturing care” hence enabling young children to achieve their developmental potential.8 approach 2: development of programmatic responses to f1000d by and with the church in this approach, korten’s second generation (type 2),17churches can run f1000d programmes in their church and surrounding (or other) communities. these could be, for example, home visiting programmes, parental training and support programmes, clinic support programmes, fatherhood programmes — to name but a few. such programmes would be best run in partnership with specialist ngos, faith-based or secular, and wherever possible in conjunction with other churches in their area. some level of integration between the science of f1000d and the beliefs and practices of the church could be obtained through collaborative approaches. churches need to adjust their programmatic approaches based on their context and resources and consider the respective roles of churches in low and high-risk areas. approach 3: promote advocacy and influence through the wider church given the scope of the church in south africa, a third suggested approach is for the church (locally and collectively) to be one of the institutions mobilising society (including its own members) to address the failure of political, societal, and cultural systems beyond its own community in support of f1000d. this advocacy and influence approach reflect korten’s third and fourth generations of social development.17 this could in time lead to the church contributing to a national movement of people who live in an active awareness of this critical phase of life. whatever approach is adopted, churches need to be helped to provide non-judgemental, inclusive parental support to all whilst continuing to hold to what it believes to be god’s best design for family. this is premised on god’s redemptive and restoring grace for those in difficult and different life circumstances — both individually and as societies. future research this exploratory research has highlighted three topics that require further research and investigation regarding strengthening the church’s response to f1000d. firstly, there is a requirement for deeper theological reflection on f1000d. whilst there is quite extensive theological engagement with childhood and youth, there is very limited engagement specifically with f1000d. it is under-represented across the theological disciplines, both in south africa and globally. early childhood has received attention in discussions on doctrinal issues such as sin and baptism, but the importance of this age group to the wellbeing of people, the church, and society more generally has not received adequate attention. this probably accounts for its limited and sporadic attention in the local church. secondly, further 20 lundie & hancox august 2020. christian journal for global health 7(3) research is required into fatherhood and initiatives effective in engaging men and fathers to promote their active, positive involvement in f1000d. there is a noticeable gap in programmes and interventions that specifically target men, both within society and churches. thirdly, there is scope for further academic research into the various topics addressed within this exploratory research, specifically around the barriers that prevent access to f1000d services and providing the necessary nurturing care within a south african context. the limitations and possible barriers to church’s involvement also need to be investigated further with regards to financial implications and testing workable models. conclusion the research, undertaken in cape town, south africa, shows that the church has a significant role to play in supporting f1000d. given the extent of the church in south africa, the potential for the individual and societal impact of a f1000d enabled and active church is significant. however, it also shows that effective engagement with f1000d is a gap within the church. given the unique life-long impact this phase has on the quality of life, it is an area about which no church or christian should be ignorant or avoidant. hence, there is a need for interventions to increase the awareness, knowledge, and skills in churches around f1000d and to equip churches to use their unique assets and strengths in this area. the findings of this research have wider application than cape town, south africa. given the international call to invest early11 and the critical nature of f1000d, there is relevance for the church globally to contribute as discussed above and support f1000d. jesus christ, the head of the church, desires that all people should live life to the full (john 10:10). the church is well placed to make a significant contribution to this life by engaging more fully with people in their f1000d and equipping and supporting parents and communities to provide children with the responsive, nurturing care they require for optimal development. references 1. lundie r, hancox d, farrell s. the church’s role in supporting human development in the first thousand days of life [internet]. cape town: common good; 2018. available from: https://www.commongood.org.za/early-life/ 2. republic of south africa. national integrated early childhood development policy. pretoria: government printers; 2015. available from: https://www.gov.za/documents/nationalintegrated-early-childhood-development-policy2015-2-aug-2016-0000 3. lindland e, richter l, tomlinson m, mkwanazi n, watt k. early means early: mapping the gaps between experts, stakeholder, and public understanding of early 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[internet]. 2016. available from: https://www.unicef.org/cbsc/files/module_1__mnchn_c4d_guide.docx 25. erasmus jc. religion as agent for social transformation: a case study from the western cape. scriptura. 2016;96:372–90. available from: https://scriptura.journals.ac.za/pub/article/view/11 63 26. biersteker l. annexure: possible programming options for 0-3 years olds: evidence for effective interventions. 2017. [correspondence email to r. lundie. 6 september 2017]. [available by e-mail ruth.lundie@commongood.org.za] https://doi.org/10.1016/s0140-6736(16)31390-3 https://apps.who.int/iris/handle/10665/272603 https://www.westerncape.gov.za/assets/departments/health/research_newsletter_issue_8_may_2017.pdf https://www.westerncape.gov.za/assets/departments/health/research_newsletter_issue_8_may_2017.pdf https://www.westerncape.gov.za/assets/departments/health/research_newsletter_issue_8_may_2017.pdf https://doi.org/10.1016/s0140-6736(16)31389-7 http://ilifalabantwana.co.za/sa-early-childhood-review-2017-now-available/ http://ilifalabantwana.co.za/sa-early-childhood-review-2017-now-available/ https://www.westerncape.gov.za/assets/departments/health/research_newsletter_issue_8_may_2017.pdf https://www.westerncape.gov.za/assets/departments/health/research_newsletter_issue_8_may_2017.pdf https://www.westerncape.gov.za/assets/departments/health/research_newsletter_issue_8_may_2017.pdf https://pediatrics.aappublications.org/content/129/1/e232 https://pediatrics.aappublications.org/content/129/1/e232 https://www.tandfonline.com/doi/abs/10.1080/09578810600893403 https://www.tandfonline.com/doi/abs/10.1080/09578810600893403 https://www.academia.edu/665950/conceptualising_religious_health_assets_redemptively https://www.academia.edu/665950/conceptualising_religious_health_assets_redemptively https://hts.org.za/index.php/hts/article/view/3836/9312#5 https://hts.org.za/index.php/hts/article/view/3836/9312#5 http://www.samj.org.za/index.php/samj/article/view/11610 http://www.samj.org.za/index.php/samj/article/view/11610 https://www.unicef.org/cbsc/files/module_1_-_mnchn_c4d_guide.docx https://www.unicef.org/cbsc/files/module_1_-_mnchn_c4d_guide.docx https://scriptura.journals.ac.za/pub/article/view/1163 https://scriptura.journals.ac.za/pub/article/view/1163 mailto:ruth.lundie@commongood.org.za 22 lundie & hancox august 2020. christian journal for global health 7(3) 27. levtov r, van der gaag n, greene m, kaufman m, barker g. state of the world’s fathers: a mencare advocacy publication. washington, dc: promundo, rutgers, save the children, sonke gender justice, and the menengage alliance. 2015. available from: https://www.savethechildren.net/sites/default/files/ libraries/state-of-the-worlds-fathers_12-june2015.pdf peer reviewed: submitted 30 aug 2019, accepted 28 may 2020, published 5 aug 2020 competing interests: none declared. acknowledgements: common good, albert geldenhuys, societas for ecd, and common ground church for financial support and backing. correspondence: ruth edith lundie, cape town, south africa. ruth.lundie@sikunye.org.za cite this article as: lundie re, hancox dm. the local church and the first thousand days of a child’s life: a mixed methods study from south africa. christ j glob health. june 2020; 7(3):622. https://doi.org/10.15566/cjgh.v7i3.323 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://www.savethechildren.net/sites/default/files/libraries/state-of-the-worlds-fathers_12-june-2015.pdf https://www.savethechildren.net/sites/default/files/libraries/state-of-the-worlds-fathers_12-june-2015.pdf https://www.savethechildren.net/sites/default/files/libraries/state-of-the-worlds-fathers_12-june-2015.pdf mailto:ruth.lundie@sikunye.org.za https://doi.org/10.15566/cjgh.v7i3.323 http://creativecommons.org/licenses/by/4.0/ references journal review may 2019. christian journal for global health 6(1) primary health care revisited: a review of the october 2018 contact issue samuel adu-gyamfia and roopa vergheseb a phd, senior lecturer, department of history and political studies, kwame nkrumah university of science and technology (knust), kumasi, ghana b md, ma, deputy medical superintendent, muthoot healthcare, kozhencherry, kerala, india introduction in this 70th anniversary of both the world health organization and the world council of churches, the 50th anniversary of the christian medical commission, the 40th anniversary of the alma-ata declaration, and the start of the ecumenical global health strategy, this commemorative special issue of contact magazine was a timely contribution to re-invigorate primary health care (phc) from a christian perspective. a compilation from multiple authors, it revisits some of the seminal articles written in the years leading to alma-ata, explores areas of advocacy and programming, visits case studies, introduces the wcc ecumenical global health strategy, and looks to the challenges and opportunities in the future.1 content concerning primary health care: are we faithful to our foundations? the first author, mwai makoka, addresses issues that were of seminal importance to phc as envisaged by the alma-ata declaration. we are duly informed that in the past, health care was regressively distributed, with the result that the great majority of mankind were and are still allowed to suffer from diseases, disabilities, and deprivations, which the world community as a whole has the skill and resources to relieve. no doubt, as amplified by this contribution, when attention is paid to the 1970s, health historians would place a premium on primary healthcare (phc) or community care. of seminal importance to this review is the fact that there is a growing awareness of the interdependence of prevention and cure, both technical interdependence and in terms of acceptability. this involves, firstly, integrated programs with the prime emphasis on prevention rather than detection and cure and, secondly, integrating the specifically medical service with programs integrated with rural development. this integration notwithstanding, the author does well by drawing the attention of the reader to that which needs much emphasis. health is an important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. as can be found in the theoretical literature, the existing gross inequality in health status in the world is unacceptable.2,3,4 the promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace. it is therefore essential to note that governments have a responsibility to ensure the health of their people which can be fulfilled only by the provision of adequate health and social measures. of equal importance, the author encourages all governments to formulate national policies, strategies, and plans of action to launch and sustain primary health care as part of a 109 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) comprehensive national health system and in coordination with other sectors. however, it has been found that communities adjust to diseases differently, based on cultural, social, and, sometimes, prevailing physical conditions in the environment and in the country. one drawback is that health care has been considered a rather low priority in the demands on community resources as compared to education and other social needs. the argument is not that we must wait until a “high” quality of care can be guaranteed and distributed equitably before we invest any resources at all in phc. rather, the argument is that we at least need to ask whether an equivalent amount of resources invested in traditional types of health care, e.g., upgrading “village midwives,” is consistently provided to support the communities that need them. in africa, structural adjustment led to several reforms which led to the issues concerning full-cost recovery in several sectors of their economy, including healthcare. however, the new millennium has witnessed the introduction of health insurance to aid citizens of countries in africa in particular to have equitable healthcare.5,6,7 building on a long tradition of engagement in education and care for the sick and destitute, churches and religious charities accelerated the establishment of schools and hospitals, applying new knowledge that became more available from the middle of the nineteenth century. these are some of the christian answers that must be supported or encouraged to suffice. looking again at global health, we have to understand the enormity of the potential for the future. technology and innovations have helped to elevate hundreds of millions of people out of poverty and have contributed significantly to the recent progress in global health. but they are by no means sufficient to achieve the great convergence of health and development. progress of that magnitude in one generation will require many factors to come together, and this is exactly why a renewed partnership between faith and development will be so critical. the question of closer collaboration between the faith and the development communities has been amplified by the theorizing literature. it will be one of the key factors to allow us to move more quickly towards these common goals of health and development.8,9,10,11 the alma-ata declaration 40 years later in the second article, odile frank ties in a very essential argument. we are in agreement with the author concerning the conference strongly reaffirming that health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity. we are equally encouraged by the persistent argument on the attainment of the highest possible level of health, which is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. with no equivocation, the theorizing literature emphasizes the argument that to achieve health for all, inequities have to be overcome, powerful interests are to be challenged, and political and economic priorities should also be transformed.12 therefore, it is imperative to emphasize with no contradiction as echoed by this section of the contribution: health is not only a matter of human rights, it is a matter of justice and requires a redistribution of wealth and significant changes in the global economic order. equity in health and social justice must be the basis for all decision making. to ensure access to health services to all, service provision through public and not-for-profit providers must be given the primacy in health system planning and implementation. this is clearly a novel way to go even in the globalized world that continuously seeks to achieve universal primary health care. it recognized health as a human right, and to attain the same, several social and economic sectors in addition to the health sector need to be actively involved and show results. health as subject of human rights has been reported by farmer who discusses pathologies of power: health, human 110 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) rights, and the new war on the poor.13 mann also highlighted the critical issues in health and human rights.14 similarly, leary discussed the right to health in international human rights law.15 however, one needs to look beyond the four walls of the hospitals where the real causes of ill-health lurk. they could be unemployment, underemployment, poor housing with overcrowding, and lack of access to nutritious food and safe water, illiteracy, and gender inequalities. to overcome all of this, people will need to be involved in planning health programs. and for that, a minimum understanding of health is essential as well as the requirement of a multisectoral approach to deal with the issues. a multisectorial approach was a strong pillar of alma ata declaration. the critical question to be re-echoed is whether affordability remains the over-riding and universal challenge. revisiting, “is phc the new priority? yes, but...” the ardent issue raised by makoka for further discussion is the need to keep the ball rolling. significantly, it has become imperative especially due to the fact that geographic and financial inaccessibility, limited resources, erratic drug supply, and shortages of equipment and staff have left many countries’ primary care services disappointingly limited in their range, coverage, and impact. there is therefore the increasing consensus that stronger health systems are key to achieving improved health outcomes. there is plenty of evidence for cost effective interventions that could vastly improve maternal and child health, for example, but less evidence on how to ensure that these services reach the most vulnerable populations to have lasting effect. though the question of phc is important in the contemporary discourse, there still remain some gaps in community-oriented initiatives that would clearly ensure phc. emphasis on evaluations of new ways of organizing primary healthcare services in specific settings are required. affordability remains the over-riding and universal challenge. what services can realistically be provided free at the first point of contact and what mix of financing mechanisms should be promoted to do so continue to be remaining essential questions both in this contribution and shall remain significant in others in the foreseeable future. all things being equal, it can be envisaged in this contribution that commitments toward health care financing as explicated in earlier literature on health financing and social insurance among others cannot be gainsaid. also, public sector general practitioners are required to concentrate on preventive programs that tackle a few well-defined diseases and tend to be dominated by quantitative objectives at the expense of individually tailored prevention and treatment. revisiting “health care and justice” gisela schneider reifies the role of the christian medical commission (cmc) which was formed in 1968 and whose first major activity was to evaluate the existing patterns of relationship between church medical institutions and the people they served. it was also a place that was deeply conscious of the tremendous dedication and selfless service that have made church-related hospitals unique symbols of the proclamation of christian love in action. in seeking to address health care and justice, core issues are the use of curative and preventive strategies or services which are effective and accessible. we believe that this will accentuate the gains made towards the issue of healthcare and justice. a concern for effectiveness will require a better balance of preventive activities. also, because of archaic medical prejudices about clinical care being the doctor’s preserve, we do not turn routine treatment over to auxiliary personnel, although it has been abundantly demonstrated that they can care for 90 per cent of illnesses as effectively as physicians. patients invest inordinate amounts of wasted time in waiting while nothing is done — both as inpatients and outpatients. certainly, in seeking for healthcare and justice this should not be the way to go. the 111 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) definition of injustice here starts with the conviction that basic morality requires equitable distribution. the greatest moral dilemma of medical care is to find the least unjust way to allocate scarce resources. we cannot just open facilities and wait for the centripetal and spontaneous inflow of patients. the concern is centrifugal in reaching out to all those in need. the cmc has shared with others increasing attempts to publicize these areas of concern. first, instead of spending all our precious resources on those who come spontaneously, we must work out new ways of defining and providing a basic minimum of services for all. the definition of this basic minimum must be locally derived and strictly limited to ensure coverage. the second part of providing equitable distribution is to set and follow priorities in care. the purpose is to focus on the measures that will do the most for particularly vulnerable groups. as concluded in this contribution, an important element in the effort to reduce injustice through better health care is to relate health deliberately to the total development of the whole person. it is only right to give attention to the needs of individuals, families, and communities. “five challenges to the churches in health work”: still relevant? bimal charles emphasizes the contribution of faith-based organizations and churches in mitigating the health challenges to communities and nations at large with their concomitant challenges. he analyses the fact that the church has yet to understand the magnitude of problem faced by the poor. concerning “the history,” he writes, among other things, that the intersection of religion and medicine does not provide us with ready-made solutions to contemporary problems. rather, it provides a broader context for understanding the complexity of illness and suffering. harmony between humanity and the gods was paramount, with sickness being an intrusion of maleficent spirits or cosmic forces rather than a symptomatic, treatable disease. while he first outlines the general practices and beliefs of these ancient peoples, he then provides a more detailed panorama, starting with basic history. he then moves to the development of healing methods and the societal roles of healers who often dealt with both the treatment of physical symptoms and the cosmic force that was believed to have caused the illness. this is consistent with the social causative theories espoused by authors like twumasi, adu-gyamfi, and oware that emphasize the need to appreciate the non-medicinal aspects of healthcare delivery that are equally important in ensuring health care.16,17 as christians, we can try to compensate by being loving and seeking appropriate practical and useful strategies to support people. however, the institutional environment itself often discriminates against the families most in need of support. an important element in the effort to reduce injustice through better health care is to relate health deliberately to the total development of the whole person. attention must be given to the needs of individuals, families, and communities. this requires real collaboration of health workers with those working in the economic and political sectors of community life. as clearly seen, this contribution dovetails into the contribution in the previous section. it has been emphasized that the church health center created a model of health care that integrates wellness and medical care while addressing the spiritual needs of those it serves. a similar philosophy is shared by adu-gyamfi and oware when they discuss the contribution of the wesleyan missionaries among the asante people of ghana.17 a wellness mentality includes thinking beyond the illnesses doctors typically address in a clinical setting to other parts of physical and emotional health that affect an individual’s quality of life. from the beginning, the church health center has focused not only on treating illness but also on helping people experience greater whole-person wellness. 112 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) review: “primary health care and the village health worker” closely linked to the broader discourse concerning phc is the contribution by dan irvine. he suggests that community health worker (chw) programs thrive in mobilized communities. community health workers as a rule and by their very nature provide services in environments where formal health services are inaccessible and people are poor. india has a long and rich history of small and large community health worker programs. a large national scheme was established in the late 1970s that aimed to provide one chw for every 1000 population in order to provide health care to rural people and to educate them in preventive health care. similarly, in ghana, there has been efforts to get community action in place, but there is still more to be done to further decentralize health to allow effective participation at the local level. health-promoting churches: a case for congregation-based health promotion programs makoka argues that congregations have an opportunity to reclaim their historic status. although some of the major causes of sickness and early death are due to sanitation, nutrition, and lifestyle, many of the societal variables we face today, violence, drugs, racism, poverty, youth gangs, divorce, single parenting, lie outside the medical care system. to reclaim the full ministry of teaching, preaching, and healing, we need to be intentional and committed to that mission. developing a congregationally based health ministry changes the paradigm of health. the future in health will be to focus on working together in integrated ways, sharing resources, and meeting one another in community. schools, hospitals, health agencies, and churches must come together with a common mission empowered by the community itself. the historical involvement of the christian medical commission and churches on the politics of breastfeeding in this section, senturias and makoka argue that one of the early justice issues is the politics of breastfeeding. historically, the wcc through the cmc and other faith-based organizations has showed keen interest in the politics of breastfeeding. however, this is a follow-up on the early 1970s warning about the dangers of not breastfeeding, the rising tide of public opinion favoring it, and the boycott of nestle in the united states. under the sub-theme “advocating internationally and at the grassroots,” the authors argue that in observance of “international year of the child” (p.33), the cmc published an article which emphasized the superiority of mother’s milk. it provides the best nourishment for the baby, protects from infections, ensures biological child spacing, and enables emotional bonding between mother and child. the cmc collaborated with the who to draft the international code of marketing for breast-milk substitutes. the literature continues to highlight the significance of breastfeeding to the mother, the baby, and the larger human community. kornides and kitsantas have argued that clinicians who supported breastfeeding also increased the odds of a woman initiating breastfeeding. in addition, interventions to increase maternal knowledge about the benefits of breastfeeding and family and clinician support for breastfeeding in the prenatal period may help increase breastfeeding rates. they concluded that encouragement to breastfeed needs to be a priority among health care providers.18 lawrence has also emphasized that the benefits of breastfeeding include savings in health care costs.19 the reference to rubenson, the program secretary of cmc, and his contribution to this discourse cannot be gainsaid. the authors of this section remind us that on feb 14, 1989, rubenson reminded the world that the struggle for health for the infants and children of the world continues especially when breast milk substitutes 113 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) were found to be routinely available. we learn from the pages of this section that, if any successes have been gained, it has come about as a result of collaborations with ngos the who and unicef. however, what is of greater consequence is the need to mount continuous pressure on stakeholders to ensure that the issue of breastfeeding remains at the heart of global health discourse. from disability to new abilities: case studies in disability care through two case studies, gift norman and raji thomas address significant issues of disability. the authors argue that despite progress in science, technology, and advocacy, disabilities of all kinds are still equated — incorrectly and by too many people — with ill health, incapacity, and dependence. admittedly, the authors seem to thread a narrow path by trying to disconnect disability from ill health or physical challenges that would require some form of support from society. this notwithstanding, the authors opine that the misperception remains that only a person who is physically agile and neurologically intact can be considered healthy. similarly, with regard to individuals with mobility difficulties, several people in the society are believed to still hold persons with mobility difficulties individually responsible for their challenges. only with accessible, comprehensive healthcare and wellness promotion services can all persons with disabilities enjoy full, engaged, and productive lives in their communities. he has also identified four main misconceptions that continue to plague how disability status has been perceived: (1) disability is equated with poor health status; (2) public health should focus only on preventing disabling conditions; (3) no standard definition of disability is needed for public health purposes; and (4) the environment is not a factor in the genesis of disability. when not specifically mentioned, disability was rarely identified as a concern by persons without disabilities. it became a concern only when it was posed as an issue on which to voice an opinion. one of the challenges, then, is to identify ways in which the health and wellness of persons with disabilities can be brought to the consciousness of the public as an issue warranting effective action and ongoing attention. faith in health: why it still matters gillian paterson points out that the technological advances of the past century tended to change the focus of medicine from a caring, service oriented model to a technological, cure-oriented model. technology has led to phenomenal advances in medicine and has given us the ability to prolong life. however, in the past few decades physicians have attempted to balance their care by reclaiming medicine's more spiritual roots, recognizing that until modern times spirituality was often linked with health care. the emphasis of the fact that people think about health and illness in multifaceted ways, evidencing a conceptual complexity that corresponds to equally complex behaviors in relation to a diversity of healing practices. the understanding of the goal of good medical care is attention to the whole patient, not just the specific illness; courses that are taught holistically, rather than by symptoms only, emphasize whole patient care. so, when learning about a patient with diabetes, students learn not only about the pathophysiology of diabetes but also about the psychosocial and spiritual issues that patients with diabetes may face. thus, when learning to take a history, students learn all aspects of the history — physical, social, emotional, and spiritual. spirituality can be an important element in the way patients face chronic illness, suffering, and loss. physicians need to address and be attentive to all suffering of their patients—physical, emotional, and spiritual. doing so is part of delivery of compassionate care. this argument is largely anchored in the literature concerning spirituality and medical care 20 114 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) a new health impetus for wcc: the ecumenical global health strategy in the final paper, lyn van rooyen adds to the non-material discourse to health specifically laying emphasis on the theological traditions of the church. health is more than physical and/or mental wellbeing, and healing is not primarily medical. this understanding of health coheres with the biblicaltheological tradition of the church, which sees a human being as a multidimensional unity and the body, soul, and mind as interrelated and interdependent. it thus affirms the social, political, and ecological dimensions of personhood and wholeness. health, in the sense of wholeness, is a condition related to god’s promise for the end of time, as well as a real possibility in the present. the author concludes that as a community of imperfect people, and as part of a creation groaning in pain and longing for its liberation, the christian community can be a sign of hope and an expression of the kingdom of god here on earth (romans 8:22-24). the holy spirit works for justice and healing in many ways and is pleased to indwell the particular community that is called to embody christ’s mission. conclusion the contact issue has drawn our attention to the fundamental role of institutions like the church in ensuring global healthcare. it has been reported that global health builds on national public health efforts and institutions. global health is concerned with all strategies for health improvement, whether population-wide or individually based health care actions, and across all sectors, not just the health sector.21 it is clear, however, that the commitment towards attainment of primary health care goals within the global health construct could be achieved through multi-dimensional approaches that are practical enough but do not reject the holistic approach contributed by faith based organizations and churches. again, as stated elsewhere in the contact issue, the church can play an important role by encouraging young church members to consider a career in health care. regional/provincial/metropolitan/districts departments of health can give bursaries to bright young people to train as nurses, clinical associates, allied health care workers, or doctors and also offer counseling, healing, and support services for those who need it. the saving hands of their messiah works through a well-trained church force that is willing to support humanity in countries and regions to meet significant global health demands. this is amply surmised in christ’s solemn word recorded in matthew 25: 35-40 (esv): for i was hungry and you gave me food, i was thirsty and you gave me drink, i was a stranger and you welcomed me, i was naked and you clothed me, i was sick and you visited me, i was in prison and you came to me . . . as you did it to one of the least of these my brothers, you did it to me. as recorded elsewhere in the contact issue, to reiterate, the value of the human being from the christian perspective calls us all to build a society where every individual is cared for according to his or her needs and not according to his or her assets. . references 1. van rooyen l, makoka m, editors [internet]. primary health care revisited: contact special series. 2018 oct;5:1-44. available from: https://www.oikoumene.org/en/what-we-do/healthand-healing/contact2018final.pdf 2. marmot m. social determinants of health inequalities. lancet. 2005;365(9464):1099-104. https://doi.org/10.1016/s0140-6736(05)74234-3 3. mackenbach jp, stirbu i, roskam ajr, schaap mm, menvielle g, leinsalu m, et al. socioeconomic inequalities in health in 22 european countries. new engl j med. 2008;358(23): 2468-81. https://doi.org/10.1056/nejmsa0707519 4. wagstaff a, paci p, van doorslaer e. on the measurement of inequalities in health. soc sci med. https://www.oikoumene.org/en/what-we-do/health-and-healing/contact2018final.pdf https://www.oikoumene.org/en/what-we-do/health-and-healing/contact2018final.pdf https://doi.org/10.1016/s0140-6736(05)74234-3 https://doi.org/10.1056/nejmsa0707519 115 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) 1991;33(5):545-57. https://doi.org/10.1016/02779536(91)90212-u 5. govender v, chersich mf, harris b, alaba o, ataguba je, nxumalo n, et al. moving towards universal coverage in south africa? lessons from a voluntary government insurance scheme. global health action. 2013;6(1):19253 https://doi.org/10.3402/gha.v6i0.19253 6. musango l, orem jn, elovainio r, kirigia j. moving from ideas to action-developing health financing systems towards universal coverage in africa. bmc int health hum r. 2012;12(1):30. https://doi.org/10.1186/1472-698x-12-30 7. adu-gyamfi s, dramani a. sustaining ghana’s national health insurance scheme through preventive healthcare strategies and legislation. int multid j soc sci. 2017;6(1):47-69. https://doi.org/10.17583/rimcis.2017.2149 8. clarke g. faith matters: faith‐based organisations, civil society and international development. j int devel. 2006;18(6):835-48. https://doi.org/10.1002/jid.1317 9. clarke g. agents of transformation? donors, faithbased organisations and international development. third world q. 2007;28(1):77-96. https://doi.org/10.1080/01436590601081880 10. lunn j. the role of religion, spirituality, and faith in development: a critical theory approach. third world q. 2009;30(5):937-51. https://doi.org/10.1080/01436590902959180 11. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock f, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015;386(10005):1765-75. https://doi.org/10.1016/s0140-6736(15)60251-3 12. ostlin, piroska, paula braveman, norberto dachs, who equity team, and who task force on research priorities for equity in health. priorities for research to take forward the health equity policy agenda. b world health organ. 83;12(2005):948. 13. farmer p. pathologies of power: health, human rights, and the new war on the poor. n am dialogue. 2003;6(1):1-4. https://doi.org/10.1525/nad.2003.6.1.1 14. mann jm, gostin l, gruskin s, brennan t, lazzarini z, fineberg hv. health and human rights. health and human rights 1994;1(1):6-23. https://doi.org/10.2307/4065260 15. leary va. (1994). the right to health in international human rights law. health hum rights 1994;1(1):24-56. https://doi.org/10.2307/4065261 16. twumasi pa. medical systems in ghana: a study in medical sociology. ghana publishing corporation, 2005. 17. adu-gyamfi s, oware r. wesleyan mission medicine in asante (1901-2000) human arts soc sci studies. 2018;18(2). 18. kornides m, panagiota k. evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes. j child health care. 2013;17(3):264-73. https://doi.org/10.1177/1367493512461460 19. lawrence ra. breastfeeding: benefits, risks and alternatives. curr opin obstet gyn. 2000;12(6):519-24. https://doi.org/10.1097/00001703-20001200000011 20. anandarajah g, hight e. spirituality and medical practice. am fam physician. 2001;63(1):81-8. 21. beaglehole r, bonita r. what is global health? global health action. 2010;3. https://doi.org/10.3402/gha.v3i0.5142 submitted 8 may 2019, accepted 14 may 2019, published 31 may 2019 competing interests: none declared. correspondence: samuel adu-gyamfi, knust, ghana. mcgyamfi@yahoo.com and roopa verghese, muthoot healthcare, kerala, india. jewelz.ninan@gmail.com https://doi.org/10.1016/0277-9536(91)90212-u https://doi.org/10.1016/0277-9536(91)90212-u https://doi.org/10.3402/gha.v6i0.19253 https://doi.org/10.1186/1472-698x-12-30 https://doi.org/10.17583/rimcis.2017.2149 https://doi.org/10.1002/jid.1317 https://doi.org/10.1080/01436590601081880 https://doi.org/10.1080/01436590902959180 https://doi.org/10.1016/s0140-6736(15)60251-3 https://doi.org/10.1525/nad.2003.6.1.1 https://doi.org/10.2307/4065260 https://doi.org/10.2307/4065261 https://doi.org/10.1177/1367493512461460 https://doi.org/10.1097/00001703-200012000-00011 https://doi.org/10.1097/00001703-200012000-00011 https://doi.org/10.3402/gha.v3i0.5142 mailto:mcgyamfi@yahoo.com mailto:jewelz.ninan@gmail.com 116 adu-gyamfi & verghese may 2019. christian journal for global health 6(1) cite this article as: adu-gyamfi s and verghese r. primary health care revisited: a review of the october 2018 contact issue. christian journal for global health. may 2019; 6(1):108-116. https://doi.org/10.15566/cjgh.v6i1.307 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://creativecommons.org/licenses/by/4.0/ editorial nov 2014. christian journal for global health, 1(2):5-6. . first-hand accounts of life in the trenches nathan grills a and elliott larson b a mbbs, mph, dphil, associate editor, cjgh; nossal institute of global health, university of melbourne, victoria, australia , b md, frcp, fidsa, editor-in-chief, cjgh with this issue the editors inaugurate a feature which we hope will be an encouragement and stimulus to further reflection and comment. we are publishing three first person accounts of experiences in what began in each case as the ordinary conduct of work as a physician. all three accounts have been written on-the-fly, so to speak. none of them offer extended reflections on the experience although the experiences might invite such comment. one purpose in publishing them is to stimulate such reflection. one is the recent first-hand account of a female physician who acquired ebola from the index case in nigeria and recovered. the patient from whom she acquired ebola prevaricated about his ebola exposure, infecting two physicians and two nursing assistants, three of whom died. by god’s grace she is healed. contributing to this healing is a combination of her knowledge of ebola, remarkable pastoral concern expressed by her pastorphysician, and a response drawing on local, national and international resources. there is joy in recovery and reunion with loved ones, gratitude for faithful spiritual help and generous medical care, acknowledgement of effective public health intervention and sorrow at the loss of esteemed colleagues. a second submission describes a circumstance which must be the lot of many missionary doctors, the need to perform a procedure or deal with circumstances beyond one’s training and experience, and clearly recognizing god at work in bringing about physical healing. prior to operating he consults specialist friends via email; a practice that is increasingly utilized in remote mission settings. 1 operating with a scalpel in one hand and a surgical textbook in another may not be all that uncommon in medical mission setting. some find this troubling. brian palmer in a recent, widely quoted slate article questioned the quality and lack of oversight of missionary medicine even while acknowledging its commitment and sacrificial dedication in the face of epidemics like ebola. 2 however, there is another aspect to this question which portends a broader perspective. missionary doctors by-and-large are educated in a conceptually oriented system where they learn the science behind their clinical acumen and are practiced in problem solving. this aspect of their background tends to get lost in an increasing concentration on clinical guidelines and protocols. equipped with the anatomic, physiologic, and pathologic understanding that is basic to a modern medical education, they are indeed equipped to confront conditions and situations they have never before encountered. such occasions are yet another challenge to the problem-solving lifestyle for which they have been trained and are called. the third report from the field takes us from triumph to tragedy. dealing with complications of labor and childbirth is common in hospitals and in communities throughout the world, especially in underserved areas, and death in childbirth continues to be a tragic accompaniment of these complications. every day, around 800 women die from preventable causes related to pregnancy and childbirth; 27% of these die from post-partum hemorrhage. 3,4 the author of this report examines the challenge to become more spiritually involved with such a patient and her family. there is a sudden and stark realization of the limitations of her technical capacities. beyond that, what does she have to offer? this is an important milestone in becoming a sensitive and compassionate physician who cares for the whole person. these three articles touch on central themes in global healthcare: prayer, faith and healing. in the first article god heals one nigerian christian from ebola whist other colleagues die beside her. in the second article god guides the hands of a doctor who is inexperienced in surgery, and the child recovers. in contrast, in the third story a 3 grills and larson nov 2014. christian journal for global health, 1(2):5-6. young woman tragically passes away despite the care of faithful christian staff. so where was god in the third case? did the surgeons not pray hard enough? did they have little faith? these situations balance each other. god does guide our hands and decisions in order to physically heal people and he does respond to prayer. however, in his sovereignty he does not always choose to heal physically. god is at work in all three stories but in different ways. the second author alludes to the paradox of god at work: “i honestly felt god was orchestrating the whole thing.” indeed, jesus physically healed some but not others, and each time it was for his glory. god heals in all three stories from the field, but in different ways. where the patient tragically passes away he heals the author by challenging her to show god’s love to those who mourn and to attend to the soul. god begins to heal the emotional trauma of the family. and god brings us home through death. the risk of publishing the second story alone is that we can be tempted to measure success merely by prayers answered and physical healing. health mission is about seeing god at work in life and death, in relief of pain and in suffering, in power and weakness, in physical healing and spiritual healing. we should be aware of not painting a picture of health missions which limits god’s power to only physical healing. health according to the bible is much more comprehensive than that, to which apolos landa’s commentary in this issue speaks. will we trust him as job did, knowing our redeemer lives? “the lord gave, and the lord has taken away; blessed be the name of the lord.” (job 1: 21, esv). references 1. emailing md2ndopinion@aol.com is one telemedicine service available to missionary doctors and another reliable service is the swinfen trust. 2. palmer b. in medicine we trust: should we worry that so many of the doctors treating ebola in africa are missionaries? slate. 2014 oct 2 [cited 2014 nov 1] available at: http://www.slate.com/articles/health_and_science/medic al_examiner/2014/10/missionary_doctors_treating_ebola _in_africa_why_people_are_suspicious_of.html 3. who. world health statistics 2014. geneva, world health organization; 2014 [cited 2014 nov 1] available at: http://apps.who.int/iris/bitstream/10665/112738 /1/9789240692671_eng.pdf?ua=1 4. say l et al. global causes of maternal death: a who systematic analysis. 2014. the lancet 2 (6): e323-e333 http://dx.doi.org/10.1016/s2214109x(14)70227-x 5. kassebaum, nj. global, regional and national levels and causes of maternal mortality during 19902013: a systematic analysis for the global burden of disease study 2013. the lancet 384 (9947): 9801004. http://dx.doi.org/10.1016/s01406736(14)60696-6 www.cjgh.org http://www.slate.com/articles/health_and_science/medical_examiner/2014/10/missionary_doctors_treating_ebola_in_africa_why_people_are_suspicious_of.html http://www.slate.com/articles/health_and_science/medical_examiner/2014/10/missionary_doctors_treating_ebola_in_africa_why_people_are_suspicious_of.html http://www.slate.com/articles/health_and_science/medical_examiner/2014/10/missionary_doctors_treating_ebola_in_africa_why_people_are_suspicious_of.html http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf?ua=1 http://dx.doi.org/10.1016/s2214-109x(14)70227-x http://dx.doi.org/10.1016/s2214-109x(14)70227-x http://dx.doi.org/10.1016/s0140-6736(14)60696-6 http://dx.doi.org/10.1016/s0140-6736(14)60696-6 review article dec 2020. christian journal for global health 7(5) effectiveness of community health worker-delivered interventions on non-communicable disease risk and health outcomes in india: a systematic review alexander milesa, matthew j reeveb, nathan j grillsc a bbiomed, md, the nossal institute of global health, university of melbourne, australia. b mbbs, mph, senior technical officer, the nossal institute of global health, university of melbourne, australia. c dphil, dph, mbbs, mph, professor, the nossal institute of global health and the australia india institute, university of melbourne, australia. abstract background and aims: non-communicable diseases (ncds) account for 61% of deaths in india. this review focuses on community health workers’ (chw) effectiveness in preventing and managing ncds in india which could help direct future research and government policy. methods: a search of pubmed, ovid, embase, and cinahl using terms related to “community health workers” and “india” was used to find articles that quantitatively measured the effect of chw-delivered interventions on ncd risk and health outcomes. results: chw interventions are associated with improved health outcomes, metabolic parameters, and lifestyle risk factors in diabetes, cardiovascular disease, and oral cancer. current literature on chw interventions for ncds in india is limited in the number of studies and the scope of ncds covered. conclusion: there is weak to moderate evidence that chws can improve ncd health outcomes in india. keywords: public health, systematic review, non-communicable disease, community health workers, india introduction more than three-quarters of deaths attributed to non-communicable diseases (ncds) occur in lowand middle-income countries (lmics), and most are preventable.1 economic development and social changes in lmics have resulted in dietary changes, reduced physical activity, and better access to healthcare to treat infectious diseases. these changes have contributed to ncds overtaking infectious diseases as the primary burden of disease in lmics including india.2-4 in india, cardiovascular disease now accounts for over 25% of deaths,5 and diabetes cases in india are expected to reach 79 million by 2030.6 india has an extreme shortage and maldistribution of healthcare workers. the density of doctors per capita in india is one-quarter of world health organisation (who) recommendations, and while 74% of india’s 1.25 billion people live in rural areas, most doctors work in cities.7 to overcome healthcare shortages, taskshifting can be employed wherein tasks are 2 miles, reeve & grills dec 2020. christian journal for global health 7(5) delegated to less specialised health workers. for example, a community health worker (chw) may fill roles previously done by a nurse. chws are health workers who receive limited training to deliver healthcare but have no formal qualifications directly related to healthcare.8 systematic reviews of chw interventions in the usa and in lmics other than india show that compared with standard care, chws can improve health outcomes for breast cancer, hypertension, and diabetes, and improve medication adherence and cardiovascular disease risk factors.8-10 china was the first country to implement a large-scale chw program during the 1920s.11 illiterate farmers were trained to become barefoot doctors who recorded births and deaths, administered first aid, vaccinated children, and gave community health education talks.11 by the 1970s, it is estimated that there were over one million barefoot doctors in china.12 the first global health conference in ata, in what is now kazakhstan, increased interest in community health worker programs with an aim to deliver “health for all.”12 however, a global recession in the 1980s led to many of these initiatives dissolving, without the necessary funding and resources.13 there were successful chw programs in lmics during the 1980s in brazil, nepal, and bangladesh. these countries all achieved improvements in child mortality throughout the 1990s.14 other countries to invest in chws since 1990 include uganda, ethiopia, pakistan, and india.12 government-funded health programs led by chws started in india in the 1970s.15 these chws, called anganwadi workers, administer basic health care to young children and mothers including nutrition education, growth monitoring, and referral to appropriate services.16 [ in 2005, the indian government launched a new chw program called the national rural health mission, where over 700,000 accredited social health activists (ashas) were recruited to work in their own communities.4 their roles include maternal counselling, encouraging births in hospitals, newborn nutrition education, infection prevention, and referral to appropriate services.4 nongovernment organisations also run community health projects and employ chws independently.17 launched in 2010, the national programme for prevention and control of cancer, diabetes, cardiovascular diseases, and stroke (npcdcs) aimed to use government-employed chws to also target ncds in india.18 despite the widespread adoption of chws in healthcare delivery, there is a paucity of data on the effect of chw interventions on ncds in india. this is significant because india has over one-sixth of the world’s population and over 2.3 million chws, or 40% of the world’s total.19,20 current literature on chws has not specifically focused on india but has focused on infectious disease prevention and maternal and child health (mch). this review examines the effectiveness of chws in the prevention and management of ncds in india to help guide future research and policy. methods databases on 16th june 2020, four online databases were searched (pubmed, ovid, cinahl, and embase) from inception date using the search strategy outlined in appendix 1. this strategy was derived from search strategies of previous systematic reviews on chws’ effectiveness.10,21 search terms search terms focused on chws and india (appendix 1 search strategy). ncds represent numerous medical conditions and no specific ncd search terms were used to prevent the unintentional omission of articles. instead, irrelevant results were manually excluded during the screening process. definitions for this review, who’s definition of ncds was used, which outlines ncds as chronic diseases resulting from a combination of genetic, physiological, environmental, and behavioural factors.22 mental health conditions were excluded to limit the review to chronic physical conditions. diseases and deaths caused by trauma, home and work accidents, natural disasters, human 3 miles, reeve & grills dec 2020. christian journal for global health 7(5) environmental hazards, pregnancy, and disability were excluded because they did not meet the criteria for ncds in this review. the definition for chws was “any health worker whose work pertains to healthcare delivery, who is given training in the context of the intervention and who has not received a healthcare degree.” this definition was based on a cochrane review of chws.8 the effectiveness of chws was defined as their ability to improve participant health outcomes or to improve disease risk factors as measured by a statistically significant change when compared to standard care. inclusion and exclusion criteria article titles and their abstracts were initially screened by two researchers (am and mr) based on inclusion and exclusion criteria. studies were only included if they focussed on ncds, used chws as a direct intervention, and quantified the chw intervention effect compared with either baseline or standard care. only primary articles published in peer-reviewed journals were included. studies were excluded if they were based outside india, not published in the english language, or the full text was unavailable. articles were not excluded based on the year of publication. full texts were evaluated using the same inclusion and exclusion criteria by the same researchers. references of chosen articles were screened to identify further studies. a third researcher (ng), an expert on public health in india, was consulted in cases where inclusion or exclusion was disputed. quality down and black’s checklist23 was used to analyse each study’s design quality (appendix 3). for randomised control trials (rcts), reporting quality was analysed with the consort checklist.24 (appendix 4) for non-ncts, the trend25 statement checklist was used (appendix 5). the quality assessment was not designed to exclude any articles. grey literature was not searched to give the review reasonable quality. 4 miles, reeve & grills dec 2020. christian journal for global health 7(5) results figure 1. selection criteria for articles m ile s, r ee ve & g ri lls 5 table 1. study characteristics author year study type sample size location type of chw ncd target group intervention comparison duration risk u/r* tian et al.26 2015 rct 1050 haryana (and tibet) volunteer community members cardiovascular high rural lifestyle modification, medication prescription, and adherence standard cardiovascular management program 12 months xavier et al.27 2016 rct 805 india-wide not specified cardiovascular high medication adherence program no intervention 12 months sharma et al.28 2016 rct 100 trained nonphysician health worker cardiovascular high assessment of cardiovascular disease risk factors and drug adherence standard care group 24 months kar et al.29 2008 rct 400 haryana and chandigarh union territory not specified cardiovascular low mixed cardiovascular risk screen with referral to doctor for treatment no intervention 5 months kar et al.29 2008 cohort study 1010 haryana and chandigarh union territory not specified cardiovascular low mixed cardiovascular risk screen with referral to doctor for treatment baseline 5 months khetan et al.30 2019 rct 1242 west bengal community health worker cardiovascular low rural health and lifestyle education. standard care 2 years balagopal et al.31 2008 cohort study 703 tamil nadu trained science graduates without health degree diabetes low rural health and lifestyle education baseline 6 months balagopal et al.32 2012 cohort study 1638 gujarat not specified diabetes low rural health and lifestyle education baseline 6 months jain et al33 2018 rct 322 maharashtra community health worker diabetes low rural chw health checks, telephone contact, and medication adherence checks standard care 6 months sankaranarayanan et al.34 2005 rct 167741 kerala non-physician health worker cancer low mixed screening program for oral cancer standard care 9 years shet et al.35 2017 rct 1144 karnataka lay health worker anaemia low rural health and lifestyle education standard care 6 months note. * urban/rural m ile s, r ee ve & g ri lls 6 table 2. key outcomes of chw interventions author ncd duration key findings p-value tian et al.26 cardiovascular 12 months medication adherence higher (46.7% vs. 17.9%) p=0.002 xavier et al.27 cardiovascular 12 months medication adherence higher (or 2.69) 95% ci 1.36– 5.34 systolic blood pressure in intervention group vs. standard care (124.4 vs. 128.0 mmhg) p=0.002 increased smoking cessation (85% vs. 52%, or 5.46) p<0.001 increased physical exercise (89% vs. 60%, or 5.23) p<0.001 increased vegetable consumption (62% vs. 52%, or 1.48) p=0.04 bmi reduction (-0.9kg/m2 vs. no change) p<0·0001 sharma et al.28 cardiovascular 24 months >80% medication adherence higher (24% vs. 8%) p=0.003 systolic blood pressure in intervention group vs. standard care (124.9 vs. 135.4mmhg) p<0.001 increased smoking cessation (80% vs. 18%) p=0.010 improved bmi (24.2 vs. 26.1) p=0.002 improved physical exercise at 12 months (96% vs. 50%) p<0.001 improved cholesterol at 12 months (152.7 vs. 176.7 mg/dl (3.95 vs. 4.57 mmol/l)) p=0.008 improved fruit and vegetable consumption (16% vs. 43.8% eating low amounts of vegetables) p=0.003 kar et al.29 cardiovascular 5 months intention to quit smoking compared with no intervention (37.2% increase vs. 2.3% increase) p<0.05 increase in medication adherence compared with no intervention (27.9% to 58.3% vs. decrease from 43.5% to 34.8%) p<0.05 decrease in systolic blood pressure in high risk individuals compared with baseline (145.6 vs. 154.4 mmhg) p<0.001 khetan et al.30 cardiovascular/ diabetes 24 months systolic blood pressure in intervention group vs. standard care (142.8 vs. 153.2mmhg) p=0.001 fbg improvement in intervention group compared with control (-43.0mg/dl [-2.39mmol/l] vs. -16.3mg/dl [-0.91mmol/l]) p=0.29 reduction in cigarettes consumed in intervention group compared with control (-3.1 vs. -3.3) p=0.62 balagopal et al.31 diabetes 6 months fbg* reduction in diabetics (60.2mg/dl [3.34mmol/l]) p=0.031 m ile s, r ee ve & g ri lls 7 author ncd duration key findings p-value fbg reduction in prediabetics (11.9mg/dl [0.66mmol/l]) p=0.001 fbg reduction in healthy individuals (3.2mg/dl [0.18mmol/l]) p=0.045 fbg reduction in prediabetic youth (18.5mg/dl [1.03mmol/l]) p=0.014 balagopal et al.32 diabetes 6 months fbg reduction in diabetics (19.08mg/dl [1.06mmol/l]) p<0.001 fbg reduction in prediabetics (6.02mg/dl [0.33mmol/l]) p<0.001 systolic blood pressure reduction in diabetics (6.21mmhg) p<0.001 systolic blood pressure reduction in prediabetics (8.57mmhg) systolic blood pressure reduction in healthy individuals (7.21mmhg) increased fruit and vegetable consumption (an increase of 0.04 serves of fruit and 0.19 serves of vegetables per day) p<0.001 increased physical exercise (increase from 24.4 to 38.0%) p<0.001 bmi reduction in diabetics (1.05%) p<0.001 jain et al.33 diabetes 6 months systolic blood pressure in intervention vs. control (126.03 vs. 128.69) p=0.651 fasting blood sugar in intervention vs. control (148.33mg/dl [8.24mmol/l] vs. 153.40 [8.52mmol/l]) p=0.654 post-prandial blood sugar in intervention vs. control (226.11mg/dl [12.56mmol/l] vs. 236.17mg/dl [13.12mmol/l]) p=0.391 total cholesterol in intervention vs. control (173.11mg/dl [4.48mmol/l] vs. 169.08mg/dl[4.37mmol/l]) p=0.67 sankaranarayanan et al.34 cancer 9 years reduced mortality from oral cancer in consumers of tobacco and/or alcohol receiving screening intervention compared with standard care (mortality rate 29.9 vs. 45.4) p=0.03 shet et al.35 anaemia 6 months anaemia cure rate at follow-up in intervention group compared with control (55.7% vs. 41.1% – rr 1.37) 95% ci 1.04–1.70 improvement in hb in intervention group compared with control (1.087 vs. 0.829 – difference of 0.257 g/dl) 95% ci 0.07–0.44 note. *fbg = fasting blood glucose 8 miles, reeve & grills dec 2020. christian journal for global health 7(5) in total, 9,687 non-duplicate articles were found, 9,640 were not studies on chws or ncds in india, or the full text was unavailable. of the 47 remaining articles 10 remained after full text screening (figure 1). study design seven studies were rcts, 26-28,30,33-35 two were cohort studies,31,32 and one article involved multiple studies, with components of both rcts and cohort study design29 (table 1). geography two studies were conducted in haryana26,29 and one each in tamil nadu,31 gujarat,32 kerala,34, west bengal,30 maharashtra,33 and karnataka.35 one study27 was based across 14 states which were not named. another trial26 was based in both haryana in india and tibet in china; however, only the indian data were analysed in this review. one article29 was based on haryana (state) and chandigarh, which is a union territory. another article28 did not specify where it was based. four studies occurred only in rural areas,26,31-33 two were in both urban and rural areas,25,30 and two did not clarify their settings27,28 (table 1 study characteristics). community health worker characteristics four studies used the term “community health worker.” 27,30,32,33 “non-physician health worker (nphw)” was used in three articles.28,29,34 “community health volunteer,”26 “lay health worker,”35 and “trained trainer”31 appeared once each (appendix 2 summary of chw characteristics). in this review, “community health worker" covers all terms. in general, chws’ demographics were not well documented. no articles stated the chws’ ages. only two articles reported chws’ gender, where both men and women were used.28,29 chws’ levels of education varied from year 1027 to tertiary education31,34 and was stated in only four articles27,31,32,34 (appendix 2 summary of chw characteristics). five studies specified that non-government chws were recruited,26,28 and only one used the term “anganwadi workers”.35 no studies had ashas (appendix 2 – summary of chw characteristics). training and remuneration training duration varied from one day26 to six months.31 three studies33,34 did not specify the training length. only three articles26,27,30 mentioned chws’ payments (appendix 2 summary of chw characteristics). non-communicable diseases five studies targeted cardiovascular disease.26-30 three studies addressed diabetes,31-33 and there was one study each on oral cancer34 and anaemia35 (table 1 study characteristics). outcomes cardiovascular disease all studies on cardiovascular disease24-30 concluded that chw interventions were effective for cardiovascular disease management (table 2 key outcomes of chw interventions). tian et al.26 found a chw-led surveillance program with lifestyle modification and medication follow-up that was associated with higher medication adherence (taking medication of >25 days in the past month) in a rural cohort aged over 40 years with cardiovascular disease when compared with standard care (46.7% vs. 17.9% at twelve months, p=0.002). xavier et al.27 compared a chw-led medication adherence program with one providing standard care in patients admitted to hospital with acute coronary syndrome27 and reported increased medication adherence (taking >80% of prescribed medications) (97% vs. 92%, p=0.006). sharma et al.24 also found higher adherence (taking >80% of prescribed medications) in patients with acute coronary syndrome following a chw intervention compared with standard care (24% vs. 8%, p =0.003).24 kar et al.29 discovered that chws’ cardiovascular screening and referral of high-risk individuals to a doctor was associated with increased medication adherence at five months compared with no intervention (27.9% to 58.3% in intervention vs. 43.5% to 34.8% in control, p<0.05). xavier et al.,27 sharma et al.,28 and khetan et al.30 reported lower systolic blood pressure in the intervention group compared with standard care (124.4 vs. 128.0 mmhg at 12 months, p=0.002),23 (124.9 vs. 135.4mmhg at 24 months, p<0.001),24 and (142.8 vs. 153.2mmhg at 24 months).26 kar 9 miles, reeve & grills dec 2020. christian journal for global health 7(5) et al.29 also found reduced systolic blood pressure when the post-chw intervention was compared with the individual’s baseline (145.6 vs. 154.4 mmhg at five months, p<0.001). at twelve months, xavier et al.27 reported improved smoking cessation (85% vs. 52%, p<0.001), increased physical exercise (89% vs. 60%, p<0.001), higher fruit and vegetable intake (62% vs. 52%, p=0.04), and bmi reduction (0.9kg/m2 vs. no change, p<0.0001) in the intervention group. similarly, sharma et al.28 found improved smoking cessation (80% vs. 18% cessation rate, p=0.010) and bmi at 24 months (24.2 vs. 26.1, p=0.002) in the intervention group. kar et al.29 also found a higher intention to quit smoking at five months (25.5% vs. 60.3%, p<0.05) compared with the baseline. in contrast, tian et al. and khetan et al.26,30 did not find a correlation between the intervention and smoking cessation at twelve months and 24 months, respectively. diabetes there were three articles on diabetes.30-32 the two articles by balagopal et al. were both cohort studies and suggested that chw-led health education and lifestyle interventions could improve metabolic parameters compared with the baseline (table 2 key outcomes of chw interventions). at six months, in one trial,31 the intervention was associated with reduced fasting blood glucose in patients with diabetes 13.4mmol/l to 10.0mmol/l (p=0.031), in prediabetic patients 6.02mmol/l to 5.36mmol/l (p=0.001), and healthy individuals 5.24mmol/l to 5.07mmol/l (p=0.045). in youth (10–17 years old) with prediabetes, fasting blood glucose was reduced (104.5 [5.81mmol/l] to 86.0mg/dl [4.78mmol/l], p=0.014). at six months, the more recent study32 reported blood glucose reduction in patients with diabetes (165.6mg/dl [9.2mmol/l] to 151.5mg/dl [8.4mmol/l], p<0.001) and patients with prediabetes (107.7 [5.98mmol/l] to 101.9mg/dl [5.66mmol/l], p<0.001). additionally, fruit and vegetable consumption (1.84 serves to 2.05 per day, p<0.001) and moderate–vigorous physical exercise (24.4% to 38.0%, p<0.001) increased in all groups. jain et al..33 compared standard care with chw visits and telephone contact over 6 months for patients attending diabetic clinics. while results tended towards improved blood pressure, fasting blood sugar, post-prandial blood sugar, and cholesterol, none were statistically significant compared with standard care. khetan et al..30 also looked at fasting blood glucose in their cardiovascular risk factor trial. it showed trends towards reduction in fasting blood glucose in people with diabetes receiving the intervention compared with no intervention (decrease by 43.0mg/dl [-2.39mmol/l] vs. 16.3mg/dl [-0.91mmol/l], p=0.29), but it was not statistically significant. cancer sankaranarayanan et al..34 ran a chw-led oral cancer screening intervention which showed that the intervention was associated with reduced oral cancer mortality over nine years (29.9 vs. 45.4 per 100,000, p=0.03) compared with standard care. anaemia shet et al..35 organised a lay-health worker intervention to reduce rates of anaemia in children with anaemia. at six months, the anaemia cure rate was higher in the intervention group as compared to control (55.7% vs. 41.1% – rr 1.37, 95% ci 1.04–1.70). there was also an improvement in average haemoglobin levels in the intervention group compared with control (1.087 vs. 0.829 – difference of 0.257 g/dl, 95% ci 0.07–0.44). study quality study quality scores ranged from 1729 to 2526 out of a possible 26 relevant questions for rcts (appendix 3). for the two non-rcts, the study quality scores were 1232 and 1431 out of a possible 20 relevant questions (appendix 3). the reporting quality scores for rcts ranged from 1833 to 2835 out of a possible 33 relevant questions (appendix 5). the reporting quality scores for the two nonrcts were 2632 and 3131 out of 54 relevant questions (appendix 4). all studies except tian et al.22 and jain et al.34 failed to describe the chw training and intervention adequately enough to allow for replication. studies that rated worse in study quality, such as kar et al.,25 sankaranarayanan et al.,33 and shet et al.,35 did not list potential adverse effects of chw 10 miles, reeve & grills dec 2020. christian journal for global health 7(5) interventions, describe loss to follow-up characteristics, or state funding sources. similarly, balagopal et al.’s two non-rcts31,32 did not list adverse effects of chw interventions, or describe or list loss to follow-up characteristics. rcts that scored worse in reporting quality, such as kar et al.,29 sankaranarayanan et al.,33 and jain et al.,34 did not report on how participants were randomised, how reporters were blinded, and what methods of subgroup analysis were used. discussion this systematic review found weak to moderate evidence that chws in india can improve medical outcomes in cardiovascular disease, diabetes, and childhood anaemia. it also found moderate evidence that they can influence risk factors for cardiovascular disease and diabetes. there is weak evidence that chw interventions can improve the detection of oral cancer. systematic reviews on chws targeting ncds exist8-10 and suggest that chws could improve health outcomes in the areas of breast cancer, hypertension, medication adherence, and diabetes. they also suggest that chws could lower lifestyle risk factors including weight, physical exercise, and smoking rates. training duration and the incentives, both monetary and non-monetary, chws receive affect performance.32 studies in this review did not comment sufficiently on incentives chws received or the content of chws’ training. to the best of the authors’ knowledge, this is the first review of literature on chws specific to india, despite india having a significant proportion of the world’s population and chws.20 additionally, this is the first review that focuses on chws targeting only ncds in an lmic. the literature on cardiovascular disease suggests that there is moderate evidence that chws can improve medication adherence and reduce lifestyle risk factors. there is also moderate evidence that chws can improve fasting blood glucose, blood pressure, and lifestyle risk factors in low risk individuals based on two studies by balagopal et al.31-32 however, in another article from jain et al.,.33 there was no statistically significant improvement in fasting blood glucose, post-prandial blood glucose, blood pressure, and triglycerides in patients with diabetes compared with standard care. the latter article attributed this to the duration of the study and small sample size. there was weak evidence for the benefit of chw involvement in oral cancer screening programs and improving anaemia rates in children. the improvements in ncd health outcomes seen in chw interventions suggest that there are benefits in broadening the scope of chws in india to also target ncd in addition to infectious diseases and mch. only shet et al.35 used “anganwadi workers” and none used “ashas” in their intervention despite these government chws constituting the majority of chws in india.20,37,38 ashas and anganwadi workers currently work in their own communities in simple health education and providing referrals to health care services and would, therefore, be prime candidates for leading ncd interventions. skills used by chws, such as child and maternal nutrition advice, are easily transferable to include simple interventions targeting diet and lifestyle. currently, few ncd interventions utilise government chws because they work predominantly in mch. ashas have only existed since 2005, and they work in public healthcare although india’s healthcare is highly privatised.39 surprisingly, only eleven articles were mentioned in this review despite chws in india numbering 2.3 million20 and india’s high burden of ncds.5,6 this suggests that there is a significant gap in current research on the potential chws may have in improving ncd health outcomes, and this warrants further research. this article supports increasing funding and resource allocation to national ncd health policies that utilise chws. research could also guide new policy as ncds become a higher proportion of india’s burden of disease. there is also the opportunity for local governments and hospitals to expand already existing chw projects to include interventions against non-communicable diseases. 11 miles, reeve & grills dec 2020. christian journal for global health 7(5) compared with another systematic review on chw interventions to improve ncd in other lmics, the results from the research in india also suggests that there is weak to moderate evidence that chw can improve ncd health outcomes.9 compared with other lmics, there is proportionally less research on chws in india given the number of chws in india.9 this review found that some ncds are underrepresented in chw interventions. these included cerebrovascular disease, chronic respiratory disease, chronic kidney disease, and cancer, which are in india’s top ten causes of mortality.40 these ncds may have the potential for chw interventions for primary or secondary prevention. it is difficult to generalise the findings across all of india. the included studies were concentrated in the wealthier southwest of india, and there was only one study in the far north or northeast.30 future chw studies should include these poorer states where the scarcity of health workers is higher and chws have greater potential to fill deficiencies in health needs. limitations comparisons between studies were difficult because they were highly heterogenous. even studies on the same disease had different designs and measured different outcomes. differences included duration, target group, chw education level, chws training duration, and content. only published peer-reviewed articles in english were included, which could have resulted in publication bias. it is likely that chw programs have been documented in grey literature but not peer-reviewed literature; however, this review sought to maximise study and data quality by excluding grey literature. quality assessment found that many studies provided insufficient chw training and intervention details for trial replication. to ensure replicability of the chw interventions it is recommended that future papers are explicit about the training program contents and the community education that chws actually provided. specifying the dates and locations of the trial, who selected the participants, the characteristics of patients lost to follow-up, and potential adverse effects is also recommended. conclusion there is weak to moderate evidence to suggest that chws can be effective in helping in the management of cardiovascular disease, diabetes, and oral cancer in low-resource settings in india; however, the evidence is limited by the number of studies and states of india which were represented in studies found by the review. additionally, most studies provide little or no detail on the training methods, training content, and, importantly, remuneration of chws, which is known to affect worker output. future studies in other indian states and in other ncds are required to provide more complete evidence on the effectiveness of chws in targeting ncds in india. references 1. islam sms, purnat td, phuong nta, mwingira u, schacht k, fröschl g. non-communicable diseases (ncds) in developing countries: a symposium report. global health. 2014;10:81. 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for health metrics and evaluation (ihme). gbd compare seattle, wa [internet]: ihme, university of washington; 2015 [cited 2019 july 03]. available from: http://vizhub.healthdata.org/gbd-compare http://doi.org/10.2105/ajph.94.3.361 http://doi.org/10.1161/circulationaha.115.015373 http://doi.org/10.1161/circulationaha.115.015373 http://doi.org/10.1016/s2213-8587(15)00480-5 http://doi.org/10.1016/j.ihj.2016.03.027 http://doi.org/10.1016/j.gheart.2019.08.003 http://doi.org/10.2337/dc07-1680 http://doi.org/10.1177/0145721712459890 http://doi.org/10.5530/jcdr.2018.3.29 http://doi.org/10.1016/s0140-6736(05)66658-5 http://doi.org/10.1001/jamapediatrics.2019.2087 https://ccmcentral.com/wp-content/uploads/2013/12/how-effective-are-chws-evidence-summary-condensed_jhsph_2012.pdf https://ccmcentral.com/wp-content/uploads/2013/12/how-effective-are-chws-evidence-summary-condensed_jhsph_2012.pdf https://ccmcentral.com/wp-content/uploads/2013/12/how-effective-are-chws-evidence-summary-condensed_jhsph_2012.pdf http://doi.org/10.1136/bmj.331.7526.1157 http://vizhub.healthdata.org/gbd-compare 14 miles, reeve & grills dec 2020. christian journal for global health 7(5) appendix 1: search strategy pubmed search number search strategy 1 (anganwadi worker* or asha* or auxiliary health worker* or barefoot doctor* or community health advisor* or community health advocate* or community health aide* or community health representative* or community health worker* or chw* or family health promoter* or lay health advisor* or lay health worker* or non-physician health worker* or volunteer health educator* or volunteer health worker* or village health worker*) and india ovid search number search strategy 1 anganwadi worker* 2 asha* 3 auxiliary health worker* 4 community health advisor* 5 community health advocate* 6 community health aide* 7 community health representative* 8 community health worker* 9 chw* 10 family health promoter* 11 lay health advisor* 12 lay health worker* 13 non-physician health worker* 14 volunteer health educator* 15 volunteer health worker* 16 village health worker* 17 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 18 india 19 17 and 18 embase search number search strategy 1 anganwadi worker* 2 asha* 3 auxiliary health worker* 4 community health advisor* 5 community health advocate* 6 community health aide* 7 community health representative* 8 community health worker* 9 chw* 10 family health promoter* 11 lay health advisor* 12 lay health worker* 13 non-physician health worker* 14 volunteer health educator* 15 volunteer health worker* 16 village health worker* 17 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 18 india 19 17 and 18 cinahl search number search strategy 1 anganwadi worker* 2 asha* 3 auxiliary health worker* 4 community health advisor* 5 community health advocate* 15 miles, reeve & grills dec 2020. christian journal for global health 7(5) 6 community health aide* 7 community health representative* 8 community health worker* 9 chw* 10 family health promoter* 11 lay health advisor* 12 lay health worker* 13 non-physician health worker* 14 volunteer health educator* 15 volunteer health worker* 16 village health worker* 17 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 18 india 19 17 and 18 appendix 2: chw characteristics author year type of chw chw age chw gender chw education gov*/ non-gov training incentive/ payment tian et al26 2015 volunteer community members nongovernment 1 day, refresher every 3-4 mo $us500 over 1 year xavier et al27 2016 chw yr. 10-12 nongovernment 5 days "modest salary”not specified sharma et al28 2016 trained nonphysician health worker mixed finished yr. 12 nongovernment 3 days kar et al29 2008 non-physician health worker 4 male, 4 female 4 days + monthly day refresher khetan et al30 2019 chw - balagopal et al31 2008 trained science graduates university graduate nongovernment 6 months balagopal et al32 2012 chw ≥ yr. 12 nongovernment 4 weeks sankaranara yanan et al33 2005 non-medical graduates university graduate jain et al34 2018 chw shet et al35 2019 anganwadi worker/ lay health worker government * government employed appendix 3: study design quality based on downs and black checklist author 1 2 3 4 5 6 7 8 9 10 11 12 13 14 tian et al26 y y y y y y y n y y y y y y xavier et al27 y y y n y y y n n n y y y y sharma et al28 y y y n y y y n n y y y y y kar et al29 y n y n n y y n y n n y y y khetan et al30 y y y n y y y y n y y y y y balagopal et al31 y y y n y y n n y y y y y balagopal et al32 y n y n y y n n y y y y y sankaranarayanan et al33 y y y n y y y n n y n y y y 16 miles, reeve & grills dec 2020. christian journal for global health 7(5) jain et al34 y y y y y y y n n y y y y y shet et al35 y y y n y y y n n n y y y y author 15 16 17 18 20 21 22 23 24 25 26 27 28 qs tian et al26 y y y y y y y y y y 25 xavier et al27 y y y y y y y y y y 22 sharma et al28 y y y y y y y y y y 23 kar et al29 n y y y y y y n y y 17 khetan et al30 y y y y y y y y y y 22 balagopal et al31 y y n y 14 balagopal et al32 n y n y 12 sankaranarayanan et al33 n y y y y y y y n n 19 jain et al34 y y y y y y y y n y 22 shet et al35 y y y y y y y y y y 20 y = yes, n = no, “-” = n/a, qs = quality score 1. is the objective of the study clear? 2. are the main outcomes clearly described in the introduction or methods? 3. are characteristics of the patients included in the study clearly described? 4. are the interventions clearly described? 5. are the distributions of principal confounders in each group of subjects clearly described? (yes/partially/no) 6. are the main findings of the study clearly described? 7. does the study estimate random variability in data for main outcomes? 8. have all the important adverse events consequential to the intervention been reported? 9. have characteristics of patients lost to follow-up been described? 10. have actual probability values been reported for the main outcomes except probability <0.001? 11. is the source of funding clearly stated? 12. were subjects who were asked to participate in the study representative of the entire population recruited? 13. were those subjects who were prepared to participate representative of the recruited population? 14. were staff, places, and facilities where patients were treated representative of treatment most received? 15. was an attempt made to blind study subjects to the intervention? 16. was an attempt made to blind those measuring the main outcomes? 17. if any of the results of the study were based on data dredging was this made clear? 18. was the time period between intervention and outcome the same for intervention and control groups or adjusted for? 19. were the statistical tests used to assess main outcomes appropriate? 20. was compliance with the interventions reliable? (adherence good or data good) 21. were main outcome measures used accurate? (valid and reliable) 22. were patients in different intervention groups recruited from the same population? 23. were study subjects in different intervention groups recruited over the same period of time? 24. were study subjects randomized to intervention groups? 25. was the randomized intervention assignment concealed from patients and staff until recruitment was complete? 26. was there adequate adjustment for confounding in the analyses from which main findings were drawn? 27. were losses of patients to follow-up taken into account? 28. was the study sufficiently powered to detect clinically important effects where probability value for a difference due to chance is < 5% appendix 4: study reporting quality based on trend statement checklist for non-rcts 17 miles, reeve & grills dec 2020. christian journal for global health 7(5) author 1c 2a 2b 3a 3b 3c 3d 4a 4b 4c 4d 4e 4f 4g 4h balagopal et al31 y y n y y y y n y y y y y n n balagopal et al32 y y n n n y n n y y y y y y n author 5 6a 6b 6c 7 8a 8b 8c 9 10a 10b 11a 11b 11c 11d balagopal et al31 y n y n n y y y y y n y balagopal et al32 y n y n n y n y y y n y author 12a.i 12a.ii 12a.iii 12a.vi 12b 13 14a 14b 14c 14d 15 16a 16b 17a balagopal et al31 y y n n n y y n n n y balagopal et al32 n n n n y y y n y n author 17b 17c 18 19 20a 20b 20c 20d 21 22 23 24 25 total balagopal et al31 n n y n y n n y y y n n y 31 balagopal et al32 y n y n n n n n n y n n y 26 y = yes, n=no, “-” = n/a 1a. information on how unit were allocated to interventions (title and abstract) 1b. structured abstract recommended 1c. information on target population or study sample 2a. scientific background and explanation of rationale (into) 2b. theories used in designing behavioural interventions 3a. eligibility criteria for participants, including criteria at different levels in recruitment/sampling plan (e.g., cities, clinics, subjects) (method/participants) 3b. method of recruitment (e.g., referral, self-selection), including the sampling method if a systematic sampling plan was implemented 3c. recruitment setting 3d. settings and locations where the data were collected 4a. content: what was given? (methods/intervention) 4b. delivery method: how was the content given? 4c. unit of delivery: how were the subjects grouped during delivery? 4d. deliverer: who delivered the intervention? 4e. setting: where was the intervention delivered? 4f. exposure quantity and duration: how many sessions or episodes or events were intended to be delivered? how long were they intended to last? 4g. time span: how long was it intended to take to deliver the intervention to each unit? 4h. activities to increase compliance or adherence (e.g., incentives) 5. specific objectives and hypotheses (method/objectives) 6a. clearly defined primary and secondary outcome measures (method/outcomes) 6b. methods used to collect data and any methods used to enhance the quality of measurements 6c. information on validated instruments such as psychometric and biometric properties 7. how sample size was determined and, when applicable, explanation of any interim analyses and stopping rules (method/sample size) 8a. unit of assignment (the unit being assigned to study condition, e.g., individual, group, community) (method/unit of assignment) 8b. method used to assign units to study conditions, including details of any restriction (e.g., blocking, stratification, minimization) 8c. inclusion of aspects employed to help minimize potential bias induced due to non-randomization (e.g., matching) 9. whether or not participants, those administering the interventions, and those assessing the outcomes were blinded to study condition assignment; if so, statement regarding how the blinding was accomplished and how it was assessed. (method/masking) 18 miles, reeve & grills dec 2020. christian journal for global health 7(5) 10a. description of the smallest unit that is being analysed to assess intervention effects (e.g., individual, group, or community) (method/units of analysis) 10b. if the unit of analysis differs from the unit of assignment, the analytical method used to account for this (e.g., adjusting the standard error estimates by the design effect or using multilevel analysis) 11a. statistical methods used to compare study groups for primary methods outcome(s), including complex methods of correlated data (method/analysis) 11b. statistical methods used for additional analyses, such as a subgroup analyses and adjusted analysis 11c. methods for imputing missing data, if used 11d. statistical software or programs used 12a.i flow of participants through each stage of the study: enrolment, assignment, allocation, and intervention exposure, follow-up, analysis (a diagram is strongly recommended) (results/participant flow) 12a.ii enrolment: the numbers of participants screened for eligibility, found to be eligible or not eligible, declined to be enrolled, and enrolled in the study 12a.iii assignment: the numbers of participants assigned to a study condition 12a.iv allocation and intervention exposure: the number of participants assigned to each study condition and the number of participants who received each intervention 12a.v follow-up: the number of participants who completed the follow-up or did not complete the follow-up (i.e., lost to follow-up), by study condition 12a.vi analysis: the number of participants included in or excluded from the main analysis, by study condition 12b. description of protocol deviations from study as planned, along with reasons 13. dates defining the periods of recruitment and follow-up (results/recruitment) 14a. baseline demographic and clinical characteristics of participants in each study condition (results/baseline data) 14b. baseline characteristics for each study condition relevant to specific disease prevention research 14c. baseline comparisons of those lost to follow-up and those retained, overall and by study condition 14d. comparison between study population at baseline and target population of interest 15. data on study group equivalence at baseline and statistical methods used to control for baseline differences (results/ baseline equivalence 16a. number of participants (denominator) included in each analysis for each study condition, particularly when the denominators change for different outcomes; statement of the results in absolute numbers when feasible (results/ numbers analysed) 16b. indication of whether the analysis strategy was “intention to treat” or, if not, description of how non-compliers were treated in the analyses 17a. for each primary and secondary outcome, a summary of results for each estimation study condition, and the estimated effect size and a confidence interval to indicate the precision (results/ outcomes and estimations) 17b. inclusion of null and negative findings 17c. inclusion of results from testing pre-specified causal pathways through which the intervention was intended to operate, if any 18. summary of other analyses performed, including subgroup or restricted analyses, indicating which are prespecified or exploratory (results/ancillary analysis) 19. summary of all important adverse events or unintended effects in each study condition (including summary measures, effect size estimates, and confidence intervals) (results/adverse events) 20a. interpretation of the results, taking into account study hypotheses, sources of potential bias, imprecision of measures, multiplicative analyses, and other limitations or weaknesses of the study (discussion/interpretation) 20b. discussion of results taking into account the mechanism by which the intervention was intended to work (causal pathways) or alternative mechanisms or explanations 20c. discussion of the success of and barriers to implementing the intervention, fidelity of implementation 20d. discussion of research, programmatic, or policy implications 21. generalizability (external validity) of the trial findings, taking into account the study population, the characteristics of the intervention, length of follow-up, incentives, compliance rates, specific sites/settings involved in the study, and other contextual issues (discussion/generalisability) 22. general interpretation of the results in the context of current evidence and current theory (discussion/overall evidence) 23. registration number and name of trial registry (other info) 19 miles, reeve & grills dec 2020. christian journal for global health 7(5) 24. where the full trial protocol can be accessed, if available (other info) 25. sources of funding and other support (such as supply of drugs), role of funders (other info) appendix 5: study reporting quality based on consort 2010 checklist for rcts author’s name 1a 1b 2a 2b 3a 3b 4a 4b 5 6a 6b 7a 7b 8a 8b 9 tian et al26 y y y y y y y n y y y y y xavier et al27 y y y y y y n n y n y y y sharma et al28 n y y y y y n n y y y y y y kar et al29 n y y y y n y n n n y y n khetan et al30 y y y y y y y n y y y y y sankaranarayanan et al33 y y y y y y y n n y n n y n jain et al34 y y y y y y y n y y y n n shet et al35 y y y y y y y n y y y y y author’s name 10 11a 11b 12a 12b 13a 13b 14a 14b 15 16 17a 17b 18 19 tian et al26 n n y y y y n y y y n n xavier et al27 y n y y y y y n n y y n n sharma et al28 n y y y y n n y y y n n kar et al29 y n y n y y y n y y y n n khetan et al30 n n y y y y y y y y y n sankaranarayanan et al33 n n y n y n n y y y y n y n jain et al34 y n y n y n n y y y y n shet et al35 y y y y y y y y y y y n author’s name 20 21 22 23 24 25 total tian et al26 y y y y y y 25 xavier et al27 y y y y n y 23 sharma et al28 y y y n n y 22 kar et al29 y y y n n y 19 khetan et al30 y y y y y y 27 sankaranarayanan et al33 n y y n n n 18 jain et al34 y y y n n y 20 shet et al35 y y y n y y 28 y = yes, n=no, “-"=n/a 1a. identification as a randomised trial in the title (title and abstract) 1b. structured summary of trial design, methods, results, and conclusions (for specific guidance see consort for abstracts) 2a. scientific background and explanation of rationale (introduction) 2b. specific objectives or hypotheses 3a. description of trial design (such as parallel, factorial) including allocation ratio (methods/trial design) 3b. important changes to methods after trial commencement (such as eligibility criteria), with reasons 4a. eligibility criteria for participants (methods/participants) 4b. settings and locations where the data were collected 5. the interventions for each group with sufficient details to allow replication, including how and when they were actually administered (methods/interventions) 6a. completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed (methods/outcomes) 20 miles, reeve & grills dec 2020. christian journal for global health 7(5) 6b. any changes to trial outcomes after the trial commenced, with reasons 7a. how sample size was determined (methods/sample size) 7b. when applicable, explanation of any interim analyses and stopping guidelines 8a. method used to generate the random allocation sequence (methods/randomisation/sequence) 8b. type of randomisation; details of any restriction (such as blocking and block size) 9. mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned (randomisation/allocation concealment mechanism) 10. who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions (methods/randomisation/implementation) 11a. if done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how (methods/blinding) 11b. if relevant, description of the similarity of interventions 12a. statistical methods used to compare groups for primary and secondary outcomes (methods/statistical methods) 12b. methods for additional analyses, such as subgroup analyses and adjusted analyses 13a. for each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome (results/participant flow) 13b. for each group, losses and exclusions after randomisation, together with reasons 14a. dates defining the periods of recruitment and follow-up (results/recruitment) 14b. why the trial ended or was stopped 15. a table showing baseline demographic and clinical characteristics for each group (results/baseline data) 16. for each group, number of participants (denominator) included in each analysis and whether the analysis was by original assigned groups (results/numbers analysed) y 17a. for each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval) (results/outcomes and estimation) 17b. for binary outcomes, presentation of both absolute and relative effect sizes is recommended 18. results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing prespecified from exploratory (results/ancillary analysis) 19. all important harms or unintended effects in each group (for specific guidance see consort for harms) (results/harms) 20. trial limitations, addressing sources of potential bias, imprecision, and, if relevant, multiplicity of analyses (discussion/limitations) 21. generalisability (external validity, applicability) of the trial findings (discussion/generalisability) 22. interpretation consistent with results, balancing benefits and harms, and considering other relevant evidence (discussion/ interpretation) 23. registration number and name of trial registry (other information/registration) 24. where the full trial protocol can be accessed, if available (other information/protocol) 25. sources of funding and other support (such as supply of drugs), role of funders (other information/funding) peer reviewed: submitted 22 aug 2020, accepted 11 nov 2020, published 21 dec 2020 competing interests: none declared. correspondence: dr. alexander miles, the nossal institute of global health, australia. alex.q.miles@gmail.com cite this article as: miles a, reeve m j, grills n j. effectiveness of community health worker-delivered interventions on non-communicable disease risk and health outcomes in india: a systematic review. christian j global health. december 2020; 7(5):__ https://doi.org/10.15566/cjgh.v7i5.439 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:alex.q.miles@gmail.com https://doi.org/10.15566/cjgh.v7i5.439 http://creativecommons.org/licenses/by/4.0/ abstract introduction methods results cardiovascular disease discussion conclusion references cite this article as: miles a, reeve m j, grills n j. effectiveness of community health worker-delivered interventions on non-communicable disease risk and health outcomes in india: a systematic review. christian j global health. december 2020; 7(5):__ https://doi.org/10.15566/cjgh.v7i5.439 original article mission hospital responses to challenges and implications for their future role in india’s health system katelyn n.g. longa, sujith j. chandyb, rich feeleyc, richard o. laingd, lance d. lairde, veronika j. wirtzf a drph, msc, boston university school of public health, boston, ma, usa; post-doctoral fellow human flourishing program and t.h. chan school of public health, harvard university, boston, ma, usa b mbbs, md, phd, frcp (edin), professor, department of pharmacology & clinical pharmacology, christian medical college, vellore, india c jd, associate professor (ret), boston university school of public health, boston, ma, usa d mbchb, msc, md, professor, dept of global health, boston university school of public health, boston, ma, usa and school of public health, university of western cape, belville, south africa e mdiv, thd, assistant professor, family medicine, assistant director, ms program in medical anthropology and cross-cultural practice, boston university school of medicine, boston, ma, usa f msc, phd, associate professor, department of global health, boston university school of public health; and director, world health organization collaborating center in pharmaceutical policy abstract background: india’s health system is currently experiencing rapid change. achieving india’s aspirations for improved population health and universal health coverage will require the contribution of all health providers; public, private-for-profit, not-for-profit, and charitable providers. among the largest charitable providers in india are christian mission hospitals, who have played a historic role in healthcare delivery to the poor and underserved. this study explored the main internal and external challenges facing mission hospitals, their response to those challenges, and the role they might play in the broader health system going forward. methods: the study employed interdisciplinary methodology to assess the top challenges and responses between 2010-2017. the theory of everyday resilience was used to categorize challenges as chronic stresses or acute shocks and to explore features of resilience in responses to challenges, along with the underlying capabilities that enable resilience responses. results and discussion: mission hospitals were impacted by social, political, and health system challenges. most operated as “stressors,” for example, strained governance structures and human resource shortages. “shocks” included major changes in health policy and increasing competition from for-profit providers. in response, some mission hospitals exhibited features of everyday resilience, traversing between absorptive, adaptive, and transformative strategies. among mission hospitals that appeared to be successfully navigating challenges, three core capacities were present: 1) cognitive capacity, understanding the challenge and developing appropriate response strategies; 2) behavioral capacity, having agency to deploy context-specific responses; and 3) contextual capacity, having adequate resources, including hardware (e.g., money, 20 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) people, infrastructure) and software (e.g., values, relationships, networks), to exercise the first two capacities. building on their history and current examples of everyday resilience, mission hospitals can contribute to the larger health system by attending to health and well-being at the margins of society, encouraging innovation, developing human resources, and engaging in policy and advocacy. conclusion: while mission hospitals face pressing internal and external challenges, many exhibit features of everyday resilience and retain strong commitment to population health and service to the poor. these features make them potentially strong actors in their local contexts as well as potential partners in the realization of improved population health across india. key words: resilience, health systems, not-for-profit, india, mission hospitals. introduction in india, 70% of outpatient care and 60% of inpatient care is provided by the private sector.1 within the “private sector” are multiple actors, including private for-profit providers, private notfor-profit providers, and traditional health providers.2,3 among private, not-for-profit providers in india, a large number are catholic and protestant mission hospitals, which collectively provide 70,000 inpatient beds across the country.4 india continues to rely heavily on private providers to address the country’s current and unmet health needs,1 including growing efforts to provide universal health coverage (uhc) to approximately 500 million of india’s poorest citizens.5 it is therefore important to understand the types of stresses and shocks facing different types of private providers, the unique forms of resilience that may be at play within specific sectors, and specific contributions that each sector can make towards improved health and well-being across the country. using a theoretical framework of “everyday resilience,”6 this project set out to explore the main challenges facing mission hospitals between 2010-2017, their response to those challenges, and the role they might play in the broader health system going forward. methods interdisciplinary methodology was employed to better understand main challenges facing mission hospitals and their contextualized role in india’s broader health system. interdisciplinary studies are those that seek to answer questions that are too broad or complex to be dealt with adequately by a single discipline or method.7 given the potential for findings to be relevant to public health, organizational theory, theology, sociology, and even political theory, the interdisciplinary approach created a framework to integrate insights into a more comprehensive understanding through the use of site visits, key informant interviews, and in-depth reviews of organizational material, internal reports, and external literature.7 the study took place between 2016-2018. site selection was guided by grounded theory methodology through cycles of iterative data collection and analysis.8 interview guides and participant observation protocols were also developed iteratively using qualitative, social science methodology.9,10 as the project sought to explore the range of experiences within indian mission hospitals, site visits and key informants were selected based on the criteria outlined in table 1. 21 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) table 1. site visit criteria criteria categories institution type mission hospital mission hospital association external public health leadership religious affiliation protestant catholic location rural semi-rural semi-urban urban perception of hospital “status”* strong recovering declining weak governance church-led church-influenced independent of church level of care primary secondary tertiary geography north** south key informant interview categories current mission hospital leadership hospital staff mission hospital association leadership retired mission hospital affiliates external public health leadership notes: * this categorization was determined using feedback from a range of key informants during the initial phase of the project. ** “north” was considered anything north of south india. south indian states included andhra pradesh, telangana, karnataka, kerala, and tamil nadu. “hospital status” was determined during preliminary interviews with a range of key informants who knew the mission hospital network well and recommended visits to different facilities to shed light on a range of experiences and struggles. when multiple people mentioned the same hospital as an example of a “strong” or “struggling” hospital, efforts were made to visit these specific locations in order to explore issues and problems from many different angles.8 during the analysis phase of the project, initial “status” categorizations were evaluated against interview and organizational data to test assumptions and glean insight. key informant interviews were conducted by an external interviewer with extensive experience working in india and with mission hospitals. inperson interviews were conducted in english, as it was the primary language used by hospital administrators within these contexts. at each facility, efforts were made to interview mission hospital leadership and frontline staff, and if possible, retirees or hospital founders. interview questions explored the following topics: personal professional history, hospital history, top challenges facing mission hospitals in the past and present, mission hospital responses to these challenges, personal and institutional values, and the ideal role of mission hospitals within the indian health system. whenever possible, key informants were interviewed more than once to help clarify certain themes and deepen understanding of particular topics. informed consent was obtained before interviews began. in a few cases, audio recordings were made with the permission of the respondent, however most interviews were not recorded. interview notes and recordings were transcribed, thematically analyzed using nvivo, and triangulated with observational data, organizational material, internal reports, and comprehensive literature review. in addition to inductively highlighting commonalities and patterns in the data, variations, outliers, and disagreements were also identified and coded. to increase the validity of the coding schema initially developed by the interviewer, members of the study team independently reviewed and compared transcripts to verify the appropriateness and comprehensiveness of the coding structure. throughout the coding and analysis phase, the study team held ongoing discussions about themes in the data and implications of the findings. while resiliencerelated codes were eventually included in the coding schema, it is important to note that this investigation was not designed as a “resilience” analysis, but rather, that interview themes led to the use of resilience as an analytical framework. for example, unprompted, respondents often used words like 22 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) shock or stress, adapt or transform; all words related to resilience theories. due to the pervasive nature of challenges best understood as “chronic stressors,” the everyday resilience (edr) framework was selected as an appropriate way to analyze the challenges and responses facing mission hospitals.6 this emerging framework is distinct from other “health system resilience” concepts used in the literature to analyze health system response to emergencies such as epidemics and natural disasters (e.g., kruk et al.).11 in contrast to focusing primarily on extraordinary events, the edr framework builds on resilience work in health systems, development, organizational theory 6,12–16 to examine chronic challenges and unexpected events that impact healthcare providers on a day to day basis, and explores features of resilience that emerge in response to such everyday challenges (figure 1). to assess shocks and stressors facing mission hospitals, “top challenges” were determined using the following criteria: 1) the challenge was mentioned at all or most hospitals, 2) the challenge was mentioned by various respondents within a hospital site, 3) the challenge took place between 2010-2017 and, 4) the challenge was supported by outside literature. top challenges were then categorized based on answers to the following questions: is the challenge a shock, a stress, or a combination of both? is the source of the challenge from the social or political sphere? if not, is the source of the challenge from the macro or meso (mission hospital) level of the health system? in which health system domain does the challenge best align, using the who health system building block17 classification? figure 1. everyday resilience framework absorptive capacity1 (persistence) transformative capacity1 (transformational responses) adaptive capacity1 (incremental adjustment) cognitive capacity “the system’s ability to have an awareness (notice or detect) of a shock or chronic challenge, interpret the challenge (sense making), analyze and understand the challenge and develop appropriate responses to the challenge”4,5 behavioral capacity “[this is] about agency. it is the ability of a system to respond to the recognized shock or stress by acting and deploying appropriate strategies.”4,5 contextual capacity “the resources (e.g. hardware and software) that can be drawn by the system to exercise both cognitive and behavioral capacities”4,5 absorptive capacity “absorptive strategies seek to neutralize low intensity or transient challenges, and return the system to its previous state with minimal or no effect on its functionality”2, 3 adaptive capacity “adaptive strategies are used when challenges are of a higher intensity and are likely to exhaust the system’s absorptive strategy; resilient organizations respond by making limited adjustments (adapting) in order to continue to function”2, 3 transform ative capacity “transformative strategies: when shocks to the system are greater and persist, they may require the system to transform into an entirely new state through significant functional and structural changes.”2, 3 e v e r y d a y r e s i l i e n c e f r a m e w o r k 1. béné c. towards a quantifiable measure of resilience. brighton: institute of development studies; 2013 2. béné c, godfrey wood r, newsham a, davies m. resilience new utopia or new tyranny?; reflection about the potentials and limits of the concept of resilience in relation to vulnerability reduction programmes. b rig h to n : in stitu te o f d e v e lo p m e n t s tu d ie s 2 0 1 2 . 3. resyst. what is everyday health system resilience and how might it be nurtured? resyst.lshtm.ac.uk; 2016 4. barasa ew, cloete k, gilson l. from bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening. health policy plan 2017;32(suppl_3):iii91–4. 5. lengnick-hall ca. adaptive fit versus robust transformation: how organizations respond to environmental change. adapt fit robust transform organ respond environ change 2005;31(5):738. cognitive capacity behavioral capacity c o n te x tu a l c a p a c it yc o n te x tu a l c a p a c ity r es ilie n c e str at eg ies o r g a n z atio n a l c a pa b ilit ies 23 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) responses to top challenges were assessed for ways they exhibited particular resilience strategies; namely, the ability to absorb (persist), adapt (make incremental adjustments), or transform (make fundamental changes) in the face of challenge. nonresilience (failure to respond) or negative resilience (persisting in a declining state) were also considered. to assess the features that gave rise to resilience, each hospital’s organizational capabilities (cognitive, behavioral, and contextual) were assessed via interview transcripts, field notes, and organizational materials. each of the three organizational capabilities were then broadly labeled as strong, moderate, or weak at the facility level. while this project was not intended to compare hospitals to each other, each hospital’s preassigned “status” (strong, recovering, declining, or weak) was compared to the ranking of its organizational capabilities (strong, moderate, or weak) to examine relationships and patterns between these categorizations. this work was reviewed and approved by the boston university institutional review board and by hospital leadership at each facility. results interview data was gathered at eleven facilities, five mission hospital associations, and two external public health organizations in 2016 and 2017, with 76 key informant interviews (interviewed in groups on three occasions) (tables 2 and 3). table 2. hospital demographics perceived hospital status strong 5 recovering 3 declining 1 weak 2 governance church-led 4 church-influenced 4 independent 3 level of care all three 7 secondary 4 location urban 3 semi-urban 3 semi-rural 1 rural 4 region north* 4 south 7 note. *“north” was considered states north of andhra pradesh, telangana, karnataka, kerala, and tamil nadu. table 3. respondent demographics gender n male 52 female 21 female group 2 male/female group 1 total 76 age n 40 or younger 11 41-60 39 61-80 19 older than 80 4 unassigned (group) 3 total 76 respondent affiliation & category n mission hospital affiliates current leadership (24) hospital staff (15) 41 mission hospital association leadership 8 retired mission hospital affiliates 17 administrators (6) staff (4) faculty (3) founders (2) association leadership (2) external public health leadership 10 total 76 24 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) 1. stresses, shocks, and the sources of challenge table 4 presents the top challenges facing mission hospitals between 2010-2017. one third of the top challenges were coded as emerging from social and political domains, while the remaining challenges were coded into the six classic “health system pillars”(17). of the six pillars, information, and medicines and technology, were mentioned with less frequency and not included as “top” challenges. social and political within the domain of social and political change, three key challenges were mentioned most frequently. the first was changing patient and employee expectations, which respondents felt were linked to societal shifts such as a growing market economy, changing professional and social norms, and increased access to technology. changing patient and employee expectations operated as a chronic stress among all hospitals during the site visits. it is increasingly difficult with competition for patients. there is an expectation from patients for instant results, [and this] leads to irrational treatment and over prescribing. hospital staff, semi-rural hospital it's becoming very difficult to retain people because of market forces. it's difficult to get people to commit to permanence; that means you join and have said you will retire from here. that is getting more and more difficult, because again of generational mindset change. new priorities of life, new format of life. so that's a challenge. hospital leader, semi-urban hospital the second challenge within the domain of social and political contexts was improper use of finances and power from external forces as well as occasionally, internal groups, which operated as a table 4: top challenges between 2010-2017 social & political challenges shock stress context changing patient and employee expectations x social & political improper use of finances or power x political and social transition x x health system challenges shock stress macro health system meso health system governance large policy changes x x poor governance structures x shifting financial flows towards for-profit healthcare x x financing increasing operational costs x changes in external funding x expanding public & for-profit health services x x service delivery continuing care for the poor amidst resource constraints x aging infrastructure x growth of for-profit healthcare employment x human resources staff shortages, esp. high-quality managers & leaders x 25 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) chronic stress. the third area of challenge, operating as both a shock and a stress, related to rapid changes in national and state political leadership and the concurrent growth of religious tension that, at times, posed challenges to healthcare facilities. governance large policy changes emanating from the macro health system were one of the two most common governance challenges impacting mission hospitals. one policy change mentioned repeatedly across interviews was the clinical establishment act (cea). the cea was passed in 2010, requiring registration and regulation of all clinical establishments in the country. while the cea was yet to be adopted by all states at the time of the project, the passing of the act at the central government level signaled a new era of health regulation and fundamentally shifted how health facilities across the country measured their standard of practice. for some mission hospitals and their affiliated clinic networks, cea operated as an initial shock, leading to clinic closures when facilities were not able to meet the heightened personnel and infrastructure requirements. the second most common set of challenges were issues around meso (mission hospital) governance which operated as a chronic stress among mission hospitals. at every level of society, there are successful mission hospitals; it’s a question of how they are run. small hospitals don’t have enough local resources to have good boards, not enough leadership. retired medical faculty, semi-urban hospital financing mission hospitals faced three prominent challenges related to financing. first, the migration of paying patients towards private, for-profit healthcare. the financial impact of private for-profit healthcare was an initial shock to many mission hospitals, especially in the early 1990s during a period of market liberalization. however, by 2010, the shock of for-profit growth had largely evolved into a chronic stress for most mission hospitals, except for those in rural areas that were just beginning to feel the effects of for-profit healthcare expansion. the second and third most frequently cited financial challenges were increasing operational costs and reductions in external funding for capital expenditures and special programs. these challenges operated as chronic stressors within the 2010-2017 period as well as historically. another challenge is with old ideas of mission hospitals, that mission hospitals are free. patients still think that we have connections [overseas]. hospital staff, healthcare provider meeting service delivery mission hospital service delivery was also challenged by three chronic stressors. first, across all interview settings (urban, rural, semi-rural, etc.), respondents referred to the ways that mission hospital service delivery volume was negatively impacted by the growth of for-profit healthcare services. volume flows were also impacted by expanding government services and health schemes for the poor with patients going to mission hospitals for services they were not able to access elsewhere as well as for more complicated issues. the second chronic challenge was continuing to care for poor patients given increased costs of care. this challenge was compounded by the perception mentioned above that mission hospitals are expected to give predominately free care or generous reductions to the final bill. third was aging infrastructure, that required repair and/or new construction and equipment purchase. human resources human resource constraints were highlighted throughout the majority of interviews. human resources were strained by hospital staff moving towards for-profit healthcare employment as well as employment outside of india (“brain drain”). staff shortages were exacerbated by insufficient numbers 26 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) of high-quality managers and leaders, placing greater burden on existing, committed, high-quality leaders. 2. responses: absorbing, adapting, and transforming to meet the challenge the use of the edr framework allowed for analysis of responses to the challenges listed above. in particular, the identification of absorptive, adaptive, and transformative responses, and, critically, identification of the capabilities that underlay responses. in the following section, a subset of responses to key challenges are described (table 5) table 5. responses to key challenges challenge response social and political change • rigorous legal compliance (absorptive) • leaning on minority status (absorptive) large policy changes (macro) • coordination & resource sharing between hospitals (transformative) • re-training nurses into community health workers (transformative) • clinic closures (non-resilience) poor governance structures (meso) • creating new governance relationships between hospital & external leadership (transformative) • incremental adjustment (adaptive) • lack of response (negative resilience) growth of private for-profit providers (financing, service delivery, and human resource) • direct engagement with for-profit healthcare (adaptive) • selective learning from for-profit healthcare (adaptive) • resistance to for-profit healthcare (absorptive) service delivery challenges related to government health expansion • empanelment with government health insurance (adaptive) • promoting partnership with government (absorptive) • co-existing without direct engagement (absorptive) social and political there were two main forms of absorptive resilience used to respond to political transition and the perception of increased scrutiny of minority religious institutions. the first strategy employed was continued, rigorous, legal compliance. many respondents described legal compliance as the “right thing to do” and even more so in an environment with perceived higher scrutiny. as the regulatory environment could be difficult to navigate, many respondents spoke about sharing information across the mission hospital network, including across religious groups, to ensure that others were up to speed and fully compliant with new laws and regulations. the second absorptive strategy among mission hospitals was to occasionally lean on their status as minority religious institutions and, when necessary, call on legal protections provided in the constitution. policy changes while the closure of some clinics represented “non-resilience,” two other notable responses to cea exhibited features of transformative resilience. the first response was collaboration between catholic and protestant hospital organizations whereby a prominent tertiary protestant hospital shared human resources, equipment, and infrastructure with the surrounding catholic clinics in accordance with cea requirements. the second transformative response was to transition catholic sister-nurses (also known as nun-nurses) working in outlying clinics into “community health enablers.” as the cea prevented these nurses from practicing beyond basic nursing care without advanced clinical oversight, this multi-prong strategy re-trained the sister-nurse workforce to deliver natural therapies, conduct family and de-addiction counseling, 27 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) provide psychological first-aid for trauma, deliver holistic geriatric and palliative care, and conduct preventive health trainings on a variety of key population health issues. governance responses to governance challenges fell into three main categories. the first category was an adaptive response with incremental, often externally mandated governance changes, for example, financial reporting requirements. the second type of response was transformative reconfiguration of governance structures between hospital and church leadership, creating increased agency for hospital leaders to oversee day to day operations and financial decisions. the third type of response was “non-response.” these were facilities that faced so many problems that they were unable to respond effectively to any challenge, including governance issues. some of these hospitals found a way to continue on in the midst of challenges, revealing the capacity for negative forms of resilience with harmful consequences, such as financial losses — or what some have called “maladaptive emergence.”18,19 responses to for-profit expansion three key responses were employed to address the growth of for-profit providers. the first adaptive response was direct engagement with for-profit healthcare. some mission hospitals participated in health industry associations at the local, state, and national level or by temporarily working for for-profit providers to learn from their methods and practice. the second, most common, adaptive response was the selective, and sometimes forced, learning from for-profit providers. in this response, mission hospitals did not have direct engagement or partnership with for-profit players but stayed abreast of changes within the for-profit healthcare world, making selective choices about when, where, and how to try and compete. for example, some pursued national accreditation board for hospitals & healthcare providers (nabh) certification, signaling high quality levels to patients. the third absorptive response was active resistance to forprofit culture and influence. this form of resistance existed mainly in the discourse about what mission hospitals are and ought to be. some respondents were emphatic that mission hospitals must resist focus on money-making, especially in circumstances where revenue generation placed extra burden on patients with limited means. responses to growth of government health initiatives mission hospitals also responded to expanding public health services in three key ways. the first adaptive response was to become empaneled providers of india’s recent expansion of government health schemes. the results of empanelment varied greatly among mission hospitals. in some places, the use of government schemes worked well, allowing for continued or expanded service provision for the poor without increased financial burden on the hospital; while in other places, empanelment was more difficult, with slow reimbursement causing the hospital to shoulder increasing debt. the second absorptive response strategy was to engage in partnership with both state and central government on specific programs and projects. this long-standing response involved many mission hospitals. for example, an urban mission hospital created a partnership with the government to provide disability services such as prosthetic limbs and wheelchairs in a district immediately outside the city. in this project, the government provided, staffed, and funded the disability services, while the mission hospital provided administrative and managerial oversight. the third absorptive response strategy was to co-exist alongside government institutions without direct participation with publicly funded health schemes or projects. 28 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) 3. the critical role of capabilities the analysis of organizational capabilities found that mission hospitals noted for their “strong” status at the beginning of the project, had strong rankings for nearly all three capabilities: cognitive, behavioral, and contextual. strikingly, respondents from “strong” hospitals often described their challenges in dire terms and expressed genuine concern about the future. however, concerns and honest critiques were communicated with more clarity and confidence from various levels of staff. these hospitals also had open, ongoing discussions — and even debates — about what a mission hospital is and what it ought to be in the context of modern india. these are all features that indicated higher levels of cognitive capacity. in strong hospitals, functional, clear governance structures between the hospital and religious leadership were complemented by high-quality leaders and managers across the hospital with authority (or “agency”) to develop and deploy responses to challenges within their own departments; all features of strong behavioral capacity. importantly, strong mission hospitals demonstrated high levels of contextual capacity. for example, deep social capital was fostered within and throughout the hospital via a variety of community-building efforts like campus housing, chapel services, shared liturgy, and open forums for discourse and debate. these hospitals were also well-connected with external resources, most notably those available through the larger mission hospital network. while it is true that strong hospitals tended to have sufficient hardware (e.g., money and people), no respondents from “strong” hospitals reported an excess of hardware resources; instead, they expressed the same concerns as other respondents about current and future resource scarcity. this finding indicates the important role of software (relationships, values, networks) in helping off-set hardware constraints. it is also important to note that strong mission hospitals in this project were located across a variety of settings: urban, semi-urban, semi-rural, and rural. some were affiliated with distinct church bodies, while others had always been independent of the church. some were in north india; others, in south india. all provided primary and secondary care, while others also offered tertiary care. the distinguishing feature of “strong mission” hospitals in this project lay in strong contextual capacity that enabled the full use of cognitive and behavioral capacities, which in turn steered these hospitals towards context-specific forms of everyday resilience. said another way, strong mission hospitals were those that nurtured people, relationships, and shared values, which in turn allowed better use of existing resources, clearer discussions about the nature and source of challenges facing the hospital, and more effective, context-specific, everyday responses to those challenges. 4. faith and future directions for mission hospitals throughout all interviews, religious values, identity, practices, and relationships shaped the discourse around challenges and responses to challenges; as well as the future vision of what mission hospitals are and ought to be. in many instances, these features also strengthened the capacity for everyday resilience, most frequently by the way that shared faith increased contextual capacity. so broadly we can say it's that our faith, the foundation in him, and the gospel gives us a different optic to see all things. retiree, semi-rural when asked about the definition of a “mission hospital,” respondents most frequently defined it as a part of the healing ministry of the church, a way to demonstrate faith, as being pro-poor, and as a means of service. looking to the future, respondents most commonly felt that mission hospitals should continue to meet the needs of society, be devoted to whole-person care, focus on 29 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) context-specific adaptations, demonstrate faith through medical work, work together with other mission hospitals, and at times, work with government. when asked about specific ways mission hospitals should enact these goals, respondents described external and internal initiatives. with regard to working with government, many mentioned state and national health schemes sponsored by the government as one of many ways to consider partnership, including india’s growing initiatives to provide uhc. internally, respondents spoke about future possibilities for mission hospitals in four broad categories: attending to health and well-being at the margins of society, innovation, developing human resources, and engaging in policy and advocacy (figure 2) figure 2. future opportunities for mission hospitals discussion everyday resilience in mission hospitals the edr framework provided a useful and relevant approach to examine stresses and shocks facing mission hospitals in light of political, social, and macro and meso health system change. to our knowledge this is the first use of the edr framework outside the african context. drawing on resilience literature 12,16,20,21 the edr framework posits that health systems (macro and meso) face a greater burden from chronic stressors compared to shocks. indeed, in the present analysis, of the top challenges facing mission hospitals, only one third (4 of 13) operated as initial shocks, each of which morphed into chronic stresses over time. the remaining challenges operated as chronic stressors in the 2010-2017 period, and in many cases, for years and decades before the analysis period. as private, not-for-profit health providers, mission hospitals faced the most prominent challenges in the domains of governance, financing, service delivery, and human resources, as well as social and political change, which supports the claim that health systems analysis is attend to health & well-being at the margins mental health, drug and alcohol abuse, elder care, palliative care, non-communicable disease care and adherence (e.g. diabetes), environmental health encourage innovation telemedicine, expanded health, wellness, and prevention programs, research, it and transparency initiatives, pooled procurement develop human resources distance learning, expanded allied health and health management training programs (e.g. quality improvement), engaging in community health initiatives outside the hospital walls engage in policy and advocacy demonstrate and advocate for sound, ethical health policies that can elevate collective advocacy at the state and national levels 30 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) not complete without attention to these powerful dynamics.6,22–24 as the analysis reveals, one form of chronic stress or shock can touch on multiple domains. for example, when respondents spoke about for-profit healthcare, their comments typically included the impact on mission hospital finances, human resources, service delivery, and patient and staff expectations. while “transformation” may seem like the most compelling resilience strategy to explore, the gold standard of everyday resilience is not transformation.15 in this analysis, the majority of responses to challenges were either absorptive or adaptive, supporting barasa et al.’s claim that everyday resilience is an emergent property of complex adaptive systems characterized by “a combination of absorptive, adaptive, and transformative strategies, underpinned by a set of cognitive, behavioral, and contextual capabilities.”6 while transformation is not always the “ideal,” two transformative responses are worth noting: coordination and resource sharing between catholic and protestant hospital networks and the re-training of sister-nurses into community health enablers. both strategies embodied the definition of transformation as moving into a new state with significant functional and structural changes.12 yet, they also seemed to exceed the definition of transformation and intersect with notions of “social innovation” in health. social innovation in health starts “from the perspective of the person or community for which the solution is being created and not only engages those affected by the challenge, but equips and empowers them.”25 for example, when new policy requirements made some clinics no longer sustainable, meditation on religious vocation led the catholic health workforce to re-imagine their health care delivery role in ways that would allow meaningful contribution to community health within the parameters of the new law. the massive undertaking to train sister-nurses in new forms of healing did not just transform the way they practiced “healthcare;” it empowered the sisternurses by reinforcing the value of their vocation and equipped them with new ways to live out their commitment to provide quality health services. it also transformed social relationships by encouraging new forms of community engagement around health, prevention, and wellbeing. the observation that “transformation” and “social innovation” share overlapping, reinforcing properties towards strengthened health systems has been made by others25,26 and is an important area for future study. nurturing everyday resilience how might everyday resilience be nurtured among mission hospitals and other frontline providers? recognizing the temptation to remain in “fire-fighting” mode — responding to the seemingly endless parade of daily challenges — the edr framework encourages consideration of three domains — cognitive, behavioral, and contextual — which in turn bolster capacity for everyday resilience. while an extensive set of recommendations is beyond the scope of this paper, we briefly suggest ways frontline providers might strengthen edr. first, assessing cognitive capacity requires consideration of the source(s) of the challenges facing frontline providers as well as their core values and guiding ethos. values also inform the “outcomes” worth tracking to know whether or not the facility is impacting the areas of most importance. for many, this will include maintained or improved delivery of quality care, but it also may incorporate outcomes like increased access to care and responsiveness to local needs. without reflection on these matters, response strategies can steer mission hospitals and other frontline providers in a variety of incoherent directions, which may ultimately add greater burden and become a source of challenge in its own right. second, assessing behavioral capacity requires reflection on a hospital’s ability to enact their response strategies. for example, how are 31 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) power and leadership shared between the hospital and external bodies? within the facility, what level of agency is afforded to leaders and managers at various levels to create and enact solutions in their own departments? finally, contextual capacity considers the hardware and software elements of the facility or health system, and ways these features can be strengthened. typically, facility or health system leaders are well aware of the financial, human, and technical resources that are or are not available. but, as the edr framework states, software features are just as important for frontline providers to assess and nurture. these include core values, relationships, networks, management and leadership skills, ideas, and the way power is shared within a facility. in the case of strong mission hospitals in our sample, it was the relationships with the wider mission hospital network, and the shared values, practices, and relationships within mission hospital facilities that seemed to most bolster contextual capacity. given the constraints on time and energy among most frontline providers, we provide in the appendix a series of questions that might facilitate reflection in each of these three domains, with the goal of “nurturing the soil” for everyday resilience among mission hospitals and other frontline health organizations in both public and private sectors. looking to the future “health for all” has been a part of india’s vision for itself since independence. throughout the latter half of the twentieth century and into the new millennium, numerous policies have called for an expansive public health system that would sufficiently meet the health needs of the population.27,28 in august 2018, the indian government rolled out its latest expansion of uhc through a program called ayushman bharatpradhan mantri jan arogya yojana (abpmjay), aimed to expand access to primary care through enhanced public facilities and increase access to secondary and tertiary care for millions of india’s poorest citizens through a network of empaneled hospitals, including non-profit and charitable providers.5,29 ab-pmjay represents one of many ways mission hospitals might consider partnership and expand care to poor patients. however, as with all external partnerships, consideration must be given to things like empanelment requirements, alignment with the needs of the local context, and reimbursement rates. additionally, government might also work with mission hospitals to explore new forms of contractual reimbursement (beyond straight fee for service) as well as the best mode of delivery for services not currently covered by national health schemes. while partnership with public initiatives is one approach, many caution against private not-forprofit or faith-based health services becoming a substitute for or being fully dedicated to government efforts, advocating instead for a “complementary” role to government.3,30,31 it is therefore important to consider opportunities that will allow mission hospitals to “meet a need” and attend to the health of the whole person (body, mind, spirit) in their local contexts. throughout interviews, respondents mentioned many promising areas for mission hospitals in the domains of attending to health and wellbeing at the margins, innovation, human resource development, and policy and advocacy (figure 2). many of these processes were already underway within various mission hospital or networks, indicating scope to deepen experimentation, conduct evaluations, and spread good ideas throughout the broader mission hospital network. attending to health and wellbeing at the margins of society will require ongoing sensitivity on the part of the mission hospitals as the needs of the country continue to change. it is interesting to note that respondents did not say that mission hospitals are meant to meet health needs; they simply said “meet a need” or “meet the need.” this response indicates scope for attention to move from explicit medical conditions to other issues that give rise to 32 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) poor health and well-being, including social determinants of health such as environmental degradation, substance abuse, and growing needs for elder care.32 mission hospitals certainly cannot meet all needs; however, within their specific contexts around the country, each hospital can closely consider and respond to the needs of their surrounding community, particularly the needs of most overlooked and marginalized members of the community. mission hospitals and mission hospital affiliates in india have a rich history of innovation, particularly in the areas of community health and medical education.33,34 currently, there are many areas of innovation underway within mission hospitals and mission hospital networks. for example, throughout 2018, the catholic health network began building an online platform for more than 30 catholic hospitals and clinics across the country to participate in joint procurement, with early data indicating substantial cost savings and scope for scale.35 as mission hospitals experiment and innovate, it is important that they share their learning not only with each other, but also with the broader community. this can be done in a variety of ways including formal research and publication on the outcomes of innovative programs. to help address india’s chronic human resource shortages in rural areas, mission hospitals can continue to build on existing platforms of medical education, consistent with national and state standards, to train a new generation of public health and medical professionals willing to serve in underserved areas. several mission hospitals in this project had distance-learning programs aimed at filling human resource gaps, particularly in rural areas. the critical role of non-clinical leaders and administrators was also observed at nearly every facility included in the project. these were typically young or middle-aged professionals with training in a variety of backgrounds (e.g., human rights, management, business administration, public health) working hard to help mission hospitals keep pace with constant political, social, and health policy changes. while traditional mbbs programs are currently adapting to the new laws about medical school admission, mission hospitals and affiliated medical schools could bolster allied health and public health training, as well as training in management, health leadership, quality improvement, and information technology, important building blocks for all mission hospitals to address existing gaps. broadening the scope of training and education could also encourage recruitment of a very different type of young person who might not have clinical interests, but who may have strong commitment to mission hospital values and aspirations. it is also important that education initiatives remain sensitive to what it means to “meet a need” within particular contexts and through the work of mission hospitals. finally, through organizations like the christian coalition for health in india4 and other groups, mission hospitals can unite and use their collective voice to advocate for sound ethical health policies at local, state, and national levels. in their work on health system resilience, kruk et al. state that health systems are strengthened by a diversity of health actors. the more resilient each type of health actor (public, private, charitable, mission hospital) the more resilient is the whole system against stresses, and particularly, major shocks.11 thus, the continued everyday resilience of mission hospitals can contribute to the strength and resilience of the broader health system towards the goal of improved population health and well-being. limitations and strengths this project originally set out to be an interdisciplinary endeavor that employed both qualitative and quantitative data, however limited time and resources precluded the possibility of gathering robust and consistent quantitative data at each site. better quantitative data could have provided the opportunity to look more carefully at the relationship between everyday resilience and 33 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) improved or expanded delivery of quality health care services, or the ability to investigate the fiscal health of each facility. other limitations included a limited set of hospitals, potential bias in sampling hospitals and interviewees, and the role of an external interviewee. to address these challenges, data triangulation was used to corroborate a voluminous amount of interview data with mission hospital material like annual reports, history books, pamphlets, newsletters, and journals to produce the present analysis. despite the limitations inherent in small qualitative studies, policy makers are increasingly leaning on qualitative evidence to understand various socioeconomic contexts, health systems, and communities.36 qualitative research, particularly when synthesized across individual studies, is a key approach to inform the development of guidelines and address implementation considerations in diverse settings and complex health systems. as such, the potential contributions of the present study, when examined alongside similar studies (e.g., see thekkekara in this issue), can outweigh its limitations. finally, given the emerging nature of the edr framework, this study contributed new insights to the theory and application in real-world settings outside of the african context,18 which should be further tested and explored in subsequent projects in india, africa, and beyond. conclusion this study identifies approaches that can enhance the strength and service capacity of mission hospitals across the country, by identifying and describing features of everyday resilience among mission hospitals in india. beyond strengthening their own resilience, mission hospitals can contribute to the strength and resilience of the broader health system towards the goal of improved population health, with particular attention to promoting the health of the whole person, body, mind, and spirit, and meeting the needs of their local contexts across the country references 1. patel v, parikh r, nandraj s, balasubramaniam p, narayan k, paul vk, et al. assuring health coverage for all in india. lancet 2015;386(10011):2422–35. https://doi.org/10.1016/s0140-6736(15)00955-1 2. gilson l, sen pd, mohammed s, mujinja p. the potential of 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https://www.nhp.gov.in/sites/default/files/pdf/bhore_committee_report_vol-1.pdf https://www.pmjay.gov.in/ 35 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) 2016;3(1):11–24. https://doi.org/10.15566/cjgh.v3i1.9 31. pallant d. keeping faith in faith-based organizations: a practical theology of salvation. army health ministry. eugene, or: wipf & stock pub; 2012. 32. dandona l, dandona r, kumar ga, shukla dk, paul vk, balakrishnan k, et al. nations within a nation: variations in epidemiological transition across the states of india, 1990–2016 in the global burden of disease study. lancet. 2017;390(10111):2437–60. https://doi.org/10.1016/s0140-6736(17)32804-0 33. grills n. the woman who changed the lives of millions [internet]. pursuit, university of melbourne. 2016. available from: https://pursuit.unimelb.edu.au/articles/the-womanwho-changed-the-lives-of-millions 34. christian medical journal of india. 100 years tribute issue. christ med j india. 2006. 35. catholic health association of india (chai). catholic health association: common procurement. 2018. telangana, india. 36. langlois ev, tuncalp o, norris sl, askeew i, ghaffar a. qualitative evidence to improve guidelines and health decision-making. bull world health org 2018;96(79-79a). http://dx.doi.org/10.2471/blt.17.206540. peer reviewed: submitted 3 march 2020, accepted 13 may 2020, published 23 june 2020 acknowledgements: we are grateful to the many people who contributed their time, insight, and expertise to this project, including respondents in india, hospital leadership, and the team of researchers in africa who developed the edr framework and continue to test its use in kenya and south africa competing interests: none declared. correspondence: katelyn long, boston, ma, usa. knlong@bu.edu cite this article as: long kng, chandy sj, feeley r, laing ro, laird ld, wirtz vj. mission hospital responses to challenges and implications for their future role in india’s health system. christian journal for global health. june 2020; 7(2):19-36. https://doi.org/10.15566/cjgh.v7i2.337 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ appendix: questions to help assess and strengthen capacities that underlie everyday resilience cognitive capacity • identifying & ranking the range of current stresses and shocks o what range of challenges currently face your health facility/system? consider challenges that might fall within each of the following categories: social, political, governance, human resources, finances, service delivery, medicines & technology, and information o among the listed challenges, which are the most pressing? o which challenges are likely to keep expanding within the current climate and context? • identifying current response strategies o what strategies are currently in use to face each of these challenges? o consider the strategies currently in use, and for each ask: https://doi.org/10.15566/cjgh.v3i1.9 https://doi.org/10.1016/s0140-6736(17)32804-0 https://pursuit.unimelb.edu.au/articles/the-woman-who-changed-the-lives-of-millions https://pursuit.unimelb.edu.au/articles/the-woman-who-changed-the-lives-of-millions http://dx.doi.org/10.2471/blt.17.206540 mailto:knlong@bu.edu https://doi.org/10.15566/cjgh.v7i2.337 http://creativecommons.org/licenses/by/4.0/ 36 long, chandy, feeley, laing, laird & wirtz june 2020. christian journal for global health 7(2) ▪ does this response allow us to carry on or persist in more or less the same state? (absorbing) ▪ does this response introduce incremental adjustments to our overall structure and practice? (adapting) ▪ does this response lead to fundamental changes to our structure and practice? (transforming) o are there any challenges for which your facility/system are simply not responding (and should be), or responding in ways that lead to slow, continuous decline? • assessing current response strategies o are the current strategies working? are they “effectively” managing challenges? *it is important to note that “effective” might have different meaning for different hospitals. if there is no clear understanding of “effective”, the hospital might consider asking what outcomes are most central to their values and goals as an organization, for example, more services for the poor, higher volumes of patients, financial stability, increased revenue, etc. • assessing values o what values, commitments, and relationships are central to the health facility/system? o how have your core values operated as a lens to understand challenges? are there any values that have been ignored or side-lined in the midst rapid response to ongoing challenges? o which values and commitments are most important in guiding responses going forward? behavioral capacity • assessing and strengthening current governance structures o what is the health facility/system’s current governance structure including external governance stakeholders? o does the current governance structure allow sufficient agency for the health facility/system to develop and enact response strategies? o if the current governance structure does not provide sufficient agency, can it be adjusted or changed in order to facilitate mutually beneficial forms of agency? o does the health facility/system have appropriate resources and leadership in place to manage changes in governance (e.g. experienced leaders and administrators, reporting mechanisms and structures for accountability, particularly fiscal accountability)? • assessing agency within the health facility/system o how much agency exists within the health facility/system? for example, do individual departments or managers have freedom to develop and deploy strategies to address challenges? o if internal agency is limited, how might appropriate forms of agency be expanded? which managers might be nurtured to help strengthen their own departments? contextual capacity • contextual capacity within the health facility/system o what is the nature of personal and professional relationships within the health facility/system? for example, relationships between levels of staff? o can lower-level staff ask questions or share their ideas with senior-level staff? o are mid-level managers empowered to create and oversee responses to challenges impacting their departments? o are there practices such as group events, celebrations, or meals where staff can connect, strengthen collective commitments, and build relationships? • contextual capacity outside the health facility/system o what is the nature of relationships between the health facility/system and the external community? o how does the health facility/system relate to other health facilities/systems in their community (both public and private)? o how does the health facility relate to other health facilities in their system? are there ways to strengthen these relationships? o how can relationships – within and between health facilities – be protected and strengthened as health facilities continue to face ongoing stresses and strains? • hardware and software o what resources – hardware and software – are available to support resilience strategies going forward? ▪ software examples: values, relationships, leadership capacity, management skills, systems and processes ▪ hardware examples: infrastructure, finances, human resources in terms of number and types of healthcare positions review article dec 2020. christian journal for global health 7(5) african pentecostalism and the 1918 influenza pandemic: the supernatural amid the fearful and implications for the covid-19 pandemic omololu ebenezer fagunwaa a mth, phd (theology), federal ministry of health, abuja, nigeria, and phd(c) (microbiology), university of huddersfield, uk abstract infectious outbreaks that lead to epidemics and pandemics are dreaded because of the adverse health, economic, and social effects. the 1918 pandemic caused by the h1n1 influenza virus killed about 40 million people worldwide. like the case of covid-19, the pandemic of 1918 kept christians, as well as people of other faiths, from worshipping together. however, african indigenous pentecostal movements and groups emerged in various parts of the continent around the same time. this period was the time of huge pneumatic experience and spiritual awakening. pentecostals devoted themselves to building their faith and praying ceaselessly during that time, and this has become the foundation of the doctrine and theological instruction of most african-initiated churches (aics). because there have been no studies that consider the 1918 flu pandemic and pentecostal response in africa, this study was undertaken. the time of the 1918 pandemic appeared to be a good opportunity for spiritual awakening. intense prayer prevailed during those times, and teaching and exposition about prayer formed the core of the theology of most aics. pandemics often bring devastation but could also be an opportunity for spiritual awakening through prayer, love in action, social justice, compassion, and care. keywords: influenza, pentecostals, practical theology, covid-19, pandemic, christian, africa introduction in 1918, the entire world was overwhelmed with a viral infection caused by a new strain of influenza virus and characterised by three waves.1,2 africa had its large share during the deadly second wave (aug–dec 1918), and the simultaneous third wave (jan–jul 1919). in the west coast of africa, the spread of the infection started in august, in a dakar, freetown, and accra, then spread to lome, lagos, and calabar. in september 1919, the pandemic broke out in douala, and in october of the same year, it reached libreville and equatorial guinea (figure 1). ultimately, the disease killed 40 million people globally, and a conservative estimate of the mortality in the african continent was 1.4 million.1,2 the 1918 influenza pandemic 53 fagunwa dec 2020. christian journal for global health 7(5) dispensation which overlapped with the move of the holy spirit in the life of indigenous african christians. many may believe pentecostalism was brought into africa and imposed on its people by western missionaries, but a persuasive argument founded on historical accounts reveals that such a premise is untrue in many countries. african pentecostalism is very organic in nature, distinctly african, and never imported.3 we will focus our analysis on two african countries, kenya and nigeria, although pentecostal movements have also become well established in liberia, sierra leone and south africa. south africa was the african country most affected by the 1918 influenza pandemic, and religious beliefs have been reported to be responsible for the high fatality rate.4,5 due to the diversity and complexity of pentecostal movements at that time and the pandemic’s devastation in south africa, an analysis of this country’s experience should form a separate academic discourse. pandemics, like the current covid-19, bring an array of health, economic, and social disruptions. the devastations renders people helpless, and it becomes difficult to see anything other than fear and evil. however, history, which studies the past and the legacies of the past in the present is essential for “rooting” people and events in time. one of the historic moments in the life of african pentecostalism was the 1918 influenza pandemic caused by the h1n1 virus. however, no study has narrated the pandemic with a focus on pentecostal events in africa. therefore, the purpose of this study is to discuss how pentecostalism was facilitated in nigeria and kenya despite the 1918 spanish flu pandemic. also presented are the pentecostal/ charismatic activities and events during the time and their implications for covid-19. methods kenya has unique indigenous as well as missionary pentecostal stories around the period of discussion. nigeria is also worth considering as the 1918 flu pandemic coincides with the organic indigenous pentecostal formation in the country. first, a literature search was conducted in google scholar, base, core, and semantic scholar to see if there has been any previous study that addressed the study aim. to discuss the pentecostal historic activities and the response at the time of the 1918 pandemic, scholarly documents were reviewed and resource materials in the pentecostal archive were explored. (https://pentecostalarchives.org/) the pentecostal archive is a consortium of pentecostal collections managed by the general council of the assemblies of god to make global pentecostal resources accessible from 1897 to the current day. an additional search was conducted on dimensions (https://www.dimensions.ai/), a database that linked data and documents in a single platform. publication dates start from the year 1665 and the platform has over 168,000 published documents for the 1918–1920 period. a further localised, indepth search was conducted on old digitalized african newspapers using a trial version of the newsbank/readex collection. (https://infoweb.newsbank.com/apps/readex). readex provides an acclaimed primary source of a collection of essential material, including newspapers from all around the globe. the digital african newspaper collections cover the period between 1835–1925. the keywords used on all the electronic databases included “kenya,” “nigeria,” “kisumu,” “mombasa,” “lagos,” “ijebu ode,” “influenza,” “plague,” “virus,” “spanish flu,” “flu,” “pentecost,” and “heal.” the location keywords helped to identify the main pentecostal figures and events. the search was initially done broadly to cover materials available in the database between 1897–2020 to get an overview of events and manuscripts relevant to this study. next, a filtered search was conducted for the years 1915– 1925 to accurately narrate events relating to the 1918 pandemic. where the main events and persons were identified, a narrower search was conducted using the names and locations that were mentioned in a specific storyline or event. about:blank about:blank about:blank 54 fagunwa dec 2020. christian journal for global health 7(5) figure 1. the spread of the h1n1 influenza virus in africa in 1918 note. some key pentecostal sites/stations in africa during the spanish flu era include alexandria (egypt), middelburg (south africa), kisumu (kenya), kinshasa (dr congo), boma (dr congo), nkolmetet (cameroon), ijebu-ode (nigeria), cape palmas (liberia), and freetown (sierra leone). results the examination in academic databases showed that there was no previous study that addressed the aim of this study. hence this is premier scholarship on the subject of african pentecostalism and the 1918 flu pandemic. pentecostalism in kenya had two independent histories, one was through missionaries and the other was an organic emergence among the natives in western kenya. the 1918 flu epidemic started during the “silent period” in kenya with little engagement from the pentecostals. the only related account shows that the kellers (pentecostal missionaries) were faithful and showed genuine concern and care for the indigenous population the lord had entrusted to them. in nigeria, a faithhealing preacher, garrick braide, was restricted from performing healing, but another charismatic group sprang up within the anglican church in the southwest of the country. different spiritual activities that characterised the response of the pentecostal movement to the pandemic were the bold application of faith, fervent prayers, and faithful expectations of supernatural healing based on the word of god when all medicines, and 55 fagunwa dec 2020. christian journal for global health 7(5) vaccines failed. the findings of the research will focus on several representative key people and movements within this period of time in kenya and nigeria. kenya kenya is an east african country along the indian ocean, sharing a long border with tanzania, somali, ethiopia, and uganda. christianity can be first traced to the portuguese (catholic) and then the british (anglican) colonization. two factors dramatically changed christianity in kenya— pentecostalism and the emergence of africaninitiated churches (aics).6 we will discuss two origins of pentecostalism in kenya and their relationship with the 1918 pandemic. the millers and the kellers give little to nothing of an account about the disease kenya’s earliest pentecostal history can be traced to clyde toliver miller (1884–1954) and his wife, lila may sturgis (1891–1978). lila was a daughter of miller’s mentor, robert waldron of kansas. in 1907, the couple left for kisumu, kenya, to work with the nilotic independent mission. at the initiative of miller, robert waldron and john buckley (a mission financier) quickly formed the “apostolic faith mission” to acquire 109 acres of mission land among the nyangori people in kisumu.7 however, in 1908, the parcel of land was bought by clyde miller in his name, and that led to stewardship disagreements with the sponsors8 and a consequent marital separation from lila7 that was responsible for the collapse of clyde miller’s mission. what can we say about miller during the influenza pandemic? the time of pandemic was a frustrating period for clyde miller as he struggled with divorce, disfavour with the government, and distrust from his sponsor. so, in 1919, he sold the mission field to a “fill-in” german missionary, otto keller (1888–1942), of pentecostal assemblies mission.9 miller’s ministry could not stand the test of the pandemic. it appeared as if god used the pandemic to repair and reposition his church. the absence of the millers names in the list of missionaries in the minutes of the 7th general council of the assemblies of god held in 1919 and the appearance of mr and mrs john buckley as missionaries in british east africa confirmed the decline of clyde miller’s missionary work.10 for otto keller, the active years of the pandemic were a time of conjugal union with another missionary (marion wittich), preparation for mission work, and childbearing.9 however, based on missionary records, we have placed the keller’s marital union a year after the pandemic in 1920.11,12,13,14 records relating to missionary activities during the pandemic about the new kenya pentecostal leaders, mr and mrs keller, especially marion keller, in 1919, gave testimonies about new converts, powerful evangelization, supernatural protection, and personal provision during her long journey from nyangori to detroit during world war 1.11,12 we also assumed that marion was already in detroit by september 1918. she wrote in may 1919: “i am more determined to go back to africa now than ever before. i have been home for only nine months and am longing to get back.”11 so, we now know why there was a “silence” about the epidemic in kenya. an editor (unnamed) in the latter rain evangel magazine of september 1920 wrote: mrs. marion wittich, who married mr keller soon after returning to east africa, was unable to return to her old station owing to certain restrictions regarding german east africa, so she and her husband are on a station at kisumu, formerly occupied by clyde miller. mr keller has been in east africa for some years but previously to this time he has not been entirely engaged in the lord’s work. he is now busy doing some personal work among the nyangori tribe, who have never had the gospel nor a missionary among them.13 it is assumed that clyde miller may not have been a dependable pentecostal voice to respond to the 1918 flu in kenya. more so, using the 56 fagunwa dec 2020. christian journal for global health 7(5) keywords “clyde,” “toliver,” “miller” between the years 1917–1922 in the consortium database did not yield any remarkable account of his engagement/response during the pandemic nor engagement with the mission sponsors. however, a search between 1913 and 1916 indicated that clyde miller wrote letters from nyangori, kisumu, kenya;15,16 received permission to stay at his post in kisumu;17 and wrote about the lack of funds.18 why was there not an adequate hint or correspondence about the 1918 influenza from both the millers and the kellers, especially at a time when various pentecostal magazines, such as international pentecostal holiness advocate, pentecostal herald, pentecostal evangel, church of god evangel, and latter rain evangel were reporting the pandemic? a search using “keller” and “kisumu” for the years 1918–1919 in the pentecostal archive did not give any result. the only appearance in 1920 was concerning the bimonthly missionary report/disbursement and mrs keller’s september letter mentioned earlier. after 1920, the kellers had many correspondences and featured articles in the pentecostal archive which further support our claim about the year of marriage and “silence” during the pandemic. this also attests to the success of their missionary work in kenya. it is worth mentioning that some years after the pandemic, the kellers trained and sponsored kivuli zakayo, a man who became a prominent indigenous figure in kenyan christian history.19 again, the repositioning of the church from greedy miller to faithful keller after the pandemic yielded long-lasting positive results. the covid-19 pandemic could also bring repair and repositioning for pentecostalism, specifically, and christianity, in general. about the kellers, we inferred that they had experiential knowledge of a wave of the plague, perhaps between late 1919 and early 1920, at nyangori. marion keller wrote: mr keller has much fever. the morning of the baptismal service he had a high fever and had to trust god to keep him as he went into the water, which he did. plague has been raging in this part of the country and has taken three of our best girls. we still have twenty-five girls and twenty boys. so you see what a family we have to care for.14 some five years after the plague, mr keller wrote an article about the zeal of africans to spread the gospel. this was published in the latter rain evangel and the bridegroom’s messenger with an extract: “… the opportunity in africa is greater [than] was ever known before in the history of the church. in the last six years since the close of the war, practically that whole country is open to the lord jesus christ.”20 it was presumed that the pandemic must have opened the hearts of african peoples to the gospel. the roho movement had no narrative about the disease the roho (spirit) movement is another pentecostal element in kenya but it was inactive during the pandemic. the movement commenced in 1912 when the spirit struck a group of church mission society (cms) converts being led by jeremiah otanga, a catechist and elder within the anglican church in ruwe, western kenya. the roho activities had been interrupted by world war 1. in 1933, alfayo odongo mango (1884–1934) and lawi obonyo (c1911–1934) reorganised the movement again.21 hoehler-fatton’s book women of fire and spirit relates the extensive narrative of roho congregations as a means of preserving the roho ancient religious history. hoehler-fatton documented oral testimonies of the working of the spirit and devotion to prayers by this group during the early years (1912–1915). thereafter, the group was scattered, and then alfayo mango (who was born and died in musanda) was possessed of the spirit in 1916. despite the rise of the new leader and his numerous religious and socio-political activities, as documented by hoehler-fatton, there was no mention of the influenza pandemic of 1918–1919. this is an indication of the noninvolvement of the organisation in the problem of the pandemic. ruwe is near musanda, and both are about 60 km away from nyangori, kisumu. the three 57 fagunwa dec 2020. christian journal for global health 7(5) historic kenya pentecostal sites are each about 900 km away from mombasa, the entry point of the influenza virus. the historic pentecostal towns of ruwe, musanda, and nyangori, kisumu are in the western regions of kenya and are considered hinterlands, without good administrative and health records.22 yet, there are reports that every district in kenya was struck by the devastating effects of influenza, even in sparsely populated regions.23 in kenya, the chronicles from the roho spiritual authorities did not suggest any experience of the pandemic,21 though the pentecostal missionary, marion keller, mentioned a plague in her 1920 letter. nigeria nigeria is a west african country along the gulf of guinea in the atlantic ocean. it shares a long border with cameroon, niger, and the benin republic. christianity came to the country in the 15th century through catholic portuguese monks but became prominent with the establishment of the church of england mission field in 1842.24 here, also, we will discuss pentecostal history in nigeria and the connection with the 1918 pandemic. it is worth noting that the pentecostal archive holds no records about the epidemic in nigeria because all foreign pentecostals in nigeria arrived at their establishments after 1918. this includes the welsh apostolic church (1931), the assemblies of god (1939), and the foursquare gospel church (1954).25 however, there is a body of documents and history from the indigenous pentecostal movement that are worth exploring. the aladura movement stood in prayers and faith for supernatural healing an anglican sexton, daddy ali (probably a nickname) of st. saviours church, ijebu ode, southwestern nigeria was guided in dreams to form a prayer group during the influenza epidemic of 1918.26,27 other prominent founding fathers within the anglican church were e.o. onabanjo, d.c. oduga, e.o.w. olukoya, and j.b. shadare, who later became the core leader of the movement. the group (later known as the precious stone or diamond society) devoted themselves to prayer and shielded themselves from “calamity that would befall the anglican church”.27,29 the “desperate situation” during a disease outbreak where there is no potent medicine, made the people attribute the pandemic to god’s chastisement.26 a pew research survey report of nigerian pentecostals stated that the precious stone society (aladura) was formed to heal influenza victims.25 however, such an assertion does hold a popular view in notable historical accounts by members of various churches and the movement itself. we note that the formation of the aladura movement was informed by the revelation received by daddy ali, which emphasized devotion to prayers. it is presumed that prayers were targeted at the healing of influenza victims and mitigating the raging of world war 1.28 the aladura group was formed during the global 1918 pandemic, but more likely before nigeria had her share of the epidemic, hence the group formation may be placed at a date before september/october 1918. our inference is that influenza was introduced in september through rapid local transmission (as discussed later), a considerably longer time after daddy ali forewarned (in at least two separate visions) of impending “calamity.”27 daddy ali’s warnings would not be considered divine revelation if the “calamity” was already established. fatokun states: the prayer group continued her activity in anglican parish, which was basically “prayer.” however, there was an event which promoted the group from a prayer group to a prophetic-healing movement. in the same year (1918), an epidemic (variously described as smallpox and bubonic plague) struck in every part of the world just during the closing month of the first world war.”29 during the epidemic, a prophetic icon was reportedly healed of influenza. a 19-year-old member of the prayer group, sophia odunlami (later named mrs ajayi), claimed to have a 58 fagunwa dec 2020. christian journal for global health 7(5) spiritual experience while sick of influenza virus for five days. she claimed to hear a voice: “i shall send peace to this house and the whole world as the world war is ended.” the young prophetess claimed that rainwater and prayer would be the most effective remedy for the influenza victims and itinerantly preached against the use of any form of medicine (both traditional and western) as a remedy to the illness and often used zachariah 14 as her favourite biblical text.29 we assumed her stern warning must have placed more emphasis on verses 11–20 because this part of the text is plague related. zachariah 14 is not an uncommon text used within the puritan/holiness movement which tags such verses as “the day of the lord” and “holiness unto the lord.” prophetess sophia odunlami was dubbed, “a god-gifted divine leader raised in an outbreak of influenza against which all charms and medicines had been useless.”29 though no verifiable evidence of her healing of influenza victims was found, one cannot infer that influenza victims were never healed. as pentecostal adherents, who have personally experienced supernatural healing, we suggest that we should document evidence of healing in the 21st century wherever possible. another member of the group was moses tunolase orimolade, and he operated in the healing ministry. anderson stated that, “crowds came to him for prayer for healing during the influenza epidemic of 1918.”30 it is an established record that the aladura prayer movement devoted themselves to prayers, longed to experience the supernatural, and spread the “supernatural” gospel, at least throughout nigeria, especially in yoruba land (fig. 2). figure 2. aladura of 1918 and the spread of christianity note. most pentecostal churches in nigeria can be traced to the aladura group or are influenced in some way by it. 59 fagunwa dec 2020. christian journal for global health 7(5) let us now consider the response of the prayer group leader to the pandemic. some months after the prayer group had been formed, the famous st. saviours’ (anglican) church complied with a government order of “lockdown” just like other churches. the colonial government, in a bid to limit the spread of the pandemic, ordered all public buildings to be closed down. the vicar-in-charge complied with this government order. his action was interpreted as an act of faithlessness by the aladura prayer group. the group resorted to intensive prayers, church members held a procession around ijebu ode town, and made prayers for deliverance.29 we think that it is important for christians to abide with constituted authorities’ efforts to break the chain of infection during epidemics. though the church was closed, it appeared praying and prophetic-healing activities remained very active. fatokun further reported: with the closure of the church, this group continued relentlessly in its praying and prophetic-healing activities with the venue of the meeting shifting to the front of their closed church and later in the house of the people’s warden and lay member of the lagos diocesan synod, mr j.b. sadare. it was at this juncture that j.b. sadare’s name became prominent as the leader of the group.29 it was reported that the bishop of lagos, the rt. rev. melville jones, praised the high morality of the precious stone society for its persistence in prayers and demonstrations of the power of god, but objected to its insistence on the exclusive use of faith healing, its opposition to the baptism of infants, and its reliance on dreams and visions for guidance.29 two years after the end of the influenza plague, a spiritual-medical argument ensued at the 1922 lagos synod meeting. shadare, the prayer group leader, had refused to have his children baptised. he argued that infant baptism was wrong, and the lord had prevented him from doing so through a vision. however, the assistant bishop of lagos, isaac oluwole, tried to debunk this claim against infant baptism. oluwole said the group was not oblivious of the fact that the pandemic was not eradicated, and children had little or no resistance against the virus, which made it quite common for children to die. such differences between the mainstream anglican church and the aladura prayer group caused a separation and led to the beginning of a new era in nigeria: the charismatic/pentecostal movement.29 ayegboyin and ishola’s epidemic report revealed: this epidemic, coupled with the economic depression that followed, had adverse effects on the church. most public institutions such as the schools, hospitals, clinics, and offices, as well as some churches, were closed by the colonial administrators. a good number of europeans returned home and not a few missionaries abandoned their congregation to heed the call to go back to their countries. several churches were without ministers and spiritual matters seemed to be fading into oblivion.”31 there was confusion, and many christians attempted to go back to the traditional religion, but a few committed christians engaged in a more practical approach to solving the prevailing problems through devotion to family worship, personal prayers, and small gatherings for prayer. garrick braide, a prophetic-healing minister was restricted another unforgettable encounter that occurred during the crisis of the 1918 pandemic was the incident that took place in the niger delta region of the country through garrick sokari braide (1882–1918). braide was an anglican catechist and was committed to evangelism and healing ministry. he preached against alcohol and idolatry prominently between 1914–1918.32,3,33 at the peak of braide’s ministry, there was a feud between him and the assistant bishop of the niger delta and benin territories—dr james johnson (c1836–1917). this culminated in two imprisonments of braide by the colonial government, and he died some months after his release in 1918.31,32,34,35 clearly, braide’s ministry 60 fagunwa dec 2020. christian journal for global health 7(5) did not enjoy the support of the missionaries or the colonial government. did braide’s healing ministry help during the 1918 pandemic? braide’s healing ministry after his 1918 release from prison is not well documented, but he is unlikely to have performed a healing for influenza victims if he died before october 1918 since community transmission increased around october/november 1918. more so, after his release in 1918, the healing ministry of garrick braide was restricted, if not suppressed. his ministry suffered and went into total oblivion. ludwig states: “when braide returned from prison in early 1918, the chiefs of bakana forbade him [from] practising healing by faith on the same scale as before.”32 the epidemiological timeline also supports our speculation that braide was unlikely to have made a healing response to the flu epidemic. in mid-september 1918, the government health authorities dispatched a telegram that declared influenza as an infectious disease and immediately put in force quarantine measures at all ports and shores. on 30th august, the governor of sierra leone transmitted via cablegram to the lagos colony the seriousness of the pandemic.36,37,38 on 14th september, three vessels (ss panayiotis, s.s. ashanti, and ss bida) arrived at lagos carrying already infected people. there was no “test and trace” system for those aboard, though symptomatic passengers were hospitalised or quarantined, and the ships disinfected and quarantined.37 tomkins noted that “of all the west african colonies, nigeria organized the most thorough measures, partly because warnings from sierra leone and the gambia had enabled administrators to plan.”38 ohadike, in 1991, published his work using colonial records that documented additional cases reported in the ocean liners s.s. ravenston at port forcados (on 27th september) and s.s. batanga at calabar (28th september).39 isolated cases of person-to-person transmissions continued until 15th november when a sudden upsurge with hundreds of cases was observed. other transmission routes, such as boat and rail systems (the major means of transportation), were implemented, and by december 1918, the infectious disease was spreading throughout nigeria. from a population of 17,690,936, the number of deaths was recorded at 454,988, hence the death rate was 2.6%.39 an account by ogunewu and ayegboyin noted that— “he was finally released in 1918 but died shortly thereafter in november of that year.”40 the authors, however, did not state any supporting reference or inference by oral narrative or other means. braide’s death is more complex according to anderson’s account, which assumes that braide died perhaps of influenza.30 could the healing minister die of influenza or by an accident? how garrick died could form the theme of another discourse that this paper will not interrogate further. again, we found no account of braide healing victims of influenza. newspaper databases show no record of faith-healing from influenza performed by any christian leader or a member of the aladura. if many healings only through prayers had happened, it would have been a regular feature in the newspapers. likewise, there was no rebuttal of such healing or mention of it, and this suggests that a successful community-wide, faith-healing against influenza was very unlikely during the spanish flu. an examination of local nigerian newspapers indicates that there was an intensive, bi-weekly advertisement of “all-purpose, cure-all” tonics such as “veno’s lighting cough cure” by the veno drug co. ltd, manchester. veno’s tonic was advertised as “the safest and surest remedy” for various upper and lower respiratory diseases including influenza.41 another popular all-purpose medicine was “phospsferine” by ashton and parson ltd, london, which was advertised to have a worldwide reputation for curing influenza and other diseases speedily.42 by september 1918, many tonic products featured as the cure to influenza in advertisement pages of newspapers such as lagos standard, nigerian pioneer, and lagos weekly record.41-44 however, during the 1918 influenza pandemic, all western medicines, mainly produced in england, did not have favourable effectual standing among the locals. the plague 61 fagunwa dec 2020. christian journal for global health 7(5) also overwhelmed native herbalists, including the muslim native herbalist’s society called “ajo aiye.”43 hence, people resorted to prayer since there was no efficacious remedy from both western and traditional medicines. a feature in the lagos weekly record newspaper reminded the readers that the pandemic was predicted/ prophesied by ode, as far back as february 1916, and the only remedy was, “a true and ardent prayer.”44 the call and devotion to prayer during the pandemic time accelerated the membership of the aladura movement. aladura membership grew during and after the 1918 pandemic. in 1923, the aladura entered a short-lived affiliation with the faith tabernacle congregation of philadelphia. faith tabernacle was introduced to the group by a member called david o. odubanjo (a reader of faith tabernacle’s sword of the spirit magazine).29,45 odubanjo joined the aladura group in 1919 and soon became a very prominent leader. he later became the first general superintendent of christ apostolic church, a splinter church of the aladura group. faith tabernacle congregation, or its magazine, did not influence the creation of the aladura prayer group, though its faith-healing teachings appeared to strengthen the group.29,46 noteworthy is that 1918 was a time of spiritual awakening, and nigerian pentecostalism emerged independently of “pentecostal” missionaries if traced to garrick braide and the later prayer group—the aladura movement. discussion some pentecostals believed only in the use of pray for supernatural healing during the 1918 influenza pandemic. however, we believe that such singular expectations of supernatural healing as the only solution directly undermines the blessings of god in nature (plants), as well as god’s character of answering prayers and meeting our human needs in different ways—including pharmaceutical discoveries. more so, the healing ministry of the church throughout the bible is practised in four ways—prayer, word, touch, and “means”. there are several instances in which medical means are used in the scripture to provide healing; for example, the fig poultice prescription (2 kings 20:7, isaiah 38:21) and olive oil (mark 6:13, james 5:14, 1 tim 5:23). prayer and faith still form the basis of christian response to the healing of people in the time of sickness or even epidemics, but a far greater variety of means are available now than ever before. the means for us in this age include relatively safe and efficacious medicines and vaccines which should be taken with thanksgiving, prayer, and faith. some authors mentioned that influenza victims were healed, though we found no primary reference for such an assertion. testimonies of healing during this period of epidemic must be documented with verifiable pieces of evidence where possible. overall, the period of the 1918 pandemic appears to be a time of great awakening in african christianity—including the birth of indigenous pentecostals, whose splinter churches are scattered all over the world with millions of members emphasizing the power of the gospel of jesus christ. conclusion the 1918 influenza infectious outbreak was dreadful, but the supernatural occurred amid the fearful pandemic, and the church expanded. kenyan and nigerian pentecostals were mostly divergent in their responses to the pandemic. kenya’s pentecostalism was inactive until closer to the end of the pandemic, while nigeria birthed its pentecostalism in the same year and responded via prayers, persistent christian faith, and longing for supernatural intervention. prayers still formed the basis of a christian response to the healing of people in a time of sickness and pandemic, like the coronavirus pandemic that is raging presently. the approach for christians during this covid-19 pandemic may be leveraging on various communication technologies such as telephone, mobile phone, zoom, skype, facebook, whatsapp, and tik-tok to organise virtual prayers, praise, and healing services, and never to physically gather together in large numbers during times of increased viral reproduction or oppose government measures 62 fagunwa dec 2020. christian journal for global health 7(5) to bring the epidemic under control. these are actions of obedience and even greater faith which should not be perceived as spiritual weakness or faithlessness. the church buildings may be closed but the church community should remain open and connected via the technological means with which we are blessed. god has blessed us with a far greater variety of means now than were present in 1918. the means for us include technologies for sustaining the faith community in situations where there are physical restrictions and safe, efficacious medicines and vaccines (whenever available), which should be accepted with thanksgiving, prayer, and faith. pandemics often bring devastation but could also be an opportunity for spiritual awakening through prayer, love in action, social justice, compassion, and care. references 1. patterson kd, pyle gf. the diffusion of influenza in sub-saharan africa during the 1918-1919 pandemic. soc sci med. 1983;17:1299-307. https://doi.org/10.1016/0277-9536(83)90022-9 2. patterson kd, pyle gf. the geography and mortality of the 1918 influenza pandemic. bull hist med. 1991;65(1):4-21. https://www.jstor.org/stable/pdf/44447656 3. kalu o. african pentecostalism: an introduction [internet]. oxford university press. 2008 [cited 2020 sep 7]. available from: https://oxford.universitypressscholarship.com/view/ 10.1093/acprof:oso/9780195340006.001.0001/acpro f-9780195340006. 4. phillips h. black october: the impact of the spanish influenza epidemic of 1918 on south africa [thesis] [internet]. cape town, south africa: the university of cape town, faculty of humanities, department of historical studies. 1984. available from: http://hdl.handle.net/11427/7852 5. phillips h. why did it happen? religious and lay explanations of the spanish “flu” epidemic of 1918 in south africa. kronos. 1987 [cited 2020 sept 14];12:72-92. available from: http://www.jstor.org/stable/41056243 6. melton gj, baumann m. religions of the world: a comprehensive encyclopedia of beliefs and practices. 2nd ed. santa barbara, california: abcclio llc. 2008. 7. larson l. mazie elizabeth winona blake [internet]. 2020. http://www.leighlarson.com/mazey_elizabeth_blake .htm 8. buckley jr. letter from mr and mrs j.r. buckley to mrs e.a. sexton, atlanta ga, us pentecostal missionaries. the bridegroom’s messenger. 1913;6(136). 9. mwaura pn. kivuli, david zakayo. j africa christ bio. 2018;3(4):5-6. available from: https://dacb.org/resources/journal/3-4/3-4oct2018-jacb-a4booklet.pdf 10. peterson b. minutes of the 7th general council of the assemblies of god. minutes general council; 1919; springfield, missouri. p.1-48. 11. wittich me. pioneering and perils of war: suffering the loss of all things. later rain evangel. 1919 june;11(9). 12. wittich me. how god backed up his word: providential leading thro’ nearly twenty thousands miles. later rain evangel. 1919 july;11(10). 13. ag, editor. from the world’s harvest field. later rain evangel. 1920 sept;12(12). 14. keller mw. sowing and reaping in foreign lands: testing days. later rain evangel. 1921 june;12(12). 15. miller ct, miller lm. from brother clyde miller and wife. bridegroom’s messenger. 1913;6(132):4. 16. sexton ea, barth hm. missionary report for month ending april 30, 1913. bridegroom’s messenger. 1913;6(132):2. 17. wightman sm. missionary gleanings: africa. bridegroom’s messenger. 1915;8(174):3. 18. wightman sm. you shall be witnesses unto me acts 1:8: nyangori, kisumu, africa. bridegroom’s messenger. 1915;8(169):3. 19. welbourn fb, ogot ba. a place to feel at home: a study of two independent churches in western kenya. oxford: oxford university press; 1966. p.76. 20. keller o. the zeal of the african to spread the gospel. bridegroom’s messenger. 1925;6(132):4. 21. hoehler-fatton c. women of fire and spirit: history, faith and gender in roho religion in western kenya. oxford: oxford university press; 1996. 22. andayi f, chaves ss, widdowson ma. impact of the 1918 influenza pandemic in coastal kenya. trop med infect dis. 2019;4(2):91. https://doi.org/10.3390/tropicalmed4020091 23. moore k. placing pandemics: history of the 191819 influenza epidemics in kenya and uganda [internet]. 2013. available from: about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 63 fagunwa dec 2020. christian journal for global health 7(5) https://ssrn.com/abstract=2352430 or http://dx.doi.org/10.2139/ssrn.2352430 24. kituase rh, achunike hc. religion in nigeria from 1900-2013. res human soc sci. 2013;3(18):45-56. 25. pew research. spirit and power – a 10-country survey of pentecostals (nigeria). 2006. available from: https://www.pewforum.org/2006/10/05/historicaloverview-of-pentecostalism-in-nigeria/ 26. fisher h. independency and islam: the nigerian aladuras and some muslim comparisons. j african history. 1970 [cited 2020 sept 7];11(2):269-77. available from http://www.jstor.org/stable/180322 27. alokan oap, alabi do, babalola sf. critical analyses of church politics and crises within the indigenous christianity in nigeria. am j soc mgmt sci. 2011;2(4):360-70. http://doi.org/10.5251/ajsms.2011.2.4.360.370 28. odubanjo do. classical dictionary of african christian biography collection [internet]. 2008. available from: https://dacb.org/stories/nigeria/odubanjo-davidosmond/ 29. fatokun sa. precious stone society [internet]. 2018. available from: https://tacnlawna.org/precious-stone-society/ 30. anderson a. african reformation: african initiated christianity in the 20th century. trenton: new jersey, africa world press. 2001; 82. isbn 086543-883-8 31. ayegboyin d, ishola a. african indigenous churches — a “praying society”: the precious stone. 1997. http://irr.org/african-indigenouschurches-chapter-eight 32. ludwig f. elijah ii: radicalisation and consolidation of the garrick braide movement 1915-1918. j religion africa. 1993;23(4):296-317. http://doi.org/10.2307/1580988 33. oladipupo jk. an assessment of the origin of nigerian pentecostalism and garrick sokari braide’s healing ministry of the niger delta (18821918) [internet]. southwestern j theology. 2019;62(1):167-83. available from: https://swbts.edu/school/school-oftheology/southwestern-journal-of-theology/ 34. turner hw. prophets and politics: a nigerian test case. bull society african church history. 1965;2:97-118. 35. ewechue r, editor. makers of modern africa. 2nd ed. london: africa books; 1991. 36. ohadike d. the influenza pandemic of 1918-19 and the spread of cassava cultivation on the lower niger: a study in historical linkages. j african history. 1981 [cited 2020 sept 8];22(3):379-91. available from: http://www.jstor.org/stable/181809 37. oluwasegun jm. managing epidemic: the british approach to 1918–1919 influenza in lagos. j asian african studies. 2017;52(4):412–24. https://doi.org/10.1177/0021909615587367 38. tomkins sm. colonial administration in british africa during the influenza epidemic of 1918–19. can j afr stud. 1994;28(1):60–83. https://doi.org/10.1080/00083968.1994.10804338 39. ohadike d. diffusion and physiological responses to the influenza pandemic of 1918–19 in nigeria. soc sci med. 1991;32(12):1393-9 https://doi.org/10.1016/0277-9536(91)90200-v 40. ogunewu m, ayegboyin d. introduction: four trailblazers of the aladura movement in nigeria [internet]. j african christian bio. 2017;2(2):3-21. available from: https://dacb.org/resources/journal/2-2/2-2apr2017jacb-ejournal2rev.pdf 41. william ga. influenza and catarrh: soon cured by veno’s lightening cough cure. lagos standard newspaper, lagos nigeria. 1918 sept;p.8. 42. phosferine. lagos weekly record newspaper, lagos nigeria. 1918 aug 4; p.7. 43. dabiri g. notice. lagos standard newspaper, lagos nigeria. 1918 oct 2;p.6. 44. igbagbo. prayer for the poor sinners to the lord: ode and mrs cleck. lagos weekly record newspaper, lagos nigeria. 1918 oct 12;p.2. 45. fatokun sa. “i will pour out my spirit upon all flesh:” the origin, growth and development of the precious stone church — the pioneering african indigenous pentecostal denomination in southwest nigeria [internet]. cyber j pentecostal-charismatic res. 2010;19:1. available from: http://www.pctii.org/cyberj/cyberj19/fatokun.html 46. mohr a. out of zion into philadelphia and west africa: faith tabernacle congregation, 1897-1925. pneuma. 2010;32:56-79 https://doi.org/10.1163/027209610x126283628876 31 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 64 fagunwa dec 2020. christian journal for global health 7(5) peer reviewed: submitted 25 sept 2020, accepted 18 nov 2020, published 21 december 2020 competing interests: none declared. acknowledgements: i want to thank dr ayokunle fagunwa of fiiro, dr afolake olanbiwoninu, and mr olalekan oladipupo of ajayi crowther university, nigeria for reading the manuscript and their feedback. appreciation to the general council of assemblies of god for preserving and making accessible the global pentecostal resources through the consortium of pentecostal archive. thank you also to those who are investigating african initiated churches. they have made available invaluable resources to which i am grateful to contribute. to god be the glory, who took me out of a microbiology laboratory and instructed me to embark on christian historical studies in a time that coronavirus shut down the entire world. correspondence: omololu fagunwa, federal ministry of health, abuja, nigeria. fagunwaomololu@yahoo.com cite this article as: fagunwa o. african pentecostalism and the 1918 influenza pandemic: the supernatural amid the fearful and implications for the covid-19 pandemic. christian j global health. december 2020; 7(5):52-64. https://doi.org/10.15566/cjgh.v7i5.455 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank abstract introduction methods results kenya nigeria discussion conclusion references field report dec 2020. christian journal for global health 7(5) utilizing social media technology during the covid-19 pandemic to assist highly vulnerable populations in the philippines daryn joy go a, natalee hung a, hannah ferrolino a, kendall wilson a, mia choi a, daniel mayhugh a, lincoln lau b a, international care ministries, manilla, philippines b phd, director of research, international care ministries, manilla, ph; assistant professor, dalla lana school of public health, university of toronto, toronto, canada; adjunct assistant professor, school of public health & health systems, university of waterloo, waterloo, canada abstract: national lockdowns and social distancing measures enforced in response to covid-19 have forced many non-governmental organizations (ngos) serving in lowand middleincome countries to suspend their operations. while low-income families continue to suffer from hunger and poverty, community quarantine restrictions additionally isolated them from town centers where healthcare, education, food, supplies, and livelihood opportunities are usually accessed. international care ministries (icm) is a philippine-based ngo that runs a poverty-alleviation program targeted towards extreme low-income households. as we re-evaluated how we may continue to effectively minister and serve our communities despite lockdown measures, we identified two priorities: (1) to serve people’s physical needs by providing food and access to healthcare and (2) to serve people’s spiritual needs through spiritual nourishment and community. in this field report, we describe how icm was able to identify and use social network platforms as an alternative to continue both service delivery and spiritual feeding remotely. we hope this example may encourage other development ngos to persevere as we all continue to seek ways to adapt to these extraordinary and seemingly ever-changing circumstances. key words: covid-19, pandemic, lowand middleincome countries, social networks, technology introduction when it first emerged, few could have imagined the novel coronavirus disease 2019 (covid-19) developing into a global crisis sending shock waves around the world. that governments often do not have sufficient resources to address needs caused by acute outbreaks of disease has become strikingly apparent. many public health and 95 go, hung, ferrolino, wilson, choi, mayhung & lau dec 2020. christian journal for global health 7(5) socioeconomic systems have been crippled as a result. these strains are exaggerated in lowand middleincome countries where healthcare infrastructures are undeveloped and financial resources are limited.1 in such contexts, nongovernmental organizations (ngos) play a crucial role in supporting government efforts to serve vulnerable communities that lack access to information, healthcare, and social safety nets.2 however, national lockdowns and social distancing measures enforced by governments in response to the covid-19 pandemic have forced many organizations to suspend their ongoing operations. these were the circumstances facing international care ministries (icm). we are a philippine-based ngo that runs a povertyalleviation program targeting extreme low-income households. when the pandemic led the philippines to implement strict lockdowns and community quarantines in march 2020, icm had to suspend all its programs across the country. although it was clear that the need would be greater than ever, we could not travel to the communities to provide food and health services to the families we serve. with households unable to undertake economic activities due to lockdown measures, the rise in hunger and poverty would be acute and exponential. in this paper, we detail how icm was able to use social network alternatives to continue both service provision and spiritual feeding within the communities. we hope this example may encourage other development ngos, as we all continue to seek ways to adapt to these extraordinary circumstances. the need in early attempts to contain the transmission of covid-19 within the philippines, the government enforced enhanced community quarantine (ecq) measures in many regions which involved imposing strict home quarantine, implementing lockdowns in places with positive covid-19 cases, and suspending public transportation systems.3 the ecq restricted icm from continuing its face-to-face programs, which meant that we were also barred from meeting with our partner pastors, all of whom play crucial roles in our poverty alleviation program. every year, icm partners with local pastors to provide support to 45,000 families, forming a network of pastors we call thrive. these pastors act as both shepherds and champions, providing spiritual guidance while also advocating for the physical and socio-economic needs of their communities. currently, icm equips and engages over 15,000 pastors in its thrive network by (1) providing guidance and resources for pastors to serve their communities and (2) holding monthly gatherings where pastors can come together and support each other in ministry. with icm’s normal operations paralyzed, our resources, networks, and approach all had to be repositioned in order to effectively meet the changing needs of our communities. the development of alternative service delivery platforms was guided by the primary objectives as follows. fill public and private health care gaps the philippines’ total expenditure on health only accounted for 4.6% of gross domestic product (gdp) in 2018,4 and the surge in hospitalizations due to the covid-19 pandemic is placing severe demands on already over-stretched resources. public and private hospitals alike have faced shortages in healthcare workers, personal protective equipment, intensive care beds, and ventilators.5 especially in the context of existing inequities in the accessibility and affordability of healthcare between the rich and the poor, there is a pressing need to fill the gaps of the overburdened system and reach underserved communities. create an alternate avenue to connect with partner pastors with icm unable to provide services and their communities’ needs growing, our partner pastors have been left feeling helpless, unable to minister to 96 go, hung, ferrolino, wilson, choi, mayhung & lau dec 2020. christian journal for global health 7(5) or provide for their own families or community members. reports we received from another survey conducted by icm from october 19 to october 27, 2020 indicated that each pastor was aware of a mean of 56 families in need of immediate food supplies (n = 226). besides addressing the needs of others, pastors themselves also need to be spiritually, emotionally, and physically supported during the pandemic. there is a need to provide ongoing support to our partner pastors who play pivotal roles in their communities, especially in times of crises. identify and help those who are most in need quarantine restrictions, coupled with rising fear and uncertainty toward the virus, has brought the local economy to a standstill, leaving many workers jobless. with the majority of the population living hand-to-mouth, hunger and poverty is an acute and ever-growing threat. in order to facilitate the coordination of efficient relief responses to vulnerable communities where food security is threatened, there is a need to obtain real time information and timely data. icm’s response with the widespread and growing use of technology and the internet in the philippines,6,7 icm sought to leverage the accessibility and convenience of social media channels to overcome the barriers of physical distancing and community movement restrictions. this led to the development of an online platform that would allow us to obtain informative data and form efficient responses to the communities. the thrive network chatbot, hosted on facebook, was launched on april 21, 2020 with the purpose of connecting with our partner pastors as bridges to the communities. as of october 2020, there were currently 2,108 pastors registered to the chatbot. this parent messenger bot consists of three parts: (1) the covid-19 assessment chatbot, (2) the lay leader leadership devotional chatbot, and (3) the rapid emergencies and disasters intervention (redi) chatbot. covid-19 assessment chatbot to fill health care gaps, the covid-19 assessment chatbot was developed in collaboration with the department of health to provide easily accessible covid-19 health information. this chatbot is an online health assessment tool that evaluates the health of pastors through a series of questions and subsequently suggests any follow-up actions, if necessary. video and text information on covid-19 are also provided with the objective of decreasing fear of covid-19 among communities attributable to misinformation. after the health assessment, pastors are posed questions on food security to provide icm with information on regional food scarcity. the covid-19 assessment chatbot has been translated into 5 dialects so that it is accessible to the full range of communities in which icm serves. lay leader leadership devotional chatbot the lay leader leadership devotional chatbot was created to support pastors as they face ministry challenges during the pandemic by providing an avenue for continuous spiritual support. within the chatbot, the lay leader learning hub provides church leaders with 2-minute, daily devotionals, equips potential pastors and lay leaders in the development of leadership and ministry skills, and connects them to a wider network of pastors in the icm pastors’ facebook group. there are now 599 pastors registered to receive the daily devotionals. rapid emergencies and disasters intervention (redi) chatbot to provide an avenue for pastors to share the immediate needs of the community, the thrive network chatbot also includes a function where pastors can register for icm’s redi network, a web-based application to report incidents and 97 go, hung, ferrolino, wilson, choi, mayhung & lau dec 2020. christian journal for global health 7(5) coordinate relief efforts to deliver food packs to the communities. in addition to the redi chatbot, pastors can also text or call a redi phone number to report emergencies and disasters to icm. in the midst of covid-19, this redi network has allowed icm to call and pray for 5,372 community leaders and has helped 1,004,349 families receive food packs. discussion the covid-19 pandemic has left communities more vulnerable than ever. while extreme low-income families continue to suffer from hunger and poverty, quarantine restrictions have additionally isolated them from town centers where healthcare, education, food, supplies, and livelihood opportunities are usually accessed. when the lockdowns were enforced, icm was also forced to suspend all of its programs across the country, challenging us to re-evaluate how we may continue to effectively minister and serve our communities remotely. to guide our efforts, we identified two priorities: (1) to serve people’s physical needs by providing food and access to healthcare and (2) to serve people’s spiritual needs through spiritual nourishment and community. as we shifted our focus as an ngo from development to emergency response, it was important that we used resources that could be readily leveraged and that had a wide reach. we came to identify two that met these criteria: (1) the widespread use of technology and social media across the philippines and (2) the wide network of pastors living among all the communities icm was serving. the use of social media has become instrumental in responding to a range of disaster and crisis situations.8 with its ability to disseminate realtime information to victims, emergency responders, and the public, it is recognized as an effective tool to identify and meet immediate needs. however, its use in fostering social support between people bearing similar burdens has tended to be overlooked. the development of the thrive network chatbot has helped us connect with partner pastors, not only providing them with an immediate platform that they can use to communicate the gaps in their communities’ healthcare and food needs, but also with spiritual nourishment and opportunities for them to connect with other pastors facing similar challenges. from initial feedback discussions, users also indicated that the information and guidance they received from the chatbot was helpful in decreasing stress and anxiety when navigating uncertainties surrounding the virus. experiencing unprecedented and crippling disruptions on the scale of covid-19 can, at times, leave us feeling helpless, but we must not lose heart. our hope is for other development ngos to persevere in preparations to adapt to changing circumstances, knowing that ultimately, we serve a god who meets people in their unique circumstances but remains unchanging in his goodness and provisions. references 1. lau ll, hung n, wilson k. covid-19 response strategies: considering inequalities between and within countries. int j equity health. 2020;19(1):137. https://doi.org/10.1186/s12939-020-01254-9 2. kandel n, chungong s, omaar a, xing j. health security capacities in the context of covid-19 outbreak: an analysis of international health regulations annual report data from 182 countries. lancet. 2020;395(10229):1047-53. https://doi.org/10.1016/s0140-6736(20)30553-5 3. office of the president of the philippines. memorandum from the executive secretary: guidelines for the management of the 2019 novel coronavirus acute respiratory disease situation [internet]. 2020 [cited 2020 aug 26]. available from: https://www.doh.gov.ph/sites/default/files/health_advisory/memorandum_from_the_e xecutive_secretary.pdf 4. philippine statistics authority. philippine national health accounts [internet]. 2019 [cited 2020 oct 14]. available from: https://psa.gov.ph/pnha-pressrelease/node/144466 5. world health organization representative office for the philippines. who philippines coronavirus about:blank about:blank about:blank about:blank about:blank about:blank about:blank 98 go, hung, ferrolino, wilson, choi, mayhung & lau dec 2020. christian journal for global health 7(5) disease (covid-19) situation report 35. geneva: who; 2020. 6. mander j, buckle c, moran s. social flagship report 2020. london: globalwebindex, 2020. 7. world bank group. individuals using the internet (% of population) – philippines [internet]. 2020 [cited 2020 aug 27]. available from: https://data.worldbank.org/indicator/it.net.user.z s?locations=ph 8. simon t, goldberg a, adini b. socializing in emergencies—a review of the use of social media in emergency situations. int j inf manag sci. 2015;35(5):609-19. https://doi.org/10.1016/j.ijinfomgt.2015.07.001 peer reviewed: submitted 9 nov 2020, accepted 30 nov 2020, published 21 dec 2020 competing interests: none declared. correspondence: lincoln lau, phd lincoln.lau@caremin.com. for further information and to access the thrive network chatbot, please see https://m.me/covid19assessment?ref=thrive cite this article as: go dj, hung n, ferrolino h, wilson k, choi m, mayhung d, lau l. utilizing social media technology during the covid-19 pandemic to assist highly vulnerable populations in the philippines. christ j global health. december 2020; 7(5):94-98. https://doi.org/10.15566/cjgh.v7i5.479 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org about:blank about:blank about:blank about:blank about:blank about:blank about:blank introduction references field report nov 2020. christian journal for global health 7(4) asha’s response to covid-19: providing care to slum communities in india jean oulund peteeta, louanne hemptonb, john r. peteetc, kiran martind a mph, phd, pt, clinical assistant professor, emerita, boston university, boston, ma, usa b bs.sc, dip sw, boston, ma, usa c md, associate professor of psychiatry, harvard medical school, boston, ma, usa d mbbs, dch, founder and director, asha community health & development society, delhi, india. abstract: slum populations, the most vulnerable to covid-19, are emerging as hotspots for transmission of the virus. comprehensive strategies for addressing this challenge exist, but reports of effective models for implementing them have been lacking. asha, a 33year old health and community development organization in delhi, india has responded to the pandemic by activating well-developed networks in the community to enact a range of interventions with encouraging results. the success of asha in controlling covid-19 in the slums reflects the realization of the values asha promotes in the community: dignity, empowerment, justice, non-violence, compassion, gratitude, generosity, optimism, joy, and simplicity. although developed by a team of christians and those of other faiths on asha’s staff, these values enjoy broad-based support within a pluralistic, hindu-influenced society. key words: covid-19, pandemic, slums, values, community, health introduction nowhere are the needs for holistic solutions greater than for the estimated one billion slum dwellers worldwide who are vulnerable to the effects of disease, poverty, and despair, live on land that does not belong to them in constant fear of eviction, and are surrounded by substance abuse, domestic violence, garbage, and political corruption.1 recognizing that slums are emerging hotspots for viral transmission, the who and the world bank have called for phased, integrated, multisectoral support to slums.2,3,4 recommended short-term strategies emphasize health, community engagement and communications; social protection, jobs, and institutional support; leveraging data for transparency, monitoring, and response; and access to basic services and adequate housing. recently, others have highlighted the potential for community health workers to improve health care utilization and outcomes in a cost-effective manner through the implementation of evidence-based approaches.5 despite a growing literature on the challenges presented for slum dwellers by the pandemic, few models for implementing these comprehensive strategies exist. delhi has a population of 21.75 million and its slums 4 million, in a country which recently surpassed 7 million cases of covid-19.6 it is also 2 peteet, hempton, peteet & martin nov 2020. christian journal for global health 7(4) home to asha (which means hope),7 a community health and development ngo set up 33 years ago by dr. kiran martin, an indian paediatrician. around 700,000 people in 91 slum colonies of delhi now benefit from the work of asha. the asha team is comprised of 87 dedicated personnel and are assisted by around 1000 women and 1500 young people from the slums who volunteer in their communities. the effect of covid-19 on 24th march 2020, the government of india overnight shut down the country in an attempt to curb the spread of covid-19. this had an immediate catastrophic impact on those living in the slums. the poorest of the poor, these people were mostly dependent on daily wage work to survive. no work in the community meant no money and the possibility of starvation within days. in some of the asha slums, there was a substantial migration because everyone lost jobs. the migration had other effects such as mental stress in the slum dwellers who decided to stay on. how would they survive? if they decided to go away, theirs was also an uncertain future. the asha team continuously counselled the families to stay put. ignorance and fear of covid-19 was also rampant. because of the population density, social distancing was impossible. while the government subsequently set up “feeding stations,” these were on the outskirts of the slums and were largely inaccessible to the weakest in the slums. the asha team knew they had to react immediately to stave off a humanitarian disaster in slum dwellers at higher risk because they were unable to socially distance, lacked access to masks and water for washing, and needed education in behavioral practices to lessen their exposure to covid-19. (figure 1) figure 1. handwashing instruction in the kalkaji slum community asha’s immediate response within days, the asha team — • activated existing, well developed networks in the slums and set up “teams of corona warriors.” these teams were mostly staffed by some 300 young volunteers of university and high schoolers whom asha had known for years and whose education they had supported. • trained the volunteers and tasked them to immediately start educating each of their local communities about covid-19 and assessing local needs of the most vulnerable. • prioritized the most vulnerable — elderly, disabled, chronically ill, pregnant women, and children under 5. • provided basic groceries and cash for basic essential needs — cooking gas, medicine, and grinding grain for families in asha slums not under quarantine who had no money left with them, to the very poor, elderly, disabled, and people with chronic illnesses (figure 2). in some slums, the ration was distributed to the whole community, but in other slums, the ration was given to 50% of the families. 3 peteet, hempton, peteet & martin nov 2020. christian journal for global health 7(4) figure 2. volunteering by women association leaders and members: asha centre in seelampur • educated everyone they contacted regarding covid-19 and how to act to reduce risk. • formed liaisons with the local police to protect rather than control and intimidate the people and with local sanitation workers to maintain toilet blocks and remove garbage. • developed supply chains and logistics, based on existing relationships, to obtain and distribute some key supplies — soap, disinfectant, ppe, food, grain, vaccines, medicines, and sanitary supplies. • provided consolation and comfort to ensure mental health well-being. warriors gave their mobile numbers to the elderly, handicapped, chronically ill, and most vulnerable. the access to warriors served as a hotline around the clock, especially in emergencies. the warriors also visited slum dwellers experiencing depression, anxiety, and loneliness, and provided social, mental, and emotional support to overcome the uncertainty arising out of the circumstances. • continued to address essential ongoing needs that had potential long term catastrophic consequences — antenatal, natal, postnatal care; vaccinations (including against typhoid as temps rose into the 100’s); ongoing treatment of chronic diseases; assistance for students leaving schools and university students who had no access to computers but needed to take exams; special nutritional programs for those under 5 and adults with critically low bmi, developed in conjunction with dietary experts in uk and us. • held special health care clinics for pregnant women, children under 5 years, patients with chronic illnesses, and for geriatric patients. • because of covid-19, special ongoing programs for malnutrition were developed. for children under 5, asha provided a high-calorie, high protein laddoo (sphere-shaped sweet) along with vitamins and other supplements. to malnourished women and adolescent girls, a nutritious drink rich in calories and protein was provided along with iron and vitamin supplements. (figure 3) figure 3. supplementary nutrition: mayapuri slum community asha works among approximately 700,000 slum dwellers. the asha team and warriors went to every house and lane to educate regarding covid19 and screened using infrared thermometers and pulse oximeters. if they found a person having flulike symptoms, they immediately referred them to the nearest covid-19 testing centre. individuals who tested positive were assessed for clinical conditions, the severity of illness, and comorbidities. the asha teams referred the patients with suggestive symptoms to designated testing centers in government hospitals, community clinics, and to mobile clinics. the covid-19 tests were and are being done free of charge, paid for by the government of delhi. the government health workers also conducted physical assessments to ensure adequate facilities for home isolation so that clusters of cases did not develop. if an adequate facility for home isolation was found, the patients were put into home quarantine. the patients were given medicines and 4 peteet, hempton, peteet & martin nov 2020. christian journal for global health 7(4) monitored regularly through phone calls and oximeters. patients with co-morbidities or severe symptoms were immediately admitted to covid-19 designated hospitals. homes of patients were quarantined for a minimum of 14 days and a poster put on the main door. contact tracing was done by the government, and all family members and neighbors were tested. the asha teams and warriors spread awareness in the community about the presence of a covid19 positive case and encouraged the slum dwellers to avoid that lane or area. they also kept in touch with the patient and the family member through phone calls, gave emotional support, and ensured proper sanitation of the area by the municipal corporation. areas where six or more people were tested positive for coronavirus were identified as “hotspots” or “containment zones” in order to recognize their probability of a high degree of viral spread. strict movement restrictions were put in place in such areas to prevent further spread of the virus, and deliveries of essential items like groceries, medicines, and dairy products were made by government authorized delivery personnel only. the asha team ensured that the area was restricted, and that slum residents stayed away from that zone. figure 4 illustrates how primary prevention, such as that provided by asha, reduced the need for health care to alleviate problems and the need to intervene with treatment. figure 4. primary and secondary prevention observations no asha volunteers have developed covid19 symptoms, and only 310 covid-19 positive patients have been found in the asha slum communities to date. with approximately 700,000 people in asha slums, this is a rate of .04%. discussion people living in the slums are the most vulnerable population in the world and have been the most affected during the covid-19 pandemic.1 only a few reports describe attempts to implement strategic interventions recommended by the who, world bank, and others.8,9 in one report, four social workers recognized food insecurity within the slum area of jabalpur, india and partnered with ngo’s to provide ration kits to some 900 families and, subsequently, worked to connect needy slum dwellers to a government protection program for vulnerable people.8 another described the effectiveness of several interventions in the dharavi, mumbai, asia’s largest urban slum of 1 million people, where a model termed “chasing the virus” was used in contrast to waiting for people to report it. after discovering a first case, the municipal corporation closed the slum cluster entrance and exit, disinfected public toilets, began door to door screening, worked with private doctors to initiate containment strategies, and partnered with ngos to build trust and provide food. in april, dharavi had 491 covid-19 cases with a 12% growth rate. after the implementation of public health measures, in may the growth rate was 4.3% and in june only 1.02%. case doubling time also improved to 43 days in may and 78 days in june.9 the infection rate of .04% in asha slums is comparable to the .05% rate reported in mumbai, though asha does not have figures showing the growth rate. the success achieved by the multi-pronged approach taken by asha in preventing morbidity and mortality, while alleviating financial stress is similarly worth noting with the hope that lessons 5 peteet, hempton, peteet & martin nov 2020. christian journal for global health 7(4) learned from these practices could make countries more effective in future pandemics.10 conclusion key factors that enabled a quick response were that asha: • is a long established, locally based and led organization with a long history in the communities it serves. • has strong, involved, local leadership that cares deeply for the people they are serving, is well connected to them and is working from a longarticulated value base of dignity, empowerment, justice, non-violence, compassion, gratitude, optimism, joy, and simplicity. • has well established supply networks in delhi and committed supporters around the world. • is small enough to be nimble and personal but large enough to serve 700,000 people. • recognizes that, even under the pressure to address immediate need, it is equally essential to address longer term values as central to asha’s approach the success of asha in controlling covid-19 in the slums also reflects the realization of the values asha promotes in the community: dignity, empowerment, justice, non-violence, compassion, gratitude, generosity, optimism, joy, and simplicity. we believe that these were demonstrated by its staff and volunteers who risked their own health to combat the humanitarian crisis of covid-19. although developed by a team of christians and those of other faiths on dr. martin’s staff, asha values are contextualized and live comfortably in hindu influenced society — neither simply restating local culture, nor foreign and hostile to it. by embodying values that respect the dignity of every person, asha is respected in pluralistic and nonchristian contexts. asha’s values are holistic, comprehensive, and used to inform decisions, for example, about whether a financial program would result in empowerment. taught, modeled, and discussed constantly, the values live in the work and not in a manual. as the pandemic in india continues to grow with about 75,000 recorded cases being added daily,6 asha’s 33 years of experience in refining and implementing its values-based approach has much to teach those working to help impoverished, multifaith communities at risk. references 1. corburn j, vlahov d, mberu b, riley l, waleska t, cajaffa t et al. slum health: arresting covid-19 and improving well-being in urban informal settlements. j urban health. 2020 apr;97:348-57. https://doi.org/10.1007/s11524-020-00438-6 2. world health organization. covid-19 strategy update [internet]. 2020 apr. available from https://www.who.int/docs/defaultsource/coronaviruse/covid-strategy-update-14 april2020.pdf?sfvrsn=29da3ba0_19 3. the world bank. covid-19 turns spotlight on slums [internet]. 2020 jun. available from: https://www.worldbank.org/en/news/feature/2020/06/1 0/covid-19-turns-spotlight-on-slums 4. the world bank. covid-19 and slums wbg-lac. a multisectoral approach [internet]. 2020 apr. available from: https://www.thegpsc.org/sites/gpsc/files/covid19_and_slums.pdf 5. peretz pj, islam n, matiz la. community health workers and covid-19 — addressing social determinants of health in times of crisis and beyond. new eng j med. 2020 sep. https://doi.org/10.1056/nejmp2022641 6. sharma a. india cases cross 7 million as experts warn of complacency [internet]. 2020 oct. available from: https://apnews.com/article/virus-outbreak-pandemicsindia-archive-3472ed5d494fb004aa384d16e2b8b4cf 7. asha. home page [internet] available from: https://asha-india.org 8. banshkar a, vinzuda a. reaching out to slum dwellers to address starvation during the 2020 pandemic in india. social work with groups. 2020 sep. https://doi.org/10.1080/01609513.2020.1819046 9. golechha m. covid-19 containment in asia’s largest urban slum dharavi-mumbia, india: lessons for policymakers globally. j urban health. 2020 aug. https://doi.org/10.1007/s11524-020-00474-2 https://doi.org/10.1007/s11524-020-00438-6 https://www.who.int/docs/default-source/coronaviruse/covid-strategy-update-14%20april2020.pdf?sfvrsn=29da3ba0_19 https://www.who.int/docs/default-source/coronaviruse/covid-strategy-update-14%20april2020.pdf?sfvrsn=29da3ba0_19 https://www.who.int/docs/default-source/coronaviruse/covid-strategy-update-14%20april2020.pdf?sfvrsn=29da3ba0_19 https://www.worldbank.org/en/news/feature/2020/06/10/covid-19-turns-spotlight-on-slums https://www.worldbank.org/en/news/feature/2020/06/10/covid-19-turns-spotlight-on-slums https://www.thegpsc.org/sites/gpsc/files/covid-19_and_slums.pdf https://www.thegpsc.org/sites/gpsc/files/covid-19_and_slums.pdf https://doi.org/10.1056/nejmp2022641 https://apnews.com/article/virus-outbreak-pandemics-india-archive-3472ed5d494fb004aa384d16e2b8b4cf https://apnews.com/article/virus-outbreak-pandemics-india-archive-3472ed5d494fb004aa384d16e2b8b4cf https://asha-india.org/ https://doi.org/10.1080/01609513.2020.1819046 https://doi.org/10.1007/s11524-020-00474-2 6 peteet, hempton, peteet & martin nov 2020. christian journal for global health 7(4) 10. patel a. preventing covid-19 amid public health and urban planning failures in slums of indian cities. policy study org. 2020. https://doi.org/10.1002/wmh3.351 submitted 19 oct 2020, accepted 27 oct 2020, published 9 nov2020 competing interests: none declared. acknowledgements: photos taken by the asha community health and development society. correspondence: prof. jean oulund peteet, boston, ma, usa. jeanpeteet@gmail.com cite this article as: peteet jo, hempton l, peteet jr, kiran m. asha’s response to covid-19: providing care to slum communities in india. christ j for global health. nov 2020; 7(4):____. https://doi.org/10.15566/cjgh.v7i4.471 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1002/wmh3.351 mailto:jeanpeteet@gmail.com https://doi.org/10.15566/cjgh.v7i4.471 http://creativecommons.org/licenses/by/4.0/ references guest editorial aug 2020. christian journal for global health 7(3) promoting inclusive early childhood development under the sdg era bolajoko o. olusanyaa a mbbs, frcpch, phd, executive director, centre for healthy start initiative, lagos, nigeria since the year 2000, the global child health agenda under the auspices of the united nations and its affiliated agencies has been largely focused on child survival with remarkable results.1,2 for example, the total number of under-five deaths dropped from 12.6 million in 1990 to 5.6 million in 2016, or 35,000 every day in 1990 compared with 15,000 in 2016.2 globally, the under-five mortality rate dropped from 93 in 1990 to 41 deaths per 1,000 live births in 2016, representing a 56% decline. the progress in improving child survival has saved the lives of 50 million children under the age of 5 years who otherwise would have died had under-five mortality remained at the same level as at the beginning of the millennium development goals in 2000. ironically, many of the beneficiaries of the global child survival programs, some of whom otherwise would have died, also experience longterm adverse outcomes.3 the sustainable development goals (sdgs) launched in 2015 thus ushered in a broader and more inclusive mandate for child health policy.4 whereas child survival still remains a major theme under the sdgs, there is explicit recognition at global, regional and national levels of the needs of the growing population of child survivors to thrive and realize their developmental potential. for example, the fourth sdg specifically calls for actions to ensure inclusive and equitable quality education and to promote life-long learning opportunities for all children, including monitoring the proportion of under-fives who are developmentally disadvantaged. the global interest in early childhood development has been driven largely by extensive evidence on the development of the human brain from conception to adulthood. this suggests that approximately 80% of a child’s brain growth and synapse development occurs before the age of 3, or within the first 1000 days after conception.5 additionally, optimal development in early childhood prepares all children, including newborns and young children with disabilities and developmental difficulties, for quality education and vocational attainment. the most prominent global initiative for early childhood development is the nurturing care framework (ncf) jointly launched by unicef and the world health organisation in 2018.6 it primarily focused on addressing the needs of an estimated 250 million children in low and middle-income countries at risk of not realizing their developmental potential due to stunting and extreme poverty. while early childhood development entails multi-sectoral engagements, the ncf seeks to promote responsive care and a nurturing environment for all children using the health sector as the main platform for intervention. the ncf also acknowledges that childhood disabilities impose a significant emotional and economic demand on the affected families and children, especially in places with inadequate infrastructure and access to services and support. for example, an estimated 53 million children under the age of 5 years have developmental disabilities and this population exceeds 290 million if the age group is extended to 20 years.7,8 these children also require 4 olusanya aug 2020. christian journal for global health 7(3) responsive care and a nurturing environment to a much greater extent than their peers without disabilities or developmental difficulties. it is noteworthy that the mission statement of unicef already emphasizes priority attention to the most disadvantaged children and the countries with the greatest need.9 faith-based organizations (fbos) have a vital role in ensuring that global child health initiatives are widely promoted and equitably implemented at the community levels. the most successful programs are usually family-centered. parents and caregivers therefore need to be empowered, engaged and supported to assure all children the best possible start in life. a list of actions recommended for fbos to foster optimal child health practices inclusive of early childhood development has been reported by unicef.9 for example, fbos can assist in bringing important early childhood development information into the family setting, emphasizing families’ obligation to provide for their young children, offering information on how to do this and supporting them when they face difficulties. they can also engage in developing peer education groups for women’s and men’s associations to share information about early childhood development, and support members whose children are not accessing appropriate services through, for example, referral and financial assistance and dissemination of information about where to seek relevant services. more crucially, fbos must seek to engage with policy makers to draw attention to the needs of the most vulnerable children that require priority attention where resources are inadequate to cater for all children. however, these actions need to reflect the emerging post-covid-19 realities. for children with special healthcare needs, the delivery of personalized interventions will be particularly challenging for parents and caregivers, thus requiring all the virtues of christ-like compassion and understanding. like the good samaritan, we must be ready to go the extra mile to support the most vulnerable and disadvantaged spiritually, emotionally and financially as much as lies within our power and sphere of influence (luke 10:25-37; matthew 5:41). the sdgs along with the convention on the rights of children10 provide a unique opportunity for ensuring that no child is left behind in the crucial early years regardless of their race, gender, nationality, disability status and economic circumstances. while the sdgs have no measurable targets or performance indicators for early childhood development, the growing interest for the well-being of all children by un agencies and their developmental partners, including fbos, holds promise of a better future. that future is now. . references 1. gbd 2016 causes of death collaborators. global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the global burden of disease study 2016. lancet 2017; 390: 1151-210. https://doi.org/10.1016/s0140-6736(17)32152-9 2. united nations inter-agency group for child mortality estimation (un igme), ‘levels & trends in child mortality: report 2017, estimates developed by the un inter-agency group for child mortality estimation’, united nations children’s fund, new york, 2017. 3. magai dn, karyotaki e, mutua am, et al. longterm outcomes of survivors of neonatal insults: a systematic review and meta-analysis. plos one. 2020;15(4):e0231947. published 2020 apr 24. https://doi.org/10.1371/journal.pone.0231947 4. un. sustainable development goals. un, new york, ny: united nations, 2015. [internet] accessed 25 july 2020. available from: http://www.un.org/sustainabledevelopment/sustaina ble-development-goals 5. shonkoff jp, phillips da, eds. from neurons to neighborhoods: the science of early childhood development. washington, dc: national academies press (us), 2000. 6. who, unicef, world bank group. nurturing care for early childhood development: a framework https://doi.org/10.1016/s0140-6736(17)32152-9 https://doi.org/10.1371/journal.pone.0231947 http://www.un.org/sustainabledevelopment/sustainable-development-goals http://www.un.org/sustainabledevelopment/sustainable-development-goals 5 olusanya aug 2020. christian journal for global health 7(3) for helping children survive and thrive to transform health and human potential. geneva: world health organization, 2018. [internet] accessed 25 july 2020. available from: http://apps.who.int/iris/bitstream/handle/10665/272 603/9789241514064-eng.pdf?ua=1 7. global research on developmental disabilities collaborators. developmental disabilities among children younger than 5 years in 195 countries and territories, 1990-2016: a systematic analysis for the global burden of disease study 2016 lancet glob health. 2018;6(10):e1100-e1121. https://doi.org/10.1016/s2214-109x(18)30309 8. olusanya bo, wright sm, nair mkc, et al. global burden of childhood epilepsy, intellectual disability, and sensory impairments. pediatrics. 2020;146(1):e20192623. https://doi.org/10.1542/peds.2019-2623. 9. unicef. partnering with religious communities for children. new york, 2012. [internet]. accessed 25 july 2020. available from: https://www.unicef.org/about/partnerships/files/part nering_with_religious_communities_for_children _%28unicef%29.pdf. 10. united nations convention on the rights of the child. 1990. uncrc 1990. [internet] accessed 25 july 2020. available at: https://www.unicef.org.uk/what-we-do/unconvention-child-rights/. competing interests: none declared. correspondence: dr. bolajoko o. olusanya, lagos, nigeria tel: +234 803 33 44 300 bolajoko.olusanya@uclmail.net cite this article as: olusanya bo. promoting inclusive early childhood development under the sdg era. christ j global health. aug 2020; 7(3):3-5. https://doi.org/10.15566/cjgh.v7i3.427 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf?ua=1 http://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf?ua=1 https://doi.org/10.1016/s2214-109x(18)30309 https://doi.org/10.1542/peds.2019-2623 https://www.unicef.org/about/partnerships/files/partnering_with_religious_communities_for_children_%28unicef%29.pdf https://www.unicef.org/about/partnerships/files/partnering_with_religious_communities_for_children_%28unicef%29.pdf https://www.unicef.org/about/partnerships/files/partnering_with_religious_communities_for_children_%28unicef%29.pdf https://www.unicef.org.uk/what-we-do/un-convention-child-rights/ https://www.unicef.org.uk/what-we-do/un-convention-child-rights/ mailto:bolajoko.olusanya@uclmail.net https://doi.org/10.15566/cjgh.v7i3.427 about:blank references case report july 2021. christian journal for global health 8(1) anterior abdominal wall abscess secondary to spontaneous rupture of liver abscess in a resource-limited, rural, surgical setting: a case report royson dsouzaa, mrudula raob, harshad arvind vanjarec, manbha rymbaid a mbbs, ms, consultant surgeon, ashwini gudalur adivasi hospital, the nilgiris, tamil nadu, india b mbbs, pgdfm, ashwini gudalur adivasi hospital, the nilgiris, tamil nadu, india c mbbs, md, associate professor, department of radiology, christian medical college and hospital, vellore, india d mbbs, ms, mch, department of hepatobiliary surgery, christian medical college and hospital, vellore, india abstract liver abscess continues to be a major surgical burden in low-and mid-low-income countries like india. spontaneous rupture into the anterior abdominal wall is an uncommon presentation of pyogenic liver abscess. a 53-year-old diabetic female presented with acute pain in the right, upper quadrant of the abdomen. on examination, she had an anterior abdominal wall abscess with tender hepatomegaly. on further evaluation with ultrasonography and plain computed tomography, a diagnosis of liver abscess in the right lobe with rupture into the anterior abdominal wall was made. she was treated successfully in a tribal secondary care hospital with an ultrasound-guided aspiration followed by surgical drainage under local anesthesia. this case report highlights that a considerable number of patients with liver abscess and its complications can be appropriately managed in resource-limited, rural, surgical centers. key words: liver abscess, spontaneous rupture, resource-limited setting, minimally invasive surgery, percutaneous drainage introduction liver abscess is one of the oldest surgical emergencies, described from the time of hippocrates.1 of the complications associated with it, rupture into the anterior abdominal wall is an unusual event and can lead to increased morbidity and mortality.2,3 much has evolved in their management with lesser invasive procedures being the standard of care. consequently, liver abscess, which was primarily a surgical condition, is now easily being managed by interventional radiologists. however, in a resource-limited, rural, surgical setting, most facilities are not properly equipped or available. management of the patient still remains in the hands of a surgeon. in this current report, we present a 53-yearold female who was diagnosed with a liver abscess which had ruptured into the anterior abdominal wall and was successfully managed with the available resources in a rural tribal health care facility. her clinical details, relevant investigations, and challenges in management have been described along with a review of the literature. 73 dsouza, rao, vanjare & rymbai july 2021. christian journal for global health 8(1) consent was obtained from the patient for her case to be reported. patient information a 53-year-old female, a tea estate worker in the nilgiris, tamil nadu, presented with a history of upper abdominal pain for 20 days. it was of insidious onset, a dull aching pain with no radiation or migration. pain was not associated with the intake of food and was relieved with analgesics. there was no history of vomiting, altered bowel habit, jaundice, or loss of appetite. the patient had had high-grade fever with chills for the previous five days with progressive worsening of the pain. she was a known type 2 diabetic on oral hypoglycemic agents and had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis eight years previously which was uneventful. clinical findings on examination, she was in acute distress due to pain. her pulse rate was 90 per minute and blood pressure was 110/70 mm of hg. her general physical examination was unremarkable. on abdominal examination, there was a swelling in the right hypochondrium measuring 3x2 cm that was tender and had locally increased temperature. the swelling was confined to the parietal wall. the liver was enlarged 2 cm below the right subcostal margin and was tender on palpation. the rest of her abdominal examination was unremarkable. diagnostic assessment with a clinical suspicion of an anterior abdominal wall abscess, the patient underwent further evaluation. the relevant laboratory investigations are summarized in table 1. to better characterize the lesion, ultrasonography (usg) of the abdomen was done that showed a hypoechoic mass in the liver with internal echoes and a parietal wall collection consistent with an abscess. following this, a plain ct was done showing a subcapsular abscess involving the right lobe of the liver with partial rupture and extension into the anterior abdominal wall (figure 1). table 1. relevant laboratory investigations test result complete blood count hemoglobin: 12.1g/dl, total wbc count: 11400 cells/mm3, differential count: neutrophils68.6%, lymphocytes30.8%, monocytes-5.6%, platelets: 3.79 lacs/mm3 creatinine 1.0 mg/dl random blood sugar 310 mg/dl liver function tests sgpt: 8.5 iu/l, sgot: 12.5 iu/l, prothrombin time: 20s, inr: 1.3 figure 1. non-contrast ct axial sections at the level of the liver demonstrating a well-defined cystic area in the right lobe of the liver in keeping with an abscess (black arrows) with focal rupture and extension into the anterior abdominal wall (white arrow) therapeutic interventions the patient was started on broad-spectrum intravenous antibiotics (piperacillin-tazobactam 4.5 g every 6 hours and metronidazole 500 mg every 8 hours), and drainage of the abscess was planned. as there was no evidence of intraperitoneal rupture of the abscess, a laparotomy 74 dsouza, rao, vanjare & rymbai july 2021. christian journal for global health 8(1) was unnecessary. however, image-guided pigtail drainage was not possible in our setting due to a lack of resources and personnel. hence, a usg guided aspiration was done to confirm the location of the abscess. following this, a 3 cm skin incision was made under local anesthesia on the premarked site, and the abscess cavity was accessed. after draining the pus, a 16f foley catheter was maneuvered into the abscess cavity to act as a drain. the wound was closed with widely placed interrupted sutures. the patient was stable after the procedure and recovered well after receiving 7 days of antibiotics. the culture from the pus grew escherichia coli which was penicillin-sensitive. the patient was discharged on post-operative day 8 with the drain in situ and was discharged on oral antibiotics and metronidazole for 4 weeks. follow-up and outcomes on follow-up, the patient was clinically well and afebrile. the wound was healthy, and the drain output serially decreased. usg after 21 days showed no residual abscess, and the drain was removed (figure 2). on 5 months’ follow-up, the patient was asymptomatic without evidence of recurrence of abscess. figure 2. follow-up usg showing a resolution of the abscess discussion liver abscesses, both amoebic and pyogenic, continue to pose a major public health problem in tropical countries like india.4-6 although there are no recent national or regional epidemiological studies to determine the prevalence of liver abscess in india, rural patients share a fair burden.4,6 the management of liver abscess has improved significantly over the years with the aid of better imaging modalities for early diagnosis and initiation of appropriate therapy.7-9 similarly, the procedural morbidity has been reduced considerably due to the employment of lesser invasive modalities like percutaneous aspiration and percutaneous drainage techniques.5,10,11 transperitoneal drainage via a laparotomy, traditionally the treatment of choice for drainage of liver abscess, has taken a back seat in the current era and is reserved only for certain complications.11,12 the successful management of a patient with liver abscess, however, depends predominantly on the available expertise and resources. distinguishing between pyogenic and amoebic abscesses is important as the management differs. patients with pyogenic abscess are generally in the advanced age group and are immunosuppressed. fever, chills, right upper quadrant pain, jaundice, weight loss, and nausea are the common manifestations. in contrast, patients with amoebic abscess tend to be young and can have a history of diarrhea in addition to abdominal pain and fever.7 in abscesses larger than 5 cm or 200 cc, drainage remains the cornerstone in treatment along with the initiation of appropriate antibiotics.13,14 metronidazole is amoebicidal and the treatment of choice in amoebic abscess, with or without percutaneous aspiration. pyogenic abscesses more frequently warrant a drainage procedure along with broadspectrum antibiotics and metronidazole. in an ideal tertiary care setup, the majority of these patients are managed by interventional radiologists using usg or ct guided pigtail catheter placement. however, this is not easily made available in many rural surgical centers like ours where the management lies in the hands of a 75 dsouza, rao, vanjare & rymbai july 2021. christian journal for global health 8(1) surgeon. although our patient was sufficiently hemodynamically stable to be referred to a more ideal facility, due to the covid-19 pandemic and travel restrictions, this was not possible. moreover, like many other rural patients, our patient preferred to get treated at a hospital close to home.15 ultrasonography is a valuable addition to a surgeon’s diagnostic tools, especially in resource poor-settings. surgeons can competently perform usg of the abdomen for focused assessment with sonography (fast) in trauma, breast, thyroid, and vascular systems.16 the presence of a hypoechoic lesion with internal echoes and an irregular margin within the liver is characteristic of an abscess which can be easily diagnosed by a surgeon.7 similarly, usg guided aspiration serves as an important diagnostic and therapeutic modality by confirming the presence of pus. we considered a ct scan after usg to rule out other smaller collections which could have been missed on usg. however, in retrospect, we feel that the ct scan was an unnecessary step as it did not aid in the ultimate management of the case. hence, we do not consider the use of ct to be routinely necessary, especially when the usg is performed by an experienced sonologist. rupture of pyogenic liver abscess is a rare complication that can lead to increased morbidity and mortality.2 the other reports of abdominal wall abscess secondary to a pyogenic liver abscess are summarized in table 2. the associated factors are postulated to be klebsiella infection, diabetes mellitus, gas formation in the cavity, and involvement of the left lobe of the liver.17 our patient was a diabetic but did not have any other associated features mentioned above. the previous laparoscopic cholecystectomy could have contributed to the pathway of spread as the abscess was close to the right hypochondrium port site. there is no consensus in the management of liver abscess ruptured into the abdominal wall. in general, this is considered a surgical emergency but the management largely depends on the site of rupture and condition of the patient.2,3,17,18 following a usg-guided localization, we were able to successfully access the abscess cavity with a small skin incision using local anesthesia. instead of a pigtail catheter, a foley catheter was used which is easily available in all rural surgical centers. there were no complications related to the drain such as infection, blockage, or displacement. table 2. review of literature on rupture of liver abscess into the anterior abdominal wall authors age gen der associated factor liver lobe abdominal region bacteria management kawosa et al (19) 31 f previous laparotomy for liver abscess right right hypochondrium klebsiella pneumoniae percutaneous drainage belabbes et al(20) 78 f choledocoduodenostomy for choldecolihtiasis left epigastrium n/a percutaneous drainage zizzo et al(2) 95 f n/a left epigastrium and umbilical region proteus mirabilis antibiotics only ndong et al(21) 6 n/a n/a left right hypochondrium staphylococ cus aureus percutaneous drainage gupta et al(22) 35 f tuberculosis right right hypochondrium and lower chest mycobacteri um tuberculosis att and usg guided aspiration current case 53 f diabetes, previous laparoscopic cholecystectomy right right hypochondrium e. coli percutaneous aspiration and surgical drainage notes: f: female, n/a: not available. ultrasound-guided drain placement is a skill that can be easily acquired by a surgeon even in cases of liver abscess without rupture. this is crucial, especially in a resource-limited rural setting. moreover, if there are procedural complications during or following the drain placement that necessitate surgical intervention, it can be handled competently by a surgeon. 76 dsouza, rao, vanjare & rymbai july 2021. christian journal for global health 8(1) conclusion the management of liver abscess has evolved considerably with aid of interventional radiological techniques in drainage of the abscess. however, many subsets of these patients can be managed in resource-limited, rural, surgical centers using usg-guided localization and drainage. spontaneous rupture of liver abscess into the anterior abdominal wall is a rare complication necessitating an early surgical intervention. the treatment consists of broadspectrum, intravenous antibiotics and drainage of the abscess depending on the location and the general condition of the patient. references 1. papavramidou n, samara a, christopoulou-aletra h. liver abscess in ancient greek and grecoroman texts. acta medico-hist adriat amha. 2014;12(2):321–8. 2. zizzo m, zaghi c, manenti a, luppi d, ugoletti l, bonilauri s. abdominal wall abscess secondary to spontaneous rupture of pyogenic liver abscess. int j surg case rep. 2016;25:110. http://doi.org/10.1016/j.ijscr.2016.06.026 3. chong vh, zainal-abidin z, hassan h, chong cf. rare complications of pyogenic liver abscess. singapore med j. 2010 oct;51(10):e169-172. 4. reddy p, ashwin k, srinivasan n, halbhavi mr. a study of treatment outcomes of liver abscess in a rural tertiary care centre. int surg j. 2019 jun 29;6(7):2439–43. http://doi.org//10.18203/23492902.isj20192970 5. manza j, makwana h, pancholi m, verma n. study of different modalities of management in patients with liver abscess in a tertiary care centre. 2018;6(1):5. http://doi.org/10.17354/liss/2018/115 6. rickard j, beilman g, forrester j, sawyer r, stephen a, weiser tg, et al. surgical infections in lowand middle-income countries: a global assessment of the burden and management needs. surg infect. 2019 dec 9;21(6):478–94. http://doi.org/10.1089/sur.2019.142 7. holzheimer rg, mannick ja, editors. surgical treatment: evidence-based and problem-oriented. munich: zuckschwerdt; 2001. pmid: 21028753. 8. donovan aj, yellin ae, ralls pw. hepatic abscess. world j surg. 1991 apr;15(2):162–9. https://doi.org/10.1007/bf01659049 9. runge vm, wells jw, williams nm. hepatic abscesses. magnetic resonance imaging findings using gadolinium-bopta. invest radiol. 1996 dec;31(12):781–8. https://doi.org/10.1097/00004424-19961200000008 10. kathel p, mudgal mm, kushwah n. comparison of various techniques used in the management of liver abscess [internet]. :5. available from: https://www.semanticscholar.org/paper/comparison -of-various-techniques-used-in-the-of-kathelmudgal/4e6a87ea91feb36b0f6ac9f1f38ad8ba4de4e 732 11. pitt ha. surgical management of hepatic abscesses. world j surg. 1990 aug;14(4):498–504. https://doi.org/10.1007/bf01658675 12. alkofer b, dufay c, parienti jj, lepennec v, dargere s, chiche l. are pyogenic liver abscesses still a surgical concern? a western experience [internet]. vol. 2012, hpb surgery. hindawi; 2012 [cited 2021 jan 22]. p. e316013. available from: https://downloads.hindawi.com/archive/2012/31601 3.pdf 13. satish kumar r, madhushankar l, nataraj naidu r, ramalingeshwara k, laxmikantha l, amit gupta m, et al. treatment strategies in liver abscess our experience. j evol med dental sci. 2013 nov 11;2(45):8768-75. https://doi.org/10.14260/jemds/1522 14. cai y, xiong x, lu j, cheng y, yang c, lin y, et al. percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta-analysis. hpb. 2014 oct 1;17. https://doi.org/10.1111/hpb.12332 15. sun x, meng h, ye z, conner ko, duan z, liu d. factors associated with the choice of primary care facilities for initial treatment among rural and urban residents in southwestern china. plos one. 2019 feb 7;14(2):e0211984. https://doi.org/10.1371/journal.pone.0211984 16. g s rozycki. surgeon-performed ultrasound: its use in clinical practice. ann surg. 1998 jul;228(1):1628. https://doi.org/10.1097/00000658-19980700000004 17. chung hwan jun, jae hyun yoon, jin woo wi, seon young park, lee ws, jung si,et al. risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess. j dig dis. 2015 jan; 16(1): 31-6. http://doi.org/10.1111/17512980.12209 18. motoyama t, ogasawara s, chiba t, suzuki e, yokota h, haga y, et al. successful non-surgical http://doi.org/10.1016/j.ijscr.2016.06.026 about:blank about:blank http://doi.org/10.17354/liss/2018/115 about:blank 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dsouza, rao, vanjare & rymbai july 2021. christian journal for global health 8(1) treatment of ruptured pyogenic liver abscess. intern med tokyo jpn. 2013;52(23):2619–22. https://doi.org/10.2169/internalmedicine.52.0980 19.kawoosa nu, bashir a, rashid b. spontaneous cutaneous rupture of a pyogenic liver abscess. indian j surg. 2010 aug;72(4):339–42. https://doi.org/10.1007/s12262-010-0131-3 20. belabbes s. anterior abdominal wall abscess revealing a pyogenic liver abscess: a case report. research 2014;1:1256. http://doi.org/10.13070/rs.en.1.1256 21. ndong a, tendeng j, ndoye n, dieye a, diallo a, elmansouri m, et al. liver abscess ruptured in the abdominal wall: a rare complication in a child. surg chron. 2019 sep 1;24:162–3. 22.gupta g, nijhawan s, katiyar p, mathur a. primary tubercular liver abscess rupture leading to parietal wall abscess: a rare disease with a rare complication. j postgrad med. 2011 oct 1;57(4):350. https://doi.org/10.4103/00223859.90095 peer reviewed: submitted 8 feb 2021, accepted 23 march 2021, published 30 july 2021 competing interests: none declared. correspondence: royson dsouza, ashwini gudalur adivasi hospital, india. roy6dsouza@gmail.com cite this article as: dsouza r, rao m, vanjare ha, rymbai m. anterior abdominal wall abscess secondary to spontaneous rupture of liver abscess in a resource-limited, rural, surgical setting: a case report. christ j glob health. july 2021; 8(1):72-77. https://doi.org/10.15566/cjgh.v8i1.507 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.2169/internalmedicine.52.0980 https://doi.org/10.1007/s12262-010-0131-3 about:blank https://doi.org/10.4103/0022-3859.90095 https://doi.org/10.4103/0022-3859.90095 mailto:roy6dsouza@gmail.com https://doi.org/10.15566/cjgh.v8i1.507 http://creativecommons.org/licenses/by/4.0/ abstract introduction discussion references editorial july 2021. christian journal for global health 8(1) benefits of a christian global health research collaborative rebecca meyera, jason paltzerb a phd, msned, bsn, rn, associate professor of nursing, california baptist university, usa b phd, mph, assistant professor of epidemiology, baylor university, usa this editorial presents the idea that a christian global health research collaborative is needed to support smallto medium-sized faith-based organizations (fbos) as they conduct original research and disseminate their findings. this innovative group would function as a christian public health resource and partnership service for mission organizations and leaders to expand best practices that integrate the benefits of public health practice with christ-centered compassion. the christian global health research collaborative would be available to work in partnership to improve health outcomes, meet the un’s sustainable development goals,1 engage communities, and provide discipleship through christian focused, holistic, and sustainable methods. based on recent research conducted on this topic,2 the three current priorities for the christian global health research collaborative would be to: 1) support global partners in the implementation of different research designs, 2) assist them with using appropriate evaluation and measurement tools, and 3) provide ways for them to disseminate findings so others can benefit from the information. there tends to be a lack of knowledge and understanding about research design and methodology in some fbos, both local and international, as well as a lack of personnel and funding.3 the need for national faithbased research networks has been identified and initiated in the past but these have been focused on a specific church network or region rather than a global exchange of research and ideas.4 offering collaborative services, such as health promotion programming, academic partnerships, and willing content experts, to these fbos will help them determine the type of research to conduct, such as qualitative, quantitative, or mixed methods. dehaven, et al, in their systematic review, concluded that faith-based programs improve health outcomes, but that “means are needed for increasing the frequency with which such programs are evaluated and the results of these evaluations are disseminated.”5 ferguson, et al, in their systematic review of faith-based social services, had similar conclusions – expressing the need to broaden existing effectiveness indicators, include the role of faith as a dimension, develop valid instruments to assess fbos, and employ more rigorous research methods. 6 depending on the design chosen, the collection of data, measurement, and analysis can take a long time, and for the novice researcher, having a collaborative, interprofessional team available to guide and mentor would be invaluable. building research capacity in resource-poor settings is a vital need for promoting global health but is not without its challenges.7 it is also biblical, when thinking about the ways paul poured into timothy in order to be enabled to teach others, for example (2 tim 2:2). the christian global health research collaborative team could train “timothies” who can then mentor and guide new researchers on their journey, working together as the body of christ to build capacity, discern truth, and strengthen the kingdom (1cor 12:12–27). as any researcher knows, there are many research and measurement tools available, such as forms, surveys, and interview guides, with most of them written in english. it can be a challenge to screen them all, especially for those whose first language is not english. then, there is the translation and validation of study instruments needed for cross-cultural research, which is 9 meyer & paltzer july 2021. christian journal for global health 8(1) time consuming. the benefit of having a christian global health research collaborative team available to help non-native english speakers select, and even screen, the best tool for their context would facilitate more research and robust exchange of ideas between settings. dissemination of valid research is important so best practices can be shared around the world. according to a study conducted in 2004, little information exists about outcome measures, and this has not changed in more than 15 years.5 however, fbos can produce positive effects in community and global health, and that information needs to be shared. the christian global health research collaborative is needed to help global partners collect, organize, analyze, write, and publish project findings in national and international journals, present at national and international conferences, verify outcome measures for donors, and help organizational leaders share their findings with local public health and policy stakeholders. currently, the public health as mission network (pham) housed within the global community health evangelism (che) network (www.chenetwork.org) is a place for representatives from universities, sending agencies, and other national and international partners to actively share ideas regarding integral mission and plan research projects and other high-quality research initiatives. there are plans already in place for the network to transition into the christian global health research collaborative. the pham network identified, through informal and formal surveys in the past few years, the ongoing need to translate models and tools for integrating faith and public health to help obtain valid data, and to disseminate findings leading to best practices within this area of ministry.8,2 challenges have been identified by studies in the past related to conducting international fieldwork; however, having interprofessional participation on both sides can help overcome perceived barriers.9 graduate and undergraduate students at christian universities are being mentored and trained by members of the pham network to analyze and integrate social and spiritual determinants of health so they can also participate with the christian global health research collaborative in the future, with the hope they will also have a passion for lifelong kingdom work. allowing graduate students to participate allows them to go beyond the theoretical content in the classroom, to applying the skills and knowledge to potential challenges in the field. other areas of research to consider in partnership with christian health organizations and sending agencies is burnout among medical missionaries, palliative care, worker burnout, depression, implementation studies, and of course, covid-19 adaptation, education, and training.10,11,12 the joint learning initiative (jli) recently released a compendium of good practices on conducting meal in partnerships with international actors and local faith actors.13 meal refers to monitoring, evaluation, accountability, and learning. they had previously produced a guide to excellence in evidence for faith groups.14 the compendium identified some of the challenges in both local and international faith-partnerships, as well as the many ways data are collected and measured, not all of which are the same as traditional methods. data collection methods, whether qualitative or quantitative, may be a concept that is new to some faith communities. faith communities may also measure their success differently and may not factor in the concept of health promotion of a community, focusing instead on numbers of individual people that attend an event, numbers of faith commitments at the end of a service or month, and money donated to various causes. while this is valuable information, there are other factors to consider. those working in public health are focused on improving the overall health and well-being of communities, so a faithbased approach that integrates data collection and science with biblical values could be very important. such biblical values contain the sacred and social aspects of human nature that include social justice, mercy, inclusion, and connection.15 using different outcome measures and reliable tools may strengthen future research about not only individuals, but communities and public health outcomes.6 the advantages of having a formal collaborative are to assist local and international partners in overcoming perceived barriers to conducting research, lead to human flourishing, provide ways to meet the uns about:blank 10 meyer & paltzer july 2021. christian journal for global health 8(1) sustainable development goals, enhance donor engagement, and improve overall community wellbeing. the reality of globalization and international alliances is important in today’s healthcare models; so, having a faith-based partnership is a valuable addition in the realm of kingdom-focused research and global health. for those who would like more information about the ideas presented in this editorial, please feel free to contact the authors. the team would also appreciate any feedback and look forward to engaging with those who are interested. references 1. united nations. department of economic and social affairs – sustainable development [internet]. 2021. available from: https://sdgs.un.org/goals 2. paltzer j, taylor k. a cross-sectional study of faith-based global health organizations to assess the feasibility of a christian research collaborative. christ j global health 8(1). july 2021. https://doi.org/10.15566/cjgh.v8i1.491 3. brand d. barriers and facilitators of faith-based health programming within the african american church. j of cult divers. 2019; 12(1): 3-8. 4. asomugha cn, derose kp, lurie n. faith-based organizations, science, and the pursuit of health. j health care poor underserv. 2011;22(1):50-5. https://doi.org/10.1353/hpu.2011.0008 5. dehaven m, hunter i, wilder l, walton j, berry j. health programs in faith-based organizations: are they effective? am j public health. 2004;94:1030-6. https://doi.org/10.2105/ajph.94.6.1030 6. ferguson k, wu q, struijt-metz d, dyrness g. outcomes evaluation in faith-based social services: are we evaluating faith accurately? re on social work pract. 2006;16:1-13. https://doi.org/10.1177/1049731505283698 7. armstrong l, finny p. building research capacity in resource poor settings triumphs and challenges. national medical journal of india. sept/oct 2016 (5): 295-6 pmid: 28098088 8. oliver j. guest editor conclusion: research agenda-setting for faith and health in development – where to now? dev prac. 2017;27(5):775-81. http://dx.doi.org/10.1080/09614524.2017.1332164 9. casale m, flicker s, nixon s. fieldwork challenges: lessons learned from a north-south public health research partnership. health promo practice. 2011;12(5):734-43. https://doi.org/10.1177/1524839910369201 10. dykstra r, paltzer j. a review of faith-based holistic health models: mapping similarities and differences. christ j global health. 2020;7(2):120-31. https://doi.org/10.15566/cjgh.v7i2.311 11. ellison em. beyond the economics of burnout. ann intern med. 2019;170:807-8. https://doi.org/10.7326/m19-1191 12. paltzer j, jonker j. adaptation to virtual congregational peer recovery groups during covid-19. christian j global health. 2020;7(4):28-32. https://doi.org/10.15566/cjgh.v7i4.431 13. joint learning initiative (jli). joint learning initiative launches ‘compendium of good practices conducting meal in partnerships with international actors and local faith actors [internet].’ 2021. available from: https://jliflc.com/2021/01/jli-meal-compendium-of-goodpractices-conducting-meal-faith-partnerships/ 14. joint learning initiative (jli). guide to excellence in evidence for faith groups [internet]. https://jliflc.com/guide-excellence-evidence-faith-groups/ 15. rozier m. religion and public health: moral tradition as both problem and solution [internet]. j relig health. 2017;56(3):1052-63. available from: https://link.springer.com/article/10.1007/s10943-0170357-5 submitted 3 feb 2021, accepted 18 march 2021, published 30 july 2021 competing interests: none declared. correspondence: rebecca meyer, california baptist university, united states of america. rmeyer@calbaptist.edu jason paltzer, baylor university, usa jason_paltzer@baylor.edu about:blank https://doi.org/10.15566/cjgh.v8i1.491 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank https://jliflc.com/guide-excellence-evidence-faith-groups/ about:blank about:blank about:blank mailto:jason_paltzer@baylor.edu 11 meyer & paltzer july 2021. christian journal for global health 8(1) cite this article as: meyer r, paltzer j. benefits of a christian global health research collaborative. christ j glob health. july 2021; 8(1):8-11 https://doi.org/10.15566/cjgh.v8i1.503 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.15566/cjgh.v8i1.503 about:blank references book review nov 2014. christian journal for global health 1(2):95-97. religion, religious organisations and development – scrutinising religious perceptions and organisations. carol rakodi, ed. routledge, 2013 huw morgan a a mbchb, frcgp, cert med ed fhea, staff tutor and executive member of partnerships in international medical education (prime); emeritus director of gp training, bristol, uk this book is part of a series of development in practice books, and is actually a collection of separately authored papers that were previously published in a double issue of the journal development in practice. the editor, who is emeritus professor at birmingham (uk) university’s department of international development, has written a helpful introduction where she outlines the approach taken by the various authors and summarises the contributions of each. she is careful to say that any statements about the relationships between religion and development, of course, reflect the authors’ own positions and worldviews. in development studies and practice in particular, she says, religion is either neglected or taken as a given. when it is considered, it tends to be seen either as an obstacle to the achievement of development aims or as a missing ingredient, which if effectively harnessed will increase the effectiveness of development efforts. she acknowledges that, “religion has not declined in importance in most countries of the south,” and that faith based organisations (fbos) involved in development have increased in number and visibility. she also states: a number of other factors contribute to the often inappropriate and unhelpful ways in which western development actors’ new interest in religion was expressed, including their failure to recognise that their own worldview is shaped by christianity . . . (and) the tendency of much writing to seek to demonstrate that . . . religious values and beliefs and religious organisations can play positive roles in development thinking, changing attitudes and behaviour, and achieving development objectives. the research presented in this book, “tries to avoid these various pitfalls.” however it is clear throughout that the authors of the various papers and the editor herself frequently fail to see that their supposed “neutrality” is a worldview in itself that colours the way they interpret their data. the papers are grouped into four main themes considering different aspects of the interaction of religion and development. the first theme is, “religion, well-being and inequality.” it includes studies from india, kenya and pakistan, considering how hindus, pentecostal christians, and muslims interpret their religious beliefs and explore the implication of those interpretations for ideas about identity, well-being, right social ordering, and the transmission of values and education. one interesting conclusion from the kenyan study is that engagement with the “prosperity gospel” advocated by some american missionaries, “is almost impossible to achieve in the context of kibera (a massive slum settlement in nairobi), where residents are concerned above all with survival.” the editor comments that these studies demonstrate: 96 morgan nov 2014. christian journal for global health 1(2):95-97. that people often engage in religious practices and adhere to apparently religious norms because these are part of the fabric of society . . . as a result the idea that it is possible to tap into religious values and beliefs to influence attitudes and behaviour . . . has to be critically assessed. this sounds suspiciously like a challenge to the claims of religion from someone who is uncomfortable with them. the second theme is, “ngos in development: are religious organisations distinctive?” these begin with a us based author suggesting that to approach this question properly requires the analysis of a religion-based ngo’s activity rather than the demonstration of it. the following three papers look at faith based ngos in nigeria, tanzania, and pakistan. in nigeria it proved relatively easy for the researchers to compare fbos with secular ngos, as many of both are involved with hiv/aids related activities in particular. the author concludes that fbos are more commonly associated with wide reach, a high degree of legitimacy, and moral authority, but that the way faith is manifested in them is highly dependent on their context (e.g., christian and secular organisations find it hard to operate in muslim-dominated states). the paper from tanzania warns of the need to consider how funding and externally driven agendas contribute to the strengths and weaknesses of both ngos and fbos. the pakistan study comments on the difficulty of assessing the distinctive influence of religion in a country where 90% of the population are muslim, and the need to distinguish between those organisations that see development activities as a way to bolster the faith of muslims and convert others, and those that link aid to justice and involvement in militancy. the third theme is, “religious organisations: influencing, responding to or resisting social change?” the first paper examines the interaction of religious organisations with the state in asiapacific countries, concluding that some fbos are active in all and some play positive roles in meeting welfare and development needs, but some are not active or ineffective and contribute to ethnic/social division and tension. the second study from tanzania and nigeria is a review of a number of pilot projects looking at how religious organisations gathered data on the outcome of government poverty reduction policies, concluding that there was no evidence that they were better placed than others to do this. the final paper examined how the women’s movement in nigeria interacted with religious ideas and groups during two campaigns for reform. this showed that the nature of the content proposed was key to acceptability or not by christian and muslim groups, and that attitudes varied between and within faith groupings. the final set of research papers considers, “religious service providers and the poor: motivations and methods.” two of these focus on the health sector and one on education. the first of the set questions the statement that fbos contribute between 30% and 70% of healthcare provision in sub-saharan africa, which they say dates back to the 1960’s. they say that evidence is lacking to substantiate the reality of this claim; however, this is surely a questionable statement as the contribution of fbos was well-documented in a who report in 2006. 1 the second focuses specifically on christian health services, seeking to assess whether the decline in their traditional funding sources has compromised their avowed intention of serving the poor. based on information from 13 countries, the authors confirm that there has been a real decline in funding and that the providers concerned are responding to this by charging user fees and working more closely with governments so they can access health sector budgets. however, the real decline in funding has reduced the capacity of some christian fbos to provide free services in remote rural areas and amongst poor urban neighbourhoods. the final paper looks at religious education providers (christian, hindu, and muslim) in two cities in india, concluding that their teaching, whilst encouraging philanthropy to the “poor other,” did not challenge 97 morgan nov 2014. christian journal for global health 1(2):95-97. the underlying causes of inequality or seek to empower the poor recipients of their charity. the book ends with, “practical notes: fbos putting religion into practice.” these are not research papers but are written by authors who believe that the organisations and programmes they describe are achieving better development because of their religious backgrounds. there are contributions from three (buddhist, muslim, and christian) authors describing how the faith underpinnings of the projects they outline have contributed to their effectiveness. the editor concludes: the complexity of the social phenomena being considered, their inter-relatedness and the multi-faceted nature of the links between them preclude . . . overarching conclusions. nevertheless the papers . . . demonstrate that it is possible and illuminating to subject religious perceptions and organisations to respectful but objective scrutiny. those reading this book in the hope of seeking clear evidence of the benefits of christian (or indeed any other) faith on development will be largely disappointed. the papers, even when written by christians, are all careful to adhere to the “objective” secular agenda presumably required by the journal. this reviewer couldn’t help wondering whether this rigorous editorial stance was in part determined by the needs of academic acceptability within the development sector literature, and reflecting that this is in fact a faith position as much as any specifically christian or other major worldview. the papers vary in their clarity and fluency, but generally, as might be expected from a collection of this nature, they are mostly not easy reading and of probably limited interest outside the academic development studies community. nevertheless, there are some significant and useful conclusions, a few of which i have attempted to summarise above. it is, however, unlikely that this book will be very useful to any christian groups working globally in health sector development, and its cost will surely be a significant discouragement to prospective purchasers. reference 1. african religious health assets program. appreciating assets: the contribution of religion to universal access in africa: mapping, understanding, translating and engaging religious health assets in zambia and lesotho in support of universal access to hiv/aids treatment, care and prevention. geneva: 2006. [cited 2014 sept 30] available from: http://www.arhap.uct.ac.za/pub_who2006.php . competing interests: none declared. correspondence: dr. huw morgan. prime, uk. jhcmorgan@gmail.com cite this article as: morgan h. religion, religious organisations and development – scrutinising religious perceptions and organisations. carol rakodi, ed. routledge 2014. christian journal for global health (nov 2014), 1(2):95-97. http://dx.doi.org/10.15566/cjgh.v1i2.41 © morgan h this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.arhap.uct.ac.za/pub_who2006.php mailto:jhcmorgan@gmail.com http://dx.doi.org/10.15566/cjgh.v1i2.41 http://creativecommons.org/licenses/by/4.0/ commentary june 2020. christian journal for global health 7(2) the role of a mission organization in building a sustainable government hospital in southern ethiopia bernt lindtjørn a a md, phd, professor, centre for international health, university of bergen, norway and hawassa university in southern ethiopia abstract in 1950, the norwegian lutheran mission (nlm) began holistic mission work, including health work in yirga alem in sidama in southern ethiopia. the hospital, which had served as a military hospital during the italian war (1936-41), became a mission hospital. this paper presents some historical developments of a government hospital managed by a mission organization, the story of its medical work, and how the nlm functioned under varying political regimes and societal environments in southern ethiopia. at the same time, societal changes occurring in norway with the weakening of mission organizations and the norwegian government’s policy that influenced external financial support for the hospital are presented and discussed. the key message of the paper is that it is possible under challenging external politics for a mission organization to collaborate with government entities even with difficult regimes. in the area of yirga alem hospital, this was done without compromising the basics of mission, but rather readjusting comparative strategies while ensuring sustainability and local ownership. the uniqueness of this work is that it explores a mission, i.e., the nlm, which developed health work within the context of a nationally owned health service. moreover, this fruitful collaboration persists until this day and previous missionaries still work to strengthen public health programs that target such major areas as tuberculosis and hiv control, maternal health, childcare, and nutrition. key words: mission history, mission hospital, sustainability, ethiopia introduction this article presents a summary of the 70 year history of the yirga alem hospital in southern ethiopia. in 1950, the norwegian lutheran mission (nlm) started health work in the town of yirga alem. the nlm’s vision, also in line with the lausanne statement, as written in its constitution, focuses on evangelization to spread the conviction that jesus christ died for our sins and forgives the sins of all who repent and believe in him. the results of evangelism include obedience to christ, and it comprises social responsibility (for example, 134 lindtjørn june 2020. christian journal for global health 7(2) health work) as one of the principal aims of evangelism and the belief that social responsibility can serve as a bridge to evangelism.1 the nlm’s goal was, and remains, to establish local churches.2 its practice is to support institutions, whether church-owned or in cooperation with governments, to develop sustainable work within a national context. within such a context, the nlm’s service has, to a large extent, followed international priority settings with health care that include the setup of basic health services, primary health care (phc), and sustainable development goals. this paper presents some historical developments of a government hospital managed by a mission organization, the story of its medical work, and how the nlm functioned under varying political regimes and societal environments in southern ethiopia. in broad terms, this is an historical description of the development of yirga alem hospital and some analysis of challenges and success factors. developments in ethiopia during the period of this study include what the ethiopianist and historian, john markakis, describes as periods of nation building during the imperial period (up to 1974), communist (derg) regime, (1974 – 1991), and nation building after 1991 that was based on ethnic federalism. this was compounded by multiple conflicts between the central government and peripheral groups.3 at the same time, societal changes occurring in norway, which included both the weakening of mission organizations and the norwegian government’s policy that influenced external financial support for the hospital, are presented and discussed. the uniqueness of this work is that it explores a mission, i.e., the nlm, which developed health work within the context of a nationally owned health service. development of the yirga alem hospital in 1948, the norwegian lutheran mission (nlm) began work in ethiopia. the organization had been expelled from china, where it had long been running hospitals, and two experienced physicians were consequently transferred from china to ethiopia. during an audience with the nlm’s general secretary, tormod vågen, emperor haile selassie requested that the nlm work in yirga alem. his majesty informed the nlm that he, prior to becoming emperor, had been the governor of sidamo and had resided in yirga alem. he told the nlm about a military hospital in the town that had been out of operation for some time. he wanted this to be a civil hospital, and asked the mission to run the hospital and provide norwegian doctors and nurses. the ensuing negotiations between the ethiopian ministry of public health (mph) and the nlm resulted in an agreement concerning the management of the yirga alem hospital (yah) originally constructed by the italians during the late 1930s. it was clear that new construction was unnecessary, and actual health work could start fairly soon. the nlm took over the hospital in march 1950, and it was staffed with just one missionary doctor and two nurses. according to the agreement between the nlm and the mph, the doctor at the yah was also the medical officer of sidamo province. consequently, the nlm was responsible for health planning, supervision of government health institutions in the region, and ensuring that the government clinics were supplied with needed drugs.4 the facilities at the yah were very basic at that time. for example, there was no electricity, and water was laboriously brought to the hospital from the nearby gidabo river on donkeys. moreover, in the 1950s, the number of hospital beds was 18, and only a few thousand outpatients were treated annually. however, services increased rapidly, and it became necessary to train staff and build additional 135 lindtjørn june 2020. christian journal for global health 7(2) housing. after a few years, the number of beds had risen to 60, and, in 1955, formal training of auxiliary nursing staff began. in 1957, the government terminated the nlm’s engagement at the yah. as a consequence, the institution was without physicians and other qualified personnel for a period of one and a half years.5 the termination of work in yirga alem occurred at a time when substantial tensions existed between the newly started nlm-supported evangelical congregations and the long-established orthodox church in sidamo.6 these evangelical congregations later became part of the ethiopian evangelical church, mekane yesus. in 1963, the nlm obtained funding from the norwegian agency for development aid (norad) for construction of a new hospital in yirga alem. king olav v of norway honored the hospital by placing its foundation stone in 1966, and it was inaugurated by his majesty haile selassie i on march 14, 1968. the norwegian minister of foreign affairs handed over the new and fully equipped hospital to the ministry of health (moh) as a gift from the norwegian people to the ethiopian people. the name was also changed to the sidamo provincial hospital. the modern hospital had 120 beds. the old hospital, with its equipment, was left to serve as a health centre for yirga alem.4 the nlm was given the responsibility of the management and operation of the new hospital. this was based on an agreement between the moh and the nlm, and this agreement was renewed every three years up to 2011. the ethiopian revolution: change and conflicts in 1974, the change of political system in ethiopia profoundly altered the running of the hospital. during the first years of the derg communist regime, unrest among hospital workers resulted in adjustments of the cooperation agreement between the moh and the nlm, and national staff were recognized as government workers and received their salaries directly from the government. they have since worked under the rules and regulations of the national central personnel agency. labor proclamation no. 64 of 1975 superseded the imperial labor relations proclamation and contained provisions of socialist labor legislation. the nlm, thus, had to manage the daily operations of the hospital according to these new requirements. this meant, among several other major impacts, that it became difficult to discharge workers. in this new arrangement, workers not fit to work at the hospital, for example, due to disciplinary issues, had to be transferred to other government institutions. it also changed the way the hospital recruited new workers as they now had to be recruited directly by the moh. it is important to note that the nlm came from a country where labor unions were an integral part of society’s way of dealing with workers’ issues; whereas, this was not the case for other mission-run hospitals in southern ethiopia. this led to the expulsion of american-based organizations from ethiopia, while scandinavian-supported work remained. another dimension to this conflict was the hostile environment that existed between the soviet-associated derg regime and the u.s. furthermore, the communists were generally hostile towards evangelical churches, and evangelical christians were persecuted during the communist period.7 one area of value conflict at the yirga alem hospital concerned the role of evangelical work at the hospital.8 the hospital, through the nlm, had since its inception employed an evangelist to administer the morning devotions to patients and workers. the local government, however, demanded that other denominations, including the ethiopian orthodox church, also be allowed to do the same and that the devotions should not take place during working hours. the nlm did not object to this. indeed, this work of the evangelist has continued until now, even if the hospital is currently run without a mission or external support. 136 lindtjørn june 2020. christian journal for global health 7(2) another, and more serious, confrontation occurred when the communist regime revised its curriculum for the health assistant (auxiliary nurse) training school, and demanded that a special emphasis on, and education in, marxism-leninism should be implemented. although the nlm staff at the hospital accepted this directive, the nlm board in norway decided to close the school. however, after two years, the school was reopened and teaching of marxism-leninism was included. in addition, the nlm continued devotions, but outside of school hours. the rationale behind the nlm’s decision, based upon advice from ethiopian evangelical church leaders and hospital staff, was the belief that although students at the auxiliary nursing school would attend compulsory classes in marxist-leninist ideology, they would not follow this teaching due to the great opposition to the communist regime that existed in the country. during the derg communist period, work at the hospital expanded to 170 national and expatriate workers, which now included three doctors and 6-9 nurses. the main work at the hospital comprised inpatient and outpatient services, with active operative functions serving a large part of the population in southern ethiopia.9 in addition, more primary health facilities were built in the catchment area of the hospital. consequently, the share of referred patients increased. the hospital had, for years, accepted emergency cases from outside of the defined catchment area, resulting in a high workload for the staff and sometimes overcrowding of the hospital. furthermore, poor patients were accepted for treatment, and the hospital allocated a substantial part of its budget for such patients.10 the agreement between the moh and the nlm put the hospital in a semi-autonomous position. for example, pharmaceuticals could be imported during periods of severe drug shortages in the country. in this way, patients were guaranteed adequate attention and treatment without undue delay, and much emphasis was placed on securing essential pharmaceuticals.11 diagnostic facilities and treatment options also improved gradually. for example, in 1985, a microbiology laboratory, including one that focused on tuberculosis culture, was added, and screening for hiv began in 1987.12,13 later, the hospital started its own production of intravenous fluids based on a close collaboration with the st. luke foundation in moshi in tanzania. in 1981, a blood bank was established and was later expanded through collaboration and funding from the ethiopian red cross society that has since supported the hospital in its management and to maintenance of a high quality at the blood bank. ultrasonography examinations started in 1987, and endoscopy examinations by means of flexible endoscopes began in 1992. indeed, the personnel who started these endoscopy examinations currently teach post-graduate courses in ethiopia on endoscopic methods.14,15 with support from the christoffel blinden mission, eye examinations and treatment have been offered since 1976. a facility that makes eyeglasses was also added. moreover, since 2000, when a new eye unit was constructed, ethiopian ophthalmologists staffed by the moh perform over 1200 cataract operations per year. with norad support and in close collaboration with the addis ababa fistula hospital (also known as "hamlin fistula hospital") a local unit was built to treat obstetric fistula. tuberculosis patients have always been treated free-of-charge at the hospital. however, a review in 1965 revealed that the treatment results were poor, mainly due to non-adherence to treatment.16 the challenge of a chronic disease that demanded long term treatment was that it often conflicted with traditional sidama beliefs concerning disease causation (see also vecchiato).17 starting in 1992, a tuberculosis control program (with the first use of direct observed treatment, short course [dots] in ethiopia), covering a defined area of sidama with approximately one million people, was organized through the hospital. since 1998, this has been integrated with the zonal health office as part of the national tuberculosis control program.13,18-24 research activities that were operational and aimed to improve services and enhance the capacity 137 lindtjørn june 2020. christian journal for global health 7(2) of hospital staff, resulted in numerous publications recognized nationally and internationally. some examples of this research include improved management of uterus rupture,25 occurrence of resistant strains of helicobacter pylori (the cause of peptic ulcer),26 identification of major risk factors for deaths among children with diarrheal diseases,27 effects of poverty on hospital admissions, and description of major cancer types in southern ethiopia.9,28,29 training of staff training of staff of all categories, including janitorial staff, laundry workers, and professional staff, was essential in the early years of the hospital since trained and skilled workers were scarce in the post-war years. already, in 1955, formalized training of auxiliary nurses (in ethiopia initially called dressers and health assistants) was implemented, as was training of nurses in 1990. with norad funds, new buildings were also constructed, and it became a well-equipped and efficient teaching institution. since 2013, the yah has also served as a medical school. in-service training and teaching were assigned a high priority, and several staff and technical personnel were sent abroad on scholarships and to engage in postgraduate studies. since 1985, other important changes occurred. ethiopian nurses, general practitioners, and specialists were assigned to the hospital in increasing numbers. by mid-1997, all positions in the hospital were held by nationals. in july 1998, 17 ethiopian physicians worked at the hospital. of these, six had specialist qualifications, and personnel resources in southern ethiopia gradually became wholly sufficient to sustain the medical activities of the yah. administration and management in the initial years of the nlm/moh cooperation, the organizational structure was simple and easily managed by an expatriate hospital director (a physician) and an expatriate nurse. the dominant control by expatriates was the natural consequence of the expectation that the nlm should manage the hospital because skilled ethiopian staff were not available after the disruption resultant from the fascist occupation. however, the significance of the hospital administrator increased when the staff, in the 1970s, were transferred to the moh payroll and were required to adhere to moh employment regulations. this also led to the inclusion of a national administrator employed by the moh. in the 1970s, a hospital board was also established, composed of members of the provincial health office and representatives from the nlm and the ethiopian evangelical church, mekane yesus (eecmy).10 its mandate was to provide guidance to management, review plans, and approve budgets. in 1997, the board was extended to include representatives from the zonal health bureau, the zonal council, and a member elected by the staff. the board was also given the authority to make certain decisions formerly under the purview of the nlm administration. the necessity for participation in management, as well as nationalization of leading positions, became increasingly evident, as was discussed in an evaluation report in 1984.10 as a result, handing over leadership to nationals, restructuring of logistics, and strengthening of the board became key priorities. in 1995, the nlm decided to negotiate with moh on nlm withdrawal from management responsibility as of january 1, 1999. the handing over of full management and financial responsibility to the government was a logical result of rapid development in the area of manpower in ethiopia, reflected in the fact that the hospital was assigned a number of ethiopian physicians and specialists. finances most of the financial input to the hospitals came from patient fees and nlm sources. however, since 1961, the government granted the hospital a lump sum for the treatment of poor patients. capital investment funding was provided by norad. over the years, a model was developed concerning how to 138 lindtjørn june 2020. christian journal for global health 7(2) finance a sustainable hospital. with the government paying salaries to the hospital staff, and with the development of a new financial structure to take care of patient fees, a model was created in which hospital expenses were covered by government salaries, and operational costs were paid with patient fees. this scheme was subsequently evaluated by the ministry of health, and today forms the basis of a new healthcare financing law for ethiopia.30 since then, all ethiopian hospitals and health centers operate under a modified version of this model. basic health services, primary health care, millennium development goals, and sustainable development goals over the period of the history of the yirga alem hospital (yah), international policies regarding the place that hospitals should occupy in health systems evolved. initially, the primary aim was to bring treatment to needy people in southern ethiopia. in the early 1960s, the concept was to provide basic health services.31 the yah was an active participant in such work, and its physicians and nurses regularly visited nearby and remote clinics. in addition, the prison in yirga alem was visited regularly, and treatment and preventive measures were carried out, especially during times of recurrent fever outbreaks.8 from 1961 to 1967, the nlm assigned a physician to cover the position of provincial medical officer of health for sidamo province.5 the moh, therefore, made an effort to strengthen the province health offices professionally in order to guide and supervise the new health centers. the nlm also took part in large scale vaccination programs, examples of which included campaigns to treat smallpox and cholera.5 this basic health care model continued until the early 1980s, when the world health organization (who) started to promote primary health care (phc).32 with the introduction of phc, norad, an important financial contributor to the hospital, began to question the role of the hospital and other nlm-related health work in the overall structure of public health work in southern ethiopia. the expatriate doctors at the hospital did not fully understand the then-dominant norad view that hospital care was not a public health priority.10 later, and with the change of who policies after the end of the cold war, as well as the findings of several studies on the global burden of diseases, these views gradually changed.33 unfortunately, many of the missionary health personnel at the hospital felt that irreparable harm had been done to essential hospital services in the name of phc. value conflicts: traditional healthcare, communism, and nationalism the nlm’s aim was to provide holistic care to the population.4 this was also in accordance with the eecmy’s view that emphasized the inherent value of man, who was deemed to possess both a spiritual and humanistic aspect.34 the general secretary of eecmy, gudina tumsa, assassinated by the derg regime in 1980, contributed to the eecmy’s holistic paradigm of the undivided human reality. tumsa’s concept of holism was grounded in the african’s view of life in its totality and led to influential development work in the 1972 paper, “on the interrelation between the proclamation of the gospel and human development.”35 mission, church, and traditional medicine during the early years of health work, this mission view, also with the vision of converting nonchristians to the protestant christian faith, collided both with traditional belief systems, as well as that of the ethiopian orthodox church. subsequently, during the communist period, conflicts arose with the government’s ideology, which favored “scientific socialism.”7 as well described by donald donham from southern ethiopia, conflicts at the hospital, thus, centered around the following three dimensions: missionary-associated protestant christianity, traditional societal values, and “modernity,” as expressed during the communist regime.7 139 lindtjørn june 2020. christian journal for global health 7(2) in ethiopia, both good health and sickness possess a religious dimension. although god may be felt to be at some distance from ordinary people, it is god who is the provider of good health. health is understood as a balance between the physiological, spiritual, cosmic, ecological, and social forces that surround people.17 good health may also be achieved by participating in different forms of rituals. for example, the protective spirits of wuqabi (amhara) and ayana (sidama and oromo) safeguard the individual and society. the causes of illness are frequently ascribed to events that surround the illness, characteristics of the patient, the elders’ beliefs about sickness, and the social status of the healer, which can include such factors as age, gender, religion, and education. based on such background factors, the illness may be concluded to have a natural or magico-religious origin. indeed, some characterize ethiopian ethno-medicine as primarily religious, while others contend that the religious and natural explanations of illness are closely interrelated.36 when the methods of treatment are religious, the healer may be perceived as an actor between man and the spiritual world. this is manifested by sorcery (kilancho sidama) and exorcism (kallitcha sidama). the way that the healers think and act regarding the causes of illnesses and their treatment of them is influenced by his or her religious background. in ethiopia, many patients use traditional medicine, but this was gradually reduced with the expansion of protestant christianity and improved education.6,17,37 in ethiopia, infectious diseases and malnutrition constitute the main health problems. less than 60% of the population has access to modern medicine and, even today, relatively few utilize it effectively.38 because of the abovedescribed established tradition, it has taken a long period of time for people to accept alternative ways of treating diseases. therefore, when the yah was started, people did not trust modern medicine, as they did not believe that it provided better cures than their traditional ways of healing. for example, this was observed in the treatment of tuberculosis at yah. in 1965, as mentioned previously, the treatment results were very poor, mainly attributable to non-adherence to treatment,16 and the disease had a religious dimension.17 sixty years later, however, after the hospital began implementing communitybased dots, treatment outcomes improved substantially.22,39 healthcare under the communist regime health care during the haile selassie period (1916 – 1974) was characterized by extreme poverty and inequality, as well as the slow development of basic health services.40 unfortunately, the situation did not improve during the subsequent communist regime. in the 1980s, ethiopia had a population of approximately 45 million people, comprised a stagnant and agriculture-based economy, and was one of the world’s poorest nations. moreover, 70% of children were mildly-to-severely malnourished, 26% of children born alive died before the age of five, and life expectancy was just 41 years.41 after the 1974 revolution, the communist government nationalized land and created 20,000 peasant associations and kebeles, units of local government. the government set ambitious goals for development in all sectors, including health. however, famine, periods with severe malnutrition and food shortages, forced resettlement programs, and civil war prevented any meaningful progress.4244 the government’s approach to health care was based on an emphasis on primary health care and expansion of rural health services, but the government allocated only 3.5% of the national budget to these purposes. attrition among health workers was also high due to a lack of ministerial support. indeed, health care was often carried out without proper authorizations, and, in rural areas, one physician served between 200,000 and 300,000 people.41 after the overthrow of the communist regime in 1991, ethiopia embarked on a new structure to govern the country based on ethnic federalism. after about 10 years of instability, large reforms within the health sector started to take form in the early 2000s. 140 lindtjørn june 2020. christian journal for global health 7(2) health care was decentralized and based on a health extension system with paid and trained health workers in each kebele. thousands of health posts and health centers were constructed, and key indicators of the development sustainable goals, such as under-five mortality, were met, while access to basic health services was increased.45,46 after 1991, the hospital again experienced a certain degree of turmoil. the main issue was that the local administrators insisted that all positions of leadership at the hospital be occupied by the local ethnic group (i.e., the sidama people). the nlm had, for many years, trained ethiopian staff for positions of leadership in line with the evaluation report of 1984.10 such a sudden change in policy made the previous capacity-building efforts superfluous, and the nlm contended that people should be selected due to their merit and not their ethnicity. however, compromises were gradually reached in which professional staff were recruited irrespective of ethnicity, and the top management of the hospital came from the local ethnic group and were acceptable to the political leadership in the area. in ensuing years, however, many missionary health personnel left the hospital, and the mission organization faced increasing difficulties in recruiting experienced personnel. the mission hospital in a national and local socio-political context working in an area, such as sidama, means that medical work has to take local, regional, and national developments in social and political dimensions into careful consideration. these were events that occurred outside of the control of a mission organization, but both directly and indirectly influenced how the hospital functioned. while these changes took place in ethiopia, changes also occurred within the norwegian lutheran mission (nlm) in norway. the organization faced increasing challenges in recruiting medical staff for such great work. this challenge was worsened by the fact that the leadership of the hospital was ethiopian, and norwegian personnel were increasingly reluctant to work under the leadership of the ministry of health (moh). the present paper has briefly addressed some of the challenges that the nlm encountered in managing the hospital during the imperial, communist, and federal state nation building periods. a common theme during these periods, however, was sidama nationalism. the sidama people live in south-central ethiopia. in its long history, they lived and developed in frequent conflict and competition with neighboring groups, mainly because of competition for farming land and pasture.47 they were, to a large extent, independent, but functioned under the influence of the semitic kings of central and northern ethiopia. it was when emperor menelik ii conquered sidama in the 1890s that conflicts between the sidama people and mengist (a term used to refer to the central ethiopian government) first escalated. the right to use land is a key element in sidama culture, and with the establishment of a nobility-dominated feudal system governing the right to use land, tensions rose markedly, beginning with menelik ii and continuing with emperor haile selassie i. when italy invaded ethiopia in 1936, some sidama groups supported the italian invasion because their original farming land was given back to the indigenous sidama people. however, after a few years, the sidama became active in the opposition movement against the fascist mussolini regime. when ethiopia again took control of the area in 1941, some of the resistance groups (faano) refused to accept the return of the privilege of landlords after italian withdrawal in sidama and did not support the mengist. the reasons for this were complex, but the right to use land in a nobilitydriven feudal system with heavy taxation constituted a key factor in opposition to the central government.47 again, when the communist regime (derg) assumed power in 1974, many in sidama initially supported derg. however, after a few years with major developments, such as collectivization and villagization (forced movement of large groups of people to villages) and forced conscription of 141 lindtjørn june 2020. christian journal for global health 7(2) young men for military service for the war in eritrea, the sidama established a liberation movement in the late 1970s. in the following years, three subprovinces in the sidama province became civil-war zones. although the hospital was not directly affected by the civil war, many civilian and military casualties were treated at the surgical ward, and many patients with malnutrition and tuberculosis were taken care of at the yah. the nlm’s work in the area led to a rapid increase in the number of protestant christians.34 the national population census in 2007 shows that approximately 50% of the population belonged to a protestant church, and recent data indicate that this may now be as high as 85%.48,49 one contributing factor to this rapid rate of conversion was that the evangelical churches were seen as a viable alternative to the old traditional religious system, and also a means of distancing themselves from the orthodox church that was associated with the nobility and feudal system of the emperors.6 the nlm, through its evangelistic and development work, mainly in education and health, thus became an ancillary agent of political change with indirect support of a major ethnic movement, in this case, sidama nationalism.50 since 1991, the sidama nationalistic struggle has aimed to attain greater autonomy with a fairer representation within a federal state structure in ethiopia. a consequence of this was that both the national and the local government wanted all positions of leadership at the hospital to be given to people of the dominant ethnic group. consequently, as the nlm had been one of the indirect supporters of greater dignity for the sidama, this led to a major crisis in the government and nlm collaboration from 1992-1995. although the nlm had developed a national leadership at the hospital, that included staff from diverse ethnic backgrounds, these potential leaders were no longer permitted to assume positions of administrative leadership. nlm and changes in norway the development of a mission hospital does not occur in a vacuum.51 it is also heavily dependent on, and is influenced by, the mission organization, in this case the nlm of norway. since the mid-1960s, the nlm received norwegian governmental support for its development program. the first large project to receive such support was the yah. in 1984, norwegian government support for the running of nlm’s health work in ethiopia was evaluated, and it was concluded that more emphasis should be placed on strengthening local capacity at the institutions, and even more so at hospitals that were managed in collaboration with the moh.10 in the following years, the aim of norwegian support became to hand over the hospital to the government and reduce the influence of norwegian expatriate staff. indeed, from 1995-97, the nlm withdrew most of its staff from the hospital. however, as the handover had not been carried out in a manner that would make the hospital sustainable, a new chapter in the development of the hospital began. this time, the hospital was managed by national staff, and norwegian professionals and financial support were gradually reduced over a period of 16 years. why did the nlm stop working at the hospital? the ownership of the hospital belonged to ethiopia, while the nlm managed the hospital for the government of ethiopia. sometimes, these facts created misunderstandings in that missionaries believed that the yah was a traditional mission-run hospital. when the nlm withdrew from the hospital, it was never the intention of the moh that the nlm should leave. instead, they wanted the collaboration to continue under more national leadership. unfortunately, this model was a challenge to implement and led to a cessation of the recruitment of expatriate personnel. in addition, the nlm did not want to continue financing such work. instead they wished to work more in other unreached areas, especially in the muslim world. although 142 lindtjørn june 2020. christian journal for global health 7(2) their intention could have been to continue mission health work, they were not to do it on a large scale as was the case in yirga alem. the withdrawal of nlm also posed a theological dilemma. specifically, the start of the work occurred with a specific invitation by the government, followed by the gudina tumsa and eecmy’s strong focus on holistic church service and the nlm’s acceptance of the lausanne declaration of 1982, while the main reason for the withdrawal was purely evangelistic. indeed, the nlm’s focus changed to a drive to reach unreached peoples and less to people in need of health services. post-2012: current status presently, the yirga alem hospital functions well as a hospital for the many people who live in yirga alem and its environs. basic hospital services continue, and the hospital has provided continuous services in the fields of surgery, internal medicine, gynecology, and obstetrics, as well as in pediatric units without any interruption of services. it is the case that some of the more specialized functions, such as endoscopy and microbiology, no longer exist. however, some new functions, such as a neonatal unit, have been established. this is an example of a successful collaboration between a traditional mission organization and a government. over many decades, the hospital has helped many hundreds of thousands of patients and established itself as a wellfunctioning hospital. the main criterion for success has also been achieved in that a government-owned hospital has expanded and continues as a hospital providing essential services to the population in its catchment area. although an evangelist still works at the hospital, the mission organization that started this work is no longer capable of running such health work primarily due to changes in its home country. this fruitful collaboration has persisted in other forms. previous missionaries still work with institutions in southern ethiopia, mainly universities, to strengthen public health programs, including those that target tuberculosis and hiv control, maternal health, childcare, and nutrition. the aim of this latter work is to continue strengthen quality-of-care, as well as teaching and research capacity, for improving health policy within the area. about myself and use of unpublished sources i am a professor in international health at the university of bergen in norway and at hawassa university in southern ethiopia. i still work in the sidama area, including the yah. by training, i am a medical doctor and surgeon with long and extensive experience in hospital work, research, disease control, institutional development, research management, and teaching and work in developing countries. my professional profile includes surgery in developing countries, population studies, health services research, maternal and child health, and control of tuberculosis, hiv and aids, malaria, and malnutrition. for almost 40 years i was a missionary doctor with the nlm, and from 1997 – 2015 i led the organization’s work at the yah. in this paper, i have documented the large political changes that occurred through publicly available references. some of the information is, however, found in the “grey literature" that i obtained through individual communications both orally and in writing. they are documented in my personal archive. an earlier version of this article has been reviewed by colleagues who worked at the hospital over the last 50 years. i also discussed the article with ethiopians well knowledgeable about developments in ethiopia, particularly in sidama. i am grateful for their comments and corrections. 143 lindtjørn june 2020. christian journal for global health 7(2) figure 1 the gate to yirga alem hospital the gate to yirga alem hospital defining the ownership of the yah: in sidamu afoo, amharic, and in english. the colors on the gate are those of the sidama national flag. on the left side is the bible verse that has been on the portal since the start of the hospital: the lord will keep watch over your coming in, from this time and forever (psa 121:8). references 1. lausanne committee for world evangelization. evangelism and social responsibility: an evangelical commitment [internet] [lop 21]. lausanne committee for world evangelization/world evangelical fellowship. 1982. available from: https://www.lausanne.org/content/lop/lop-21 2. norwegian lutheran mission. constitution of nlm oslo [internet]. nlm. 2018 [cited 2020 feb 5]. available from: https://www.nlm.no/globalassets/dokumenter-ogfiler/formelle-dokumenter/grunnregler-ogstrategidokumenter/constitution-of-nlm-approved-in2018.pdf 3. markakis j. ethiopia: the last two frontiers [reprint]. woodbridge: boydell & brewer 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http://etd.aau.edu.et/bitstream/handle/123456789/4511/markos%20tekle.pdf?sequence=1&isallowed=y http://dx.doi.org/10.1093/cdn/nzz051.p04-040-19 http://catalog.ihsn.org/index.php/catalog/3583 146 lindtjørn june 2020. christian journal for global health 7(2) 50. haile g, lande a, rubenson s. the missionary factor in ethiopia: papers from a symposium on the impact of european missions on ethiopian society. lund university, august 1996. peter lang pub inc; 1998. 51. møgedal s, bergh m. challenges, issues and trends in health care and the church's mission. int rev mission. 1994;83(329):257-76. pubmed pmid: 1469. peer reviewed: submitted 27 feb 2020, accepted 4 may 2020, published 23 june 2020 competing interests: none declared. correspondence: bernt lindtjørn, mjølkeråen, norway. bernt.lindtjorn@uib.no cite this article as: lindtjørn b. the role of a mission organization in building a sustainable government hospital in southern ethiopia. christian journal for global health. jun 2020; 7(2):133146. https://doi.org/10.15566/cjgh.v7i2.351 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:bernt.lindtjorn@uib.no https://doi.org/10.15566/cjgh.v7i2.351 http://creativecommons.org/licenses/by/4.0/ book review dec 2021. christian journal for global health 8(2) all creation groans: toward a theology of disease and global health, edited by daniel w. o'neill and beth snodderly, pickwick 2021 william newbrandera amha, mae, phd, international public health & health economics consultant, usa introduction of the many problems of this world, pandemics and disease are a major cause of humankind’s misery. this fact is highlighted by the current covid-19 pandemic and the death and destruction it has inflicted on the world across all populations and countries. the common approach of the global health community has been to focus on science and medicine to deal with the corrupted creation that has been afflicted with disease and its many ramifications on the human body. disease impacts individuals, families, and communities, not just physically, but also spiritually, socially, psychologically, and ecologically. the effects are felt on an individual and collective basis. in seeking solutions, the global health community has often been blind to spiritual elements having any relevance in identifying root causes. our hope, as christians in a fallen world, rests in god having every intention of healing this world from the ill forces brought about by evil through redemption, both spiritual and physical. the absence of solutions presents an opportunity and obligation for the church and christians to be involved in alleviating disease and promoting health, as god intended. but we need a new theological element to our perspective in order to see how fighting disease and promoting health is part of our spiritual responsibility in carrying out god’s plans for reclaiming all of creation. this challenge is not intended as a guilt-laden obligation for christians in global health, but rather, it is as an opportunity to partner with god, other christians, and the church in redeeming and reclaiming the creation, including man, to what god wills and what he will bring about in the “new earth” to come. to this end, the book “all creation groans: toward a theology of disease and global health” makes a wonderful contribution to addressing our wellknown global health issues by seeking out solutions with an inclusive theological element. its editors, o’neill and snodderly, state: “there is an increasing call in the christian community to promote global health, as an indispensable part of glorifying god, by thoughtful application of evidence-based and biblically-based approaches for new levels of innovation and service . . .”(p. xxvii). summary the metanarrative of the book provides the grounds for a deeper, thoughtful re-enunciation by christians of a missiological agenda to bring healing and wholeness to those afflicted by disease. the book is quite ambitious in addressing the issue of christians’ active involvement in lessening and reversing the mayhem caused by disease and suffering in god’s creation from a variety of perspectives: theological, scientific, medical research, philosophical, historical, and regional. this is accomplished by tapping an impressive array 42 newbrander dec 2021. christian journal for global health 8(2) of 16 experts to pen the 19 chapters, as well as the introduction and epilogue. the authors are physicians and health care workers, theologians, scientists, researchers, public health specialists, seminary professors, missiologists, and pastors, many with practical global health experience. the result is an assortment of traditions and perspectives on the origin of evil, sources of disease, and the responsibility of believers and the church to be a part of god’s greater plan to alleviate disease and promote health. foundational to many of the views expressed in this book is the influence of ralph winter, a missionary, missiologist, mission strategist who was an advocate to shift the church’s great commission focus from observing political borders to emphasizing people groups across such boundaries, especially those people groups which were unreached. he died in 2009, but prior to that sought to shake up the church’s theology of disease by getting it to focus on eliminating disease, not just alleviating its impact on individuals and their communities. he was one of the first evangelicals to posit the need for the church to not only evangelize the world, but to fight disease: “to awaken, energize, and nourish the christian imagination to include a new form of service to bring glory to god by exploring and conquering the roots of diseases.”(p. xxx). hence, o’neill and snodderly state in the introduction, “once we acknowledge disease in the category of “evil,” we can see the need to mobilize the body of christ to seek to fight disease at its origins as a means of anticipating “god’s eventual world.”(p. xxx). yet, the areas examined are not done in a simplistic manner but recognize the multiple determinants of health: physical, social, psychological, and environmental. fundamental to it all is an emphasis on the underlying spiritual dimensions. the book provides a solid background of theology and discusses on the origins of evil in the universe and beginning with a review of the historical theological perspectives of disease through the ages. the chapters introduce a wide range of perspectives on aspects of theology with respect to evil, disease, and its origins in order that there be no “blind spots” in the case put forward by the book. these chapters on theology include: • historical, contemporary and globalized theologies of disease (ch. 1), • the biblical context for a theology of disease (2), • a theology of creation: order out of chaos (3), • early church perspectives on the cosmic conflict (4), • a theology of health for the nations (6), • a theology of ecology: earth care and health (7), • a theology of love in the first epistle of john (8). these are helpful in providing a full complement of theological perspectives on disease, evil, god’s plan for “the new earth,” and the christian’s response and role in being an instrument of god’s grand designs. the book then moves on to provide chapters on our response to disease based upon various perspectives (evangelical, pentecostal tradition, west africa, east africa) and disciplines (anthropology, scientist, medical researchers, public health, and missiology). one of the strengths of the book is that it is intended not only for physicians and scientists but a wider audience focused on global health issues. so, the editors include a chapter that is a tutorial: “a scientist’s perspective on disease and death” by biochemical geneticist richard gunasekera is a useful introduction for nonscientists to basic genetics, genetic diseases, infections from bacteria and viruses, technologies dealing with disease, including nanotechnologies to eradicate pathogens, and satan’s role in disease. this is helpful in understanding disease and its source from a scientific and spiritual perspective for all of us who are not research scientists. gunasekera concludes “hence, the causality of genetic diseases 43 newbrander dec 2021. christian journal for global health 8(2) (from inherited genes or from random mutations) or from infectious agents such as retroviruses which insert their dna into the very genome of other organisms, causing suffering, pain, and death, could be, in turn, attributed to the ‘works of the devil.’”(p. 170) the final two chapters, 18 and 19, by gregory boyd of woodland hills church, provide a case for the chaos and disease seen in this world as being a result of satan’s efforts. the tares of matthew 13:24-30 include disease being sown by evil spiritagents to disrupt god’s creation. for those who doubt that disease was a corruption of nature, chapter 19 provides responses to five objections to the corruption of nature hypothesis. boyd strongly states the need to recapture the original purposes of god for creation by destroying the works of the devil, including disease. in the epilogue, o’neill provides a series of eleven responses and solutions to the situation and how global health efforts can be part of the solution. review the editors and various authors of this book lay out a clear challenge for the church: to eradicate disease, as ralph winter and dan fountain laid the foundation for meeting that goal as part of god’s plan and design for the fallen world. they also layout various strategies, reasons, and approaches for doing so. the richness of the breadth of authors brought together by the editors, o’neill and snodderly, in this volume makes it an opulent resource for thoughtful discussion and debate, whatever the reader’s background. what emerges from the wealth of authors is that fighting disease requires more than physicians and medical personnel—it also requires other disciplines and specialists dealing with the physical, mental, social, and most importantly, the spiritual. the need is for scientists, researchers, public health practitioners, legal experts, community and social advocates, and spiritual leaders to work in an integrated manner to address taking god’s creation back and working for it to be as god intended. the book’s central foundation is a vision of believers participating in helping the release of the world from disease, and the means by which god blesses the nations as he promised in genesis that he would do through abraham and his descendants. while the diversity of perspectives adds to the richness of the book, it also makes it a real challenge for the editors to be able thread a consistent unifying message of posits, arguments, and explanations. this is to be expected from a work with such varied and numerous authors representing multiple disciplines. yet, it enriches the discussion and debate that ensues from wrestling with these issues. this book, with its multiple perspectives and backgrounds of the various authors, contributes immensely to not only knowledge on the subject of disease and global health within a spiritual perspective, but to vigorous discussion and debate on evil as the source of disease and the myriad of root causes and varying approaches the church may undertake to address and ultimately eradicate disease, as god intends. the arguments presented, especially by o’neill and snodderly, in bringing together the various chapters, are clear and substantiated with solid and rigorous scholarly examination of the issues. one of the strengths of this publication is that it always integrates the spiritual element as an integral element in all of its explorations, rather than reverting to a strictly scientific perspective and then adding a spiritual angle at the end. the reader of this book will be treated to a wide-ranging discussion of many approaches to developing a theology of disease in order to improve global health. it may be read from start to finish to gain a depth of understanding of the key issues in alleviating disease and promoting health to better understanding the church’s range of the unique opportunities to address disease in a comprehensive manner. alternatively, the reader may do a “pick and choose” of the chapters to address those issues about disease and global health that are of the 44 newbrander dec 2021. christian journal for global health 8(2) greatest interest. the bottom line: this book makes a significant contribution to directing and redeploying the christian global health community’s focus on bringing healing and wholeness to the world: “we must also reveal by our actions his [god’s] concerns for the conquest of evil and disease.” (p 188). submitted 17 oct 2021, accepted 27 oct 2021, published 27 dec 2021 competing interests: none declared. correspondence: william newbrander, pittsburgh, pa, usa. wcnewbrander@gmail.com cite this article as: newbrander w. all creation groans: toward a theology of disease and global health, edited by daniel w. o'neill and beth snodderly, pickwick 2021. christ j global health. dec 2021; 8(2):41-44. https://doi.org/10.15566/cjgh.v8i2.589 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:wcnewbrander@gmail.com https://doi.org/10.15566/cjgh.v8i2.589 http://creativecommons.org/licenses/by/4.0/ introduction summary review original article july 2021. christian journal for global health 8(1) a cross-sectional study of faith-based global health organizations to assess the feasibility of a christian research collaborative jason paltzera, keyanna taylorb a phd, mph, assistant professor of epidemiology, baylor university, united states of america b baylor university, united states of america abstract background: religiosity and spirituality are recognized determinants of health, yet many faith-based organizations do not conduct or publicly disseminate research or evaluation data to inform practice. the purpose of this study was to assess the feasibility of establishing a collaborative to support small to medium-sized, christian, global health organizations in producing stronger evidence regarding the practice and application of integral mission health models. methods: a cross-sectional study was done using a digital, mixed-method (openand closed-ended questions) survey. the survey was distributed through a convenience sample of christian global health networks and member organizations representing over 1,000 primarily small to medium sized organizations. information was collected regarding organizational research and evaluation publication/presentation experience, collaborative interests, evaluation and research barriers, and priorities. results: responses totaled 116 and came from christian health and development organizations in africa, asia, and north america. the survey revealed three organizational research priorities and areas of desired assistance from a collaborative: 1) disseminating impacts, 2) evaluation skills and resources, including integral mission measurement tools, and 3) research design resources and services. interests varied depending on whether the organization was based inside or outside of the united states. discussion: the study aimed to identify priorities and barriers of christian health organizations around research and outcomes evaluation. the findings suggest that a christian research collaborative is not only feasible but could serve organizations throughout the world that have a desire to conduct more rigorous evaluation and research studies and disseminate and publish their results yet lack the time, knowledge, or resources to do so. future studies should explore financial support systems to sustain a collaborative and create a model that could accommodate the different research and evaluation priorities depending on the location of the organization. 13 paltzer & taylor july 2021. christian journal for global health 8(1) key words: faith-based, global health, development, evaluation, research introduction religious entities have played an important role in the provision of health services and improving health outcomes in lowand middleincome countries (lmics).1,2 some reports state as high as 70 percent of all services being provided by faith-based organizations (fbos) in developing countries.3-6 the contributions of fbos in alleviating the burden of hiv/aids is well known. for example, in 2004 the world health organization estimated fbos as comprising 20 percent of all agencies worldwide working towards hiv/aids support.7 this is specifically relevant in countries in sub-saharan africa (ssa) where fbos provide the most aid, second to governmental providers.8 with nearly 85 percent of the world’s population identifying as religious, it is inherent that fbos play a critical role in the health and development of communities.9 faith-based health entities provide financial, human, and technical resources across primary, secondary, and tertiary care levels.4,10 improved geographic access, increased response systems, and greater trust and influence among community members are often strengths of fbos in health and development efforts.4,10-13 faith-based health entities can facilitate resilience within national health systems with the ability to continue service even during periods of political, financial, ideological, and health shifts or crises.4,14-15 fbos are often the established and trusted organizations that promote values such as connection, forgiveness, agency, blessing, and hope which serve to promote human flourishing.16 furthermore, religious entities and fbos have long histories of advocating for justice and against inequality among communities, given their ability to reach the poorest and offer a basis for understanding suffering and justice through spiritual teaching.17-18 however, faith-based organizations face challenges related to evaluating and conducting rigorous research that considers important associations extending beyond basic output measures. strengthening their research capacity will increase the evidence-based strategies to fight poverty and injustice and improve health through and alongside these entities.19 strengthening the research and evidence around faith-based approaches will encourage public-private (faith) partnerships. the public sector recognizes the importance of the private community, particularly in the delivery and financing of health services.20 in 2010, the world health assembly passed a resolution which encouraged countries to engage with the private sector including faith-based agencies that can provide essential healthcare services to hard-to-reach communities.21 expanding and deepening such nontraditional partnerships may serve to further community wellbeing.16 the motivation for private and public entities to engage with each other is often supported by the premise of mutual values and objectives regarding quality health care and improving access to and quality of resources.11,22 alignment of public health and religion through private-public partnerships can be a barrier due to a lack of a common language and goals, existence of evidence-based strengths on both sides, and acknowledgement of ideological differences.17,23-24 strengthening the research on spiritual determinants and program effectiveness from faith-based health organizations published in credible sources and journals can improve alignment and, therefore, strengthen critical public-private partnerships.24 effective partnerships with fbos can also increase their capacity to utilize existing research in order to contribute to the movement of knowledge toward better global health practices to meet the sustainable development goal number 17: “partnerships for the goals.” the existing gap in evidence limits the influence of fbos by not understanding the different mechanisms of how faith-related factors add value to the public-private 14 paltzer & taylor july 2021. christian journal for global health 8(1) partnership.10-11,26 this lack of evidence may perpetuate imbalances of research and practice between public/secular and private fbos.27 in order to adjust the balance, researchers and faith-based community health providers need to find ways to collaborate in the research processes and move toward a common language addressing current and emerging needs.27 the purpose of this study was to identify research and evaluation experience, research and evaluation-related capacities, and obstacles to conducting research and outcome evaluations among small to medium sized christian global health organizations. the goal was to identify interest areas and objectives of a christian research collaborative aimed at strengthening the evidence supporting the practice and application of holistic health and integral mission in diverse contexts. methods a cross-sectional study was done using an online english-language survey incorporating open and closed-ended questions to assess the research and evaluation interests, capacities, and barriers of fbos to conducting more rigorous studies. the survey link was sent via email and social media platforms (facebook and twitter) to a convenience sample of christian health networks and member lists representing more than a thousand organizations and institutions. the survey notification messages, or posts, likely did not reach all of the network organizations, and the authors did not directly communicate with the sample of potential respondents. this is a limitation in understanding the true number of those not responding compared with the network members not receiving the request to complete the survey link. another likely reason for nonresponses from organizations was the language of the survey, english. respondents (n=144) represented healthcare and clinic service organizations (22 percent), capacity building organizations (38 percent), churches or houses of worship (12 percent), and higher education (12 percent) from countries in africa, asia, and north america. respondents included some large international fbos with most representing smallto medium-sized organizations based on organizational reach and revenue sources (private donations versus government grants) determined from organizational websites and prior knowledge of the organizations represented. this study did not analyze organizations based on size and could be a focus of a future study. universities and government agencies were excluded (n=28) to focus on community-focused health organizations. it is expected that focusing solely on community-based global health organizations will allow for a more specific exploration of how evaluation and research capacity can be strengthened outside of the academic and government sectors. a follow-up study could focus on potential academic partners to support a collaborative. survey questions included closedended questions concerning experience in publishing in peer-reviewed journals, conference presentations, research and evaluation support, and selected research barriers. closed-ended questions were analyzed with univariate and bivariate statistics using a significance level of p<0.05. open-ended questions asked about priorities of a potential collaborative and general research and evaluation interest areas. open-ended questions were analyzed using thematic inductive qualitative analysis approach.28 an inductive analysis approach was used to allow the themes to emerge from the data.28 all open-ended questions were read and coded by both authors. disagreements in coded responses were discussed and reconciled to determine the appropriate theme. the analysis was conducted in two stages. first, survey responses were coded by both reviewers. secondly, codes were categorized into overall themes guiding the interests, capacities, and obstacles of the fbo’s respondents. table 1 lists the identified themes and codes used to determine the themes. the analysis compared us-based with non-us-based organizations because of the unique 15 paltzer & taylor july 2021. christian journal for global health 8(1) funding environment and organizational resources accessible to us organizations. all respondents provided consent prior to initiating the survey and given the option to withdraw from the survey at any point. table 1. thematic categories and related codes created from the inductive qualitative analysis themes codes research design and methodology design analysis data management data collection evaluation measuring impact monitoring needs assessment community assessment cost effectiveness baseline data best practice/evidence identification sustainability evidence reproducibility outreach capacity building literature reviews maternal health infectious disease disease health impact mental health social health impact epidemiology sexual/reproductive health health improvement global health program development/quality improvement publicity promotion communication funding increasing personnel mobilization materials labor resources accreditation mentorship advocacy community involvement community input implementation media and marketing education training leadership cultural awareness critical thinking planning implementation increasing clientele grassroots efforts gender inequality ethics team strengthening ownership employee involvement product development dissemination technical writing policy sharing information networking partnership editing services fellowship/dialogue kingdom impact community health evangelism (che) evangelism mission or ministry spirituality spirituality of health christian impact results the analysis included 116 organizations with 64 (55 percent) based in the united states. of the total, 30 (25.9 percent) were categorized as healthcare organizations, 17 (14.7 percent) churches 16 paltzer & taylor july 2021. christian journal for global health 8(1) or houses of worship, 18 (15.5 percent) mission agencies, and 51 (44.0 percent) capacity building organizations. table 2 shows the results of organizations with research experience, research and evaluation interest areas, and barriers. table 2. research & evaluation experience, selected interest areas, and perceived barriers (4 & 5, 5-point likert scale). us-based organizations (n=64) (%) non-us-based organizations (n=52) (%) total (n=116) (%) p-value current research experience experience publishing in a peer-reviewed journal 24 (37.5) 19 (36.5) 43 (37.1) 0.965 experience presenting at an academic conference 35 (54.7) 23 (44.2) 58 (50.0) 0.534 rated interest disseminate impacts 51 (79.7) 44 (84.6) 95 (81.9) 0.581 research and evaluation methods 54 (84.4) 41 (78.9) 95 (81.9) 0.416 faith-based research consulting 46 (71.9) 37 (71.2) 83 (71.6) 0.409 academic & professional presentations 40 (62.5) 35 (67.3) 75 (64.7) 0.828 publishing peer-reviewed articles 39 (60.9) 35 (67.3) 74 (63.8) 0.554 barriers few financial resources to conduct research 39 (60.9) 36 (69.2) 75 (64.7) 0.353 no time to write-up results in a publishable format 40 (62.5) 24 (46.2) 64 (55.2) 0.078 limited knowledge of evaluation and research methods 27 (42.2) 32 (61.5) 59 (50.9) 0.038* no time to collect data 37 (57.8) 20 (38.5) 57 (49.1) 0.038* no time to analyze data 37 (57.8) 17 (32.7) 54 (46.6) 0.007* measurement is not viewed as a priority 7 (10.9) 8 (15.4) 15 (12.9) 0.478 other 13 (20.3) 8 (15.4) 21 (18.1) 0.439 note. * significance (p<0.05) determined using chi-square test. more than a third of the organizations (37 percent) had experience publishing in a peerreviewed journal with no difference between us and non-us-based organizations. half had experience presenting at a professional or academic conference at the time the survey was conducted (december 2018 – february 2019). research and evaluation interest areas and barriers were measured using a 5point likert scale of strongly disagree to strongly agree. agree and strongly agree responses were collapsed as a positive response to each statement. over 80 percent of organizations expressed interest in 1) gaining a greater capacity to disseminate impacts of their programs and 2) greater understanding of research and evaluation methods. the third ranked interest was faith-based consulting services as an interest area among 72 percent of organizations with little difference based on location. academic or professional presentations and publishing were highly selected by more than 60 percent of organizations. the top barriers to research and evaluation were 1) financial resources to conduct research (65 percent) and 2) time to write-up the results (55 percent). time to write-up results was higher among us-based organizations along with time to collect data and time to analyze the data (58 percent among us-based organizations). knowledge about research and evaluation methods was the second barrier for non-us organizations (62 percent) and a point of divergence between us and non-us organizations (p=0.038). the differences in time to collect data and analyze results as barriers were statistically significant between us and non-us organizations (p=0.038 and 0.007, respectively). 17 paltzer & taylor july 2021. christian journal for global health 8(1) table 3 shows the results of the qualitative thematic analysis of service interest areas and expressed objectives of a christian research collaborative. the service/resource most commonly mentioned by the organizations was evaluation skills and resources (29 percent) followed by research design resources and services (23 percent). this is in line with the focus of the survey. the third most mentioned resource was program development resources. this highlights the potential use of a collaborative to help organizations apply research and evaluation to inform organizational growth. us and non-us-based organizations shared these three most commonly mentioned services/resources. the suggested primary objective of a christian collaborative mirrors the requested services/ resources of providing evaluation tools (29 percent). the second most mentioned objective of a collaborative pertained to measuring integral mission or kingdom impact—the impact of integrating spiritual and physical factors in one model or program (22 percent). among us-based organizations, these two objectives are similarly the first and second most mentioned; however, among non-us-based organizations, the first and second most mentioned objectives of a collaborative pertained to the provision of evaluation tools (26 percent) and the dissemination of information and sharing ideas (26 percent). only 9 percent of usbased organizations mentioned the objective of disseminating information and sharing ideas, which highlights the differences in objectives among us versus non-us organizations. table 3: thematic analysis of service/resource interest areas and collaborative objectives. us-based organizations (n=64) (%) non-us-based organizations (n=52) (%) total (116) (%) if you had access to an external christian researcher or evaluator, what services or resources would you want? evaluation skills and resources 22 (34.4) 11 (21.2) 33 (28.5) research design resources and services 15 (23.4) 12 (23.1) 27 (23.3) program development resources and services 10 (15.6) 12 (23.1) 22 (19.0) integral mission measures, resources, and services 9 (14.1) 7 (13.5) 16(13.8) identifying best practices to implement 5 (7.8) 8 (15.4) 13 (11.1) opportunities to disseminate resources or services 6 (9.4) 5 (9.6) 11 (9.5) unsure/other 3 (4.7) 1 (1.9) 4 (3.5) what objectives or priorities would be appealing to you if you had the opportunity to participate in a christian collaborative for evidence-based practice? evaluation tools 19 (29.7) 14 (26.9) 33 (28.5) integrating kingdom impact measures 14 (21.9) 11 (21.2) 25 (21.6) guide program development efforts 12 (18.8) 11 (21.2) 23 (19.8) disseminating information and sharing ideas 6 (9.4) 14 (26.9) 20 (17.2) coordinating best practices 10 (15.6) 5 (9.6) 15 (12.9) facilitate research design and projects 7 (10.9) 7 (13.5) 14 (12.1) unsure/other 5 (7.8) 1 (1.9) 6 (5.2) 18 paltzer & taylor july 2021. christian journal for global health 8(1) table 4 summarizes the willingness-to-pay for consultation or services regarding research or evaluation projects. a quarter of the organizations (27 percent) were willing to pay up to us $1,000 with another 38 percent willing to pay up to us $500. only 10 percent stated they would not be willing to pay at all. no significant differences were observed in willingness-to-pay among us and nonus organizations (p = 0.548) table 4. willingness-to-pay for evaluation and research services. us-based organizations (n=64) (%) non-us-based organizations (n=52) (%) total (116) (%) p-value* $0 8 (12.5) 4 (7.7) 12 (10.3) 0.548 $1-500 20 (21.3) 25 (48.1) 45 (38.8) $501-1,000 19 (29.7) 13 (25.0) 32 (27.6) $1,001-5,000 10 (15.6) 7 (13.5) 17 (14.7) more than $5,000 4 (6.3) 2 (3.9) 6 (5.2) other 3 (4.7) 1 (1.9) 4 (3.5) note. *significance was determined using chi-square test. discussion the results show a high degree of interest in disseminating impact and understanding research and evaluation methods. us and non-us faith-based organizations want to grow their capacity to measure outcomes (evaluation) and test hypotheses (research) to inform program growth or new areas of service as well as publicly disseminate and share findings. this dissemination could include academic or professional forums to exchange ideas with other similar organizations or in the peer-reviewed literature (64 percent interest). these are complementary and confirm that organizations consider this a high priority even though only a third to a half have prior experience with this type of dissemination. consulting services in faith-based research and evaluation were of interest to 72 percent of the respondents. across all the options listed, there was an overall high-level of interest among the responding organizations. barriers of financial resources and time to write-up results were expected. this is in line with those organizations that may have some level of monitoring and evaluation already happening but do not have the time or are uncertain what to do with the data that has been collected. among us-based organizations, the time to collect and analyze the data was also high, suggesting that organizations may not be certain about the measurement design or strategies used to collect the data which lead into the analysis and interpretation. organizations often collect program output data that may or may not align with the organization’s theory of change or logic model resulting in a disconnect between the data and expected outcomes. identifying valid and easy-to-use instruments can help address this barrier as well as analytical methods that help establish a comparison group such as propensity score matching. in the area of holistic and faith-based health ministry, there are not many tools that equip organizations with the ability to measure the spiritual determinants of health in relationship to the physical, social, environmental, and economic determinants.30 the ones that do exist require an established evaluation and learning team or additional support to implement the tools with fidelity. these findings suggest that there is a need and a demand for such integral mission or holistic health instruments that can be implemented without much demand on existing staff time or cost. among international organizations, there is a need to increase the level of knowledge around 19 paltzer & taylor july 2021. christian journal for global health 8(1) research design and methods. a faith-based collaborative focused on serving small to medium sized organizations could be a valuable resource to link organizations and their work to various opportunities for quantifying and disseminating the evidence they are observing in the field. twelve percent of organizations mentioned interest in having the collaborative be a facilitator of research projects. a follow-up study could clarify this expressed objective among organizations, which would significantly influence the services provided by a collaborative. this is highlighted by the finding that 15 percent of respondents would be willing to pay between $1,000-$5,000 for evaluation or research services. most of the respondents were willing to pay us $1,000 or less with more than half of the international organizations willing to pay up to us $500. purposes of a qualitative analysis may be to generate a model or hypothesis for subsequent study, to better understand patterns, to explore difficult to quantify topics, or to validate quantitative findings. with this qualitative analysis, a model including priorities, objectives, and barriers was generated for subsequent study and validation. figure 1 summarizes the top three priorities (blue) and maps corresponding secondary themes (green) that support them based on the open-ended questions. figure 1. a model of suggested priorities, supporting objectives, and potential barriers based on the thematic analysis. 20 paltzer & taylor july 2021. christian journal for global health 8(1) top barriers (black) that need to be addressed in order to create an effective collaborative that provides evaluation and research services desired by faith-based organizations are also shown. a collaborative should emphasize the priority of helping organizations disseminate their own evidence but also create opportunities to learn from other similar organizations working in their region or topic area. this dissemination may help minimize the tension between and increase opportunities to build private-public sector partnerships in global health. such partnerships may lead to greater financial resources for ongoing measurement and research. the collaborative could help organizations develop their own tools or provide access to a selection of free or low-cost validated health measurement tools, including integrated kingdom impact measures. this could be accompanied by training and support on how to apply the tools to their specific environmental context and theoretical questions related to key program assumptions. as organizations strengthen their kingdom-focused evaluation and research capacity, evidence will be available and accessible to create publishable and presentable materials for dissemination and sharing through professional platforms. current efforts in forming evidence-generating collaborations among faith-based organizations are limited. one example is an initiative of the global che (community health evangelism) network called the public health as mission research network. the network consists of global health practitioners and researchers focused on discussing, sharing, and designing research studying the integration of faith, public health, and development. the accord research alliance is another example focusing on measuring what matters in the field of christian relief, development, and advocacy. a third example is the joint learning initiative on faith and local communities (jli). the jli has worked collaboratively with local, national, and global faith groups to develop the guide to excellence in evidence for faith groups.30 according to jli, gathering and collecting evidence helps organizations track how their work impacts the communities they serve in alleviating poverty and improving overall well-being. christian health organizations regardless of size or location may benefit from a collaborative that aligns with and addresses the priorities and barriers identified here. this study has several limitations, including possible selection bias based on a convenient sample of organizations that were part of the networks used to distribute the survey link. since the survey was digital and in english, it excluded many organizations that do not have consistent access to the internet or are not comfortable responding in english. this study is also limited by a low response rate which may introduce additional self-selection bias. while over 1,000 organizations were likely exposed to the survey link through network newsletters, email messages, and social media posts to participate in the survey, only 116 organizations provided complete responses. the total number of individuals representing organizations that may have received the survey link and chose not to complete it or who simply failed to open the message containing the invitation is unknown. this low response rate may reflect organizational challenges or the low priority for the evaluation of practices and/or to disseminate research among fbos. the purpose of this study was to explore topics and themes around a christian collaborative to support faith-based global health organizations in their capacity to design, collect, analyze, write, and disseminate evidence of their work. the study is limited in its ability to make associations between organization types and existing capacities. a strength of the study is broad scope and geography of organizations exposed to the survey given the reach of member networks used to distribute the survey. the relatively large sample size allowed the analysis to be stratified by us and non-us organizations resulting in a greater understanding of perceptions and needs around 21 paltzer & taylor july 2021. christian journal for global health 8(1) capacities to conduct community-based health research. conclusion the findings show the need for and interest in a faith-based research and evaluation collaborative or system. there are some differences in interests and barriers between us and non-us-based organizations that should be considered to focus efforts according to the perceived need and available resources. the study identified three priority areas among christian health organizations focusing on 1) assistance in disseminating results of program impacts, 2) strengthening evaluation skills and tools, including integral or holistic mission measurement tools, and 3) guidance in identifying research design resources and services. future research should test the feasibility of a faith-based collaborative to further clarify a process for meeting the objectives identified in this 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http://www.irhap.uct.ac.za/irhap/research/pastproject s/healthcontribution 5. world health organization. faith-based organizations play a major role in hiv/aids care and treatment in sub-saharan africa. geneva, switzerland: world health organization. 2007 [cited 2020 nov 3]. available from: http://www.who.int/mediacentre/news/notes/2007/np 05/en/index.html 6. olivier j, wodon q. playing broken phone: assessing faith-inspired health care provision in africa. dev practice. 2012;22(5-6). 7. world health organization. the world health report 2004: changing history, community participation in public health. geneva, switzerland: world health organization. 2004 [cited 2020 nov 3]. available from: https://www.who.int/whr/2004/en/report04_en.pdf?u a=1 8. us department of state. building on firm foundations: the 2015 consultation on strengthening partnerships between faith-based organizations and pepfar to build capacity for sustained responses to hiv/aids. washington, dc: us department of state. 2015 [cited 2020 nov 3]. available from: https://www.state.gov/wpcontent/uploads/2019/08/building-on-firmfoundations-the-2015-consultation-onstrengthening-partnerships-between-faith-based.pdf 9. pew forum. the global religious landscape. pew forum. 2020 [cited 2020 nov 3]. available from: https://www.pewforum.org/2012/12/18/globalreligious-landscape-exec/ 10. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock f, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015;386(10005): 1765-75. https://doi.org/10.1016/s0140-6736(15)60251-3 11. boulenger d, criel b. the difficult relationship between faith-based health care organisations and the public dector in sub-saharan africa: the case of contracting experiences in cameroon, tanzania, chad and uganda. antwerp: itg press, 2012. 232 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 22 paltzer & taylor july 2021. christian journal for global health 8(1) pp. [studies in health services organisation & policy]. 12. duff jf, buckingham ww. strengthening of partnerships between the public sector and faithbased groups. lancet. 2015;386(10005):1786–94. https://doi.org/10.1016/s0140-6736(15)60250-1 13. karam a, clague j, marshall k, olivier j. the view from above: faith and health. lancet. 2015;386(10005): e22–e24. https://doi.org/10.1016/s0140-6736(15)61036-4 14. deroeck d. making health-sector non-governmental organizations more sustainable: a review of ngo and donor efforts. special initiatives report. bethesda, md: partnerships for health reform project. 1998;14. 15. dimmock f, olivier j, wodon q. half a century young: the christian health associations in africa. in: olivier j, wooten q, editors. the role of faithinspired health care providers in sub-saharan africa and public-private partnerships. washington dc: the world bank. 2012 [cited 2020 nov 3];71-103. available from: https://openknowledge.worldbank.org/handle/10986/ 13572 16. koh hk, coles e. body and soul: health collaborations with faith-based organizations. am j pub health. 2019;109(3): 369-70. http://doi.org/10.2105/ajph.2018.304920 17. idler e, levin j, vanderweele tj, khan a. partnerships between public health agencies and faith communities. am j public health. 2019;109(3):346-7. http://doi.org/10.2105/ajph.2018.304941 18. james r. handle with care: engaging with faithbased organizations in development. dev pract. 2011;21(1):09-117. https://doi.org/10.1080/09614524.2011.530231 19. norman r, odotei o. faith integration and christian witness in relief and development. christian relief, development, and advocacy, 2019;1(1): 31-43. https://crdajournal.org/index.php/crda/article/view/2 07 20. roehrich jk, lewis ma, george g. are publicprivate partnerships a healthy option? a systematic literature review. soc sci med. 2014;113:110-9. https://doi.org/10.1016/j.socscimed.2014.03.037 21. world health organization. who assembly resolution: strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services. 63rd world health assembly, a63/25. geneva, switzerland: world health organization. 2010 [cited 2020 nov 3]. available from: https://apps.who.int/gb/ebwha/pdf_files/wha63/a6 3_25-en.pdf 22. boulenger d, barten f, criel b. contracting between faith-based health care organizations and the public sector in africa. rev faith int aff. 2014;12(1):21-9. https://doi.org/10.1080/15570274.2013.876730 23. blevins jb, jalloh mf, robinson da. faith and global health practice in ebola and hiv emergencies. am j public health. 2019;109(3):37984. available from: https://ajph.aphapublications.org/doi/abs/10.2105/aj ph.2018.304870 24. paltzer j. the local church and faith-based organizations. in: ireland j, editor. for the love of god: principles and practice of compassion in missions. eugene, or: wipf & stock. 2017;230-43. 25. fort al. the quantitative and qualitative contributions of faith-based organizations to healthcare: the kenya case. christ j global health. 2017;4(3):60-71. https://doi.org/10.15566/cjgh.v4i3.191 26. whyle e, olivier j. models of engagement between the state and the faith sector in sub-saharan africa – a systematic review. dev pract. 2017;27(5):684-97. https://doi.org/10.1080/09614524.2017.1327030 27. olivier j, scott v, molosiwa d, gilson l. embedded systems approaches to health policy and systems research. in: savigny d, blanchet k, maidenhead at, editors. applied systems thinking for health systems research: a methodological handbook. open university press. 2017:14-52. 28. thomas dr. a general inductive approach for analyzing qualitative evaluation data. am j eval. 2006;27(2): 237-46. https://doi.org/10.1177%2f1098214005283748 29. dykstra r, paltzer j. a review of faith-based holistic health models: mapping similarities and differences. christ j global health. 2020;7(2):121-32. https://doi.org/10.15566/cjgh.v7i2.311 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 23 paltzer & taylor july 2021. christian journal for global health 8(1) 30. joint learning initiative on faith & local communities. guide to excellence in evidence for faith groups [internet]. 2016 [cited 2020 nov 3]. available from: https://jliflc.com/guide-excellenceevidence-faith-groups/ peer reviewed: submitted 10 dec 2020, accepted 25 jan 2021, published __ july 2021 competing interests: none declared. correspondence: jason paltzer, baylor university, united states of america. jpaltzer1@gmail.com cite this article as: paltzer j, taylor k. cross-sectional study of faith-based global health organizations to assess the feasibility of a christian research collaborative. christian journal for global health. july 2021; 8(1):12-23. https://doi.org/10.15566/cjgh.v8i1.491 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v8i1.491 about:blank abstract introduction methods results discussion conclusion references 1. koenig hg. religion, spirituality, and health: the research and clinical implications. isrn psychiatry. 2012:1-33. http://dx.doi.org/10.5402/2012/278730 book review dec 2020. christian journal for global health 7(5) creating shared resilience: the role of the church in a hopeful future by david m. boan and josh ayers. langham global library, 2020 pieter nijssena a bi-vocational pastor at crossroads christian church, woodstock, ct, former executive director, tri-town shelter services, usa introduction in the book of deuteronomy, we are encouraged to love god with every aspect of our personhood. this is played forward in dr. luke’s first writing to theophilus and is supported by fellow gospel writers, matthew and mark. taken collectively, the aspects of personhood are heart, soul, mind, body, and strength (deut. 6:5; 11:13; col. 4:14; luke 10:27; cf matt. 22:37; mark 12:30). this is prayed forward in paul’s correspondence to those in thessalonica (1 thess. 5:23). j. knox chamblin noted, paul writes as a whole person whose reason, emotion, and will constantly interact with each other as he writes. just as paul writes by the united exercise of his reason, emotions, and will, so the informative, affective and directive are woven together in his letters.1 carl f.h. henry, former (1968) editor of christianity today, explained that, the dearth of evangelical social concern is partly due (1) to neglect of the good news of salvation by social gospelers, (2) to the decimation of evangelical capability by liberal control of such ecclesiastical resources as the denominations and schools, and most of all (3) to the reaction against protestant liberals’ attempts to achieve the kingdom of god on earth through political and economic changes, excluding the supernatural redemptive facets of christian faith.2 franz delitzsch stated that, biblical psychology is no science of yesterday. it is one of the oldest sciences of the church. as early as the second century, we find, in the literature of the period, a book by melito of sardis, of which eusebius and jerome make mention; and early in the third century the work of tertullian pursues the history of the soul from its eternal source and temporal mode of origination.3 in more recent views on integrative theology, lewis & demarest write, coherent thinking and authentic living in the modern world require that a person view life holistically rather than in fragments. a coherent understanding of reality begins with god’s perspective mediated by general and specific revelation. we propose that christians consider the paradigm of integrative theology.4 in 1981, jim wallis wrote, “churches today are tragically split between those who stress conversion but have forgotten its goal, and those who emphasize christian social action but have forgotten the necessity for conversion.”5 wrestling with this tension, along with the ongoing rediscovery of the biblical concept of shalom and its relationship to human development and communal thriving takes resilience. 100 nijssen dec 2020. christian journal for global health 7(5) in creating shared resilience, david m. boan and josh ayers share their experiences and reflections and make valuable contributions to other laborers in the growing harvest field of development. this book seeks to answer the question, “how is it that some individuals and communities seem to suffer less harm than others when faced with comparable crises or disasters and seem to cope with these impacts better and recover from harm more quickly?” (p.1) summary the authors draw attention to the tensions that exist within local faith communities (lfcs) regarding their own identities. “in fact, some lfc leaders argue, quite fairly, that focusing on disaster can harm the lfc by allowing disaster work to compete with or confuse the true identity of the lfc.” (p.3) while expressing this as a legitimate concern, they encourage lfcs to collaborate with non-government organizations and government organizations for the betterment of the communities of which they are a part. each of these communitybased entities share a compassionate concern for others, and when they are brought into a relationship with one another, this can result in cross-pollination of best practices. the question they pose, “what better demonstration of the healthy influence of the lfc than to help create a healthy, resilient community?” (p.3) is unpacked in the chapters that follow. the authors rightly discern another longstanding tension when stating that “the evangelical church has wrestled with the tension between seeking converts and seeking justice.” (p.3) lfcs stepped inside the ring with the great reversal: reconciling evangelism and social concern by david moberg. this was a prophetic call to the church at-large and ignited a movement that has gained considerable traction. lfcs have increasingly moved from an either/or mentality to one of both/and. strongholds have been broken as inroads have been restored. words and works have become linked, and communities and individuals within them have been seen, supported, and serviced. resilience is the result of collaborative efforts at building resource capacity within communities. the question as to what is resilience is answered in chapter one. several definitions from differing disciplines and metaphors are given that are helpful and which demonstrate the broadness and fluidity of the term itself. a search in academic journals published between 1960 and 2018 for the words “resilience,” “disaster,” and “development” showed “a nearly 1700-fold increase, demonstrating the increase in usage of resilience by relief and development practitioners and academics.” (p.9-10) over this same time period, lfcs have learned to think both theologically and developmentally, although oftentimes using different language. the chapter addresses the relationship of lfcs to resilience and worldviews. “to start with, we suggest that faith is not simply an element of resilience. faith, when understood broadly, is central to resilience insofar as it shapes our worldview.” (p.14) the reference to the factors that result in the ability of the individual to access and make use of resources touches lfcs and connects them to development and relief initiatives at their core. “the lfc speaks directly to the moral, ethical, and spiritual uses of resources for the common good.” (p.38) chapter two brings theology to bear on resiliency and its relationship to shalom. they are not the first, nor will they be the last among evangelicals to make this connection. referencing rene padilla’s work, they cite the requirements for a christian church to practice integral mission, i.e., a commitment to christ as lord of everything, discipleship as a lifestyle, and being incarnational. (p.41) dr. abraham kuijper delivered a public address entitled, “sphere sovereignty,” on oct. 20, 1880 at the inauguration of the free university, amsterdam. in this address he declared, “there is not a square inch in the whole domain of our human existence over which christ, who is sovereign over all, does not cry, ‘mine!’” indeed, if jesus is not 101 nijssen dec 2020. christian journal for global health 7(5) lord of all, he is not lord at all. “integral mission is a call to awareness that our lives are created socially and have social consequences, whether we choose to recognize these or not.” (p.43) their referencing of the cape town commitment is particularly relevant, given the churches difficult history regarding evangelism and social involvement. ironically, while they spoke out against apartheid as structural sin, they did so while blind to their own spiritual apartheid regarding proclamation and demonstration. chapter two suggests a helpful reordering between facts and documentary evidence and that of stories and meaning. they place facts as secondary to meaning, arguing that meaning determines influence. (p.44) introducing advocacy as “part of god’s nature” (p.46) is consistent with jesus, himself, referring to the promised holy spirit as the advocate (john 14:26). regarding lfcs, “as evangelicals, we possess robust theologies for dealing with personal sin, but limited resources for dealing with structural or institutional sin.” (p.47) to this, scripture presents jesus as the advocate (1 john 2:1-2). “we see resilience as a holistic process – one based on access to resources, quality of relationships, a commitment to justice and respect for all members of the community – then shalom is a valuable way to capture this concept.” (p.51) chapter two calls evangelicals to make room for shalom in their understanding of salvation, personally and communally. chapter three introduces several principles promoting resilience, along with the four essential practices of seeking justice, building social capital, creating restoration, and engagement. (p.64) this important groundwork provides the underpinning for chapter 4, which deals with application within lfcs. while both ngos and lfcs are valued, their distinctive contributions to resilience are outlined. the author’s use of case studies is a very helpful way to ensure that the principles are applied, and it helps us to see what resilience can look like. chapter 5 contains several such case studies that reflect the diverse ways in which lfcs can foster resilience. evangelicals have long recognized that the bible occurs within a cultural context, resulting in the need for responsible contextualization within respective cultures. review the creation mandate and prophetic call continues to restore balance and resource capacity building collaboratively (gen. 1:27-30; micah 6:8; phil. 2:3-4). the conversation regarding the reversal continues to reawaken the church to reclaim her place as “vessels of and vehicles for change” (2 cor. 5:16-19), especially during times when faced with disasters. creating shared resilience weighs in on the conversation and brings focus to our vision and helps define best practices moving forward. the authors give the conversation begun by others traction. when “evangelicals learned firsthand the conditions under which people lived and quickly added social welfare programs, their large numbers and fervent commitment made them the most important force in the nation’s first war on poverty.”2 shalom builds resource capacity in others, thereby strengthening resilience. resilience is an important part of sustainable development. the insights shared in creating shared resiliency can bring clarity to the other disciplines addressing development work fostering wellness within communities. drawing on the best practices of others offers the best hope of creating a more flourishing world, thereby mitigating the effects of the fall. “your kingdom come, your will be done, on earth as it is in heaven” (matt. 6:10). much like the global community health education (che) network with 962 organizations serving impoverished communities in urban and rural settings in 136 countries, creating shared resilience provides cross pollination that ensures lfcs are good stewards of the earth and its abundant resources, especially in times of crisis. the word resilience is a much-needed word to be added to our vocabulary regarding development. 102 nijssen dec 2020. christian journal for global health 7(5) creating shared resilience focuses on the concept of resilience, and, if it is released in a second edition, it would be beneficial to draw from the works of others, such as miller,6 myers7, corbett & fikkert,8 and rowell9 in the field of transformational development. those on the front lines of promoting shalom need to engage one another in the pursuit of best practice, good stewardship, and maximum transformation. this sharing of concepts and practices fulfills “as iron sharpens iron, so one (practitioner) sharpens another” (proverbs 27:17). creating shared resilience comes at a time when the whole world is dealing with a current crisis brought on by covid-19. this pandemic has resulted in disastrous economic downturns and social isolation to such a degree that every level of society has been affected. sociologists define society as having three levels: the macro (society at large), meso (groups, communities, and institutions), and micro (individuals). these circumstances provide lfcs with an opportune time to model biblical community and express resilience. by adhering to the public health regulations, having smaller gatherings provides support and an environment where confession can indeed be curative (james 5:13-16). god made us social beings and declared, “it is not good for man to be alone. i will make a helper suitable for him” (genesis 2:18). even god, himself, lives in relationship with the son and the spirit. furthermore, he lives in relationship with creation and the church. the benefits of linking spirituality to health are well attested to. harold g. koenig’s review of original data-driven quantitative research published in peer reviewed journals between 1872 and 2010 makes this case clear, citing 596 sources.10 in moments of disaster or crisis which inevitably come, as lfcs practice authentic biblical care and promote resilient communities, this gives proclamation of the gospel credibility. this builds resiliency for all. references 1. chamblin jk. paul & the self: apostolic teaching for personal wholeness. grand rapids: baker books; 1993. p. 17,29. 2. moberg d. the great reversal: reconciling evangelism and social concern. portland: wipf & stock publishing; 2006. p. 35, 28-29. 3. delitzsch f. a system of biblical psychology. edinburgh: t& t clark; 1855. 4. lewis gr, demarest, ba. integrative theology: historical, biblical, systematic, apologetic, practical. grand rapids: zondervan; 1987. p. 7. 5. sider rj. good news and good works: a theology for the whole gospel. grand rapids: baker books; 2007. p. 101. 6. miller dl. discipling nations: the power of truth to transform cultures. 2nd ed. seattle: ywam publishing; 2001. 7. myers bl. walking with the poor: practices of transformational development. maryknoll: orbis books; 2008. 8. corbett s, fikkert b. when helping hurts: how to alleviate poverty without hurting the poor . . . and yourself. chicago: moody publishers; 2012. 9. rowell j. to give or not to give? rethinking dependency, restoring generosity & redefining sustainability. downers grove: intervarsity; 2007. 10. koenig hg. religion, spirituality, and health: the research and clinical implications. isrn psychiatry. 2012;278730. https://doi.org/10.5402/2012/278730 submitted 3 dec, accepted 12 dec, published 21 dec 2020 competing interests: none declared. correspondence: pieter nijssen, connecticut, usa. phl.nijssen@gmail.com cite this article as: nijssen p. creating shared resilience: the role of the church in a hopeful future by david m. boan and josh ayers. langham global library, 2020. christian j global health.dec 2020; 7(5):99-102. https://doi.org/10.15566/cjgh.v7i5.489 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to vie a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.5402/2012/278730 mailto:phl.nijssen@gmail.com https://doi.org/10.15566/cjgh.v7i5.489 http://creativecommons.org/licenses/by/4.0/ references guest editorial july 2021. christian journal for global health 8(1) caring for the earth for better health and well-being of all: addressing climate change as a planetary health emergency james hospedales a a md, msc, former director of caribbean public health agency (carpha), and founder of earthmedic/earthnurse. introduction most of the major public health problems with which i have wrestled in my life—epidemics and pandemics, natural disasters, and chronic noncommunicable diseases (ncds)—are all symptomatic of, or related to, climate change and/or destruction of the environment. as a christian, the roots lie in lack of respect for our creator and lack of reverence for the goodness and inter-dependence of all of creation. climate change is a public health crisis because it is destroying the conditions for life. the unprecedented, deadly heatwaves in the pacific northwest of the united states are a current example. “patient earth” is showing many signs of ill-health, particularly the increasing global temperature after thousands of years of stability, caused mainly by human activities (figure 1).1 figure 1. global land temperature index source: nasa. climate change: vital signs of the planet (https://climate.nasa.gov/vital-signs/globaltemperature/) though natural cycles have altered earth’s climate previously, current global warming is mainly attributable to human activity —specifically to burning of fossil fuels such as coal, oil, gasoline, and natural gas (particularly with the advent of globalized industrialization), causing a stronger greenhouse effect2 with atmospheric carbon dioxide levels now at 419 ppm, the highest in 4 million years.3 the implications are profound for the health and wellbeing of people, economies, and the planet. in response, 196 countries joined in the united nations convention for climate change in 2015 with the aim of limiting global warming to well below 2, preferably 1.5, degrees celsius, compared to preindustrial levels.4 the g7/g20 and others have long recognised the vulnerability of small island and lowlying developing states (sids) to the adverse impacts of climate change5, including food insecurity6, population displacement, and forced migration.7 faith community partnerships have started to take a role in addressing these issues for the pacific sids, which highlights opportunities to address climate-related global health risks in other regions.8 bearing witness in my observation of the environment in trinidad and the caribbean for 50+ years, across “climate timescales,” i have seen continued degradation of natural systems, with many direct and indirect health impacts. as a boy in trinidad, we had sea grass beds and clear seawater; then seagrass beds became barren mudflats, the fiddler crabs disappeared, there were far fewer fish, and the water grew turbid. much of the coastline became polluted https://climate.nasa.gov/vital-signs/global-temperature/ https://climate.nasa.gov/vital-signs/global-temperature/ 4 hospedales july 2021. christian journal for global health 8(1) from the oil and gas industry, and plastic waste choking drains and rivers contributed to worsening floods, littering coasts, and harming wildlife. the weather has become hotter and drier in trinidad and tobago (0.7 degrees celsius increase from 1990 to 2019).9 near-annually, human-made forest fires last longer and spread further, destroying some 300,000 acres of forest, wildlife, property and sometimes, lives.10 the damaged watersheds contribute to worse floods during the rainy season, undermining agriculture, and food security11, and increasing the risk for vector borne diseases. record floods in october 2018 effectively cut trinidad in half, resulting in temporary disruption in access to health and other essential services. as coordinator of chronic disease prevention and control in the pan american health organization (paho) 2006-2012, i could discern that the costly epidemics of ncds—cardiovascular diseases, diabetes, chronic respiratory diseases, and cancer— had similar associations with climate change. for example, fossil fuel-dependent, mechanised agriculture, and motorised transport contribute to greenhouse gas emissions, and pollution as well as sedentariness, unhealthy diets, and obesity, major risk factors for the burdensome ncds. epidemics and extreme weather as inaugural director of the caribbean public health agency (carpha)12, i was faced with two new arboviral disease epidemics, chikungunya13 and zika14 viruses, in 2014 and 2016, respectively, the latter declared by who as a public health emergency of international concern (pheic). the aedes aegypti mosquito vector thrives in breeding sites in water drums, discarded tires, etc., and warming weather is projected to increase its invasive potential.15 at the same time, we faced “slow-moving disasters” such as increasing childhood obesity, an unhealthy food environment —high in sugar, animal fats, salt and calories—and a loss of use of sustainably grown, indigenous crops. these and other conditions compound adverse health impacts of climate change. focusing the science to the caribbean16, we are to expect hotter, drier weather, overall; with longerlasting category 4/5 super storms and inundations of rain. as epidemiologist at the caribbean epidemiology centre (carec) 1987-1993 and on the paho/who caribbean disaster response team, we mobilised after major hurricanes, e.g., gilbert, hugo, in the late 80s and early 90s. over the almost three decades since, i’ve seen that hurricanes have become more frequent and destructive. from hurricane matthew in 2015, the longest-lived category 4/5 hurricane; to the triple-whammy of hurricanes jose, irma, and maria in 2017, that destroyed 225% of dominica’s gdp, damaging health facilities and severely affecting health determinants such as water and sanitation; to the slow-moving hurricane dorian, that ravaged the bahamas; to the wild atlantic hurricane 2020 season with a record 30 named storms; we are living in an era of consequences. theological reflections i believe science gives us tools to better glimpse the amazing nature of god, and the earth as a delicately balanced, living system, which we are only just beginning to comprehend. in genesis, the opening book of the bible, god said “it was good” five times as the earth, seas, plants, animals, and humans were created. yet, we are not being good stewards over what we have been given charge (gen 1:28). global populations of mammals, birds, fish, reptiles, and amphibians have dropped by 68% between 1970 and 2016. insects, trees and forests— part of the whole web of life—are also being threatened on an unprecedented scale with irreplaceable biodiversity loss.17 much of this is driven by human overconsumption, population growth and intensive agriculture, according to a major new assessment of the abundance of life on earth.18 this situation has stimulated much theological reflection worldwide, including the papal 5 hospedales july 2021. christian journal for global health 8(1) encyclical of 2015, “on care for our common home.”19 if god made the earth and everything in it and saw that “it was good” and commissioned the first humans to have responsible dominion of the whole creation, does the lack of respect, exploitation, and neglected care for nature offend god? two themes can be discerned in the old and new testaments: respect for the creator and respect for the interdependence of creation. psalm 104 echoes the goodness of all of creation and the inter-dependence of creation, the cycle of life, and the responsibility of people to manage their environment. romans 1:1920 speaks of the wonder of creation being a manifestation of god’s power and divine nature, so that those who fail to glorify him in practicing this dual respect for god and nature are “without excuse.” gus speth, co-founder of the nrdc and ceo of the un development program, had some insights worthy of consideration: i used to think that top environmental problems were biodiversity loss, ecosystem collapse and climate change. i thought that thirty years of good science could address these problems. i was wrong. the top environmental problems are selfishness, greed and apathy, and to deal with these we need a cultural and spiritual transformation.20 conclusion a lifetime of environmental observations, my scientific and medical training, my engagement with the public sector, and my faith in god all point to the conclusion that the earth is sick and “dying” as we face the 6th great extinction crisis, traced mostly to human activities.21 only with an unprecedented coming together of diverse partners, including the faith community, to care for our common home can we maintain our life support systems, see the world transformed, and protect the most vulnerable in our societies. the signs and symptoms of an ailing earth in 2020/21 are myriad: record heat and co2 levels, with drought, population displacement and migration; extensive wildfires—e.g., australia, brazil, california; wild atlantic hurricane and pacific typhoon seasons; major floods in china; irreplaceable bio-diversity loss; and loss of the arctic ice shield, our planet’s air conditioning system.22 how can we regain and foster hope and see healing in our ailing world? addressing climate change can have many benefits for population health. based on decades of research, the lancet in 2018 published a review which stated that while climate change was the greatest threat to public health, addressing climate change could be the “greatest global health opportunity of the 21st century,”23 as climate action at scale has immediate health co-benefits. as an epidemiologist, i worry that we have no controls; that we do not know what happens to a planet exposed to such widespread insults, since we have not been here before. this editorial therefore issues a call to all doctors, nurses, faith leaders, and public health professionals to awaken to the climate and health crisis at hand; get better informed and then act to improve the health of individuals, society, and the planet to avoid a catastrophe. god made the world and everything in it, and remarked upon the goodness of all of creation, interdependent for their lives and livelihoods, but corrupted at the core. god’s work is to make all things new and to establish justice and peace. he asks us to join in that objective. in serving god and caring for others and the environment, there is no conflict. we must recognize the importance of human activity both to draw down or to build up human and planetary health. in many ways, we are exceeding the amazing regenerative capacity of the underlying natural systems on which our health and well-being, lives and livelihoods depend. in order to restore the balance and to mitigate catastrophe, aligning with divine objectives and seeking his participation is a good starting place. 6 hospedales july 2021. christian journal for global health 8(1) “may god give us the grace to come together in one accord to care for all that he has created.” earthnurse candace scofield, trinidad. references 1. intergovernmental panel on climate change. ipcc fifth assessment report [internet]; 2014. available from: https://www.ipcc.ch/site/assets/uploads/2018/02/ar5 _syr_final_spm.pdf 2. nasa. the causes of climate change. global climate change: vital signs of the planet. [internet] available from https://climate.nasa.gov/causes/ 3. noaa research news. carbon dioxide peaks near 420 parts per million at mauna loa observatory [internet]; 2021 june 7. available from: https://research.noaa.gov/article/artmid/587/articlei d/2764/coronavirus-response-barely-slows-risingcarbon-dioxide 4. united nations climate change. the paris agreement [internet]; 2016. available from: https://unfccc.int/process-and-meetings/the-parisagreement/the-paris-agreement 5. united nations climate change. global climate action pathway finance vision and summary [internet]; 2021. available from: https://unfccc.int/sites/default/files/resource/finance_ vision%26summary.pdf 6. lenderking hl, robinson s, carlson g. climate change and food security in caribbean small island developing states: challenges and strategies. international journal of sustainable development & world ecology. 2020 aug 11;28(3):238-245. https://doi.org/10.1080/13504509.2020.1804477 7. julca a, paddison o. vulnerabilities and migration in small island developing states in the context of climate change. nat hazards. 2010;55:717–728. https://doi-org.online.uchc.edu/10.1007/s11069-0099384-1 8. mitchell r b, grills n j. a historic humanitarian collaboration in the pacific context. christ j global health. 2017 jul;4(2):87-94. https://doi.org/10.15566/cjgh.v4i2.160 9. world data.info. the climate in trinidad and tobago. [internet]. available from: https://www.worlddata.info/america/trinidad-andtobago/climate.php 10. rampersad s. destruction of the northern range between 1987-2018. . . 276,000 acres ravaged by fire [internet]. trinidad & tobago guardian. 2021 jul 26. available from: https://www.guardian.co.tt/news/destruction-of-thenorthern-range-6.2.802110.0bc76ef0b3 11. eitzinger a, farrell a, rhiney k, camona s, van loosen i, taylor m. trididad & tobago: assessing the impact of climate change on cocoa and tomato [internet]. international center for tropical agriculture policy brief no. 27. december 2015. available from: https://cdkn.org/wpcontent/uploads/2014/04/ciat_pb27_trinidadand-tobago-assessing-the-impact-ofclimate-change-on-cocoa-andtomato.pdf 12. hospedales cj. caribbean public health: achievements and future challenges. the lancet public health. 2019 july 1;4(7):e324. https://doi.org/10.1016/s2468-2667(19)30102-1 13. olowokure b, francis l, polson-edwards k, nasci r, quénel r, aldighieri s, rousset d, gutierrez c, ramon-pardo p, dos santos t, hospedales cj. the caribbean response to chikungunya. the lancet infectious diseases. 2014 nov 11;4(11):1039-1040. https://doi.org/10.1016/s1473-3099(14)70948-x 14. francis l, hunte s-a, valadere am, polson-edwards k, asin-oostburg v, hospedales cj. zika virus outbreak in 19 englishand dutch-speaking caribbean countries and territories, 2015-2016. revista panamericana de salud pública. 2018;42: e120. 15. iwamura t, guzman-holst a, murray k. accelerating invasion potential of disease vector aedes aegypti under climate change. nature commun. 2020;11: 2130. https://doi.org/10.1038/s41467-020-16010-4 16. london jb. implications of climate change on small island developing states: experience in the caribbean region. journal of environmental planning and management. 2007 jan 22;47(4):491-501. https://doi.org/10.1080/0964056042000243195 17. greenfield p. humans exploiting and destroying nature on unprecedented scale – report [internet]. the guardian. 2020 sept 9. available from: https://www.theguardian.com/environment/2020/sep/ 10/humans-exploiting-and-destroying-nature-onunprecedented-scale-report-aoe https://www.ipcc.ch/site/assets/uploads/2018/02/ar5_syr_final_spm.pdf https://www.ipcc.ch/site/assets/uploads/2018/02/ar5_syr_final_spm.pdf https://climate.nasa.gov/causes/ https://research.noaa.gov/article/artmid/587/articleid/2764/coronavirus-response-barely-slows-rising-carbon-dioxide https://research.noaa.gov/article/artmid/587/articleid/2764/coronavirus-response-barely-slows-rising-carbon-dioxide https://research.noaa.gov/article/artmid/587/articleid/2764/coronavirus-response-barely-slows-rising-carbon-dioxide https://unfccc.int/process-and-meetings/the-paris-agreement/the-paris-agreement https://unfccc.int/process-and-meetings/the-paris-agreement/the-paris-agreement https://unfccc.int/sites/default/files/resource/finance_vision%26summary.pdf https://unfccc.int/sites/default/files/resource/finance_vision%26summary.pdf https://doi.org/10.1080/13504509.2020.1804477 https://doi-org.online.uchc.edu/10.1007/s11069-009-9384-1 https://doi-org.online.uchc.edu/10.1007/s11069-009-9384-1 https://doi.org/10.15566/cjgh.v4i2.160 https://www.worlddata.info/america/trinidad-and-tobago/climate.php https://www.worlddata.info/america/trinidad-and-tobago/climate.php https://www.guardian.co.tt/news/destruction-of-the-northern-range-6.2.802110.0bc76ef0b3 https://www.guardian.co.tt/news/destruction-of-the-northern-range-6.2.802110.0bc76ef0b3 https://cdkn.org/wp-content/uploads/2014/04/ciat_pb27_trinidad-and-tobago-assessing-the-impact-of-climate-change-on-cocoa-and-tomato.pdf https://cdkn.org/wp-content/uploads/2014/04/ciat_pb27_trinidad-and-tobago-assessing-the-impact-of-climate-change-on-cocoa-and-tomato.pdf https://cdkn.org/wp-content/uploads/2014/04/ciat_pb27_trinidad-and-tobago-assessing-the-impact-of-climate-change-on-cocoa-and-tomato.pdf https://cdkn.org/wp-content/uploads/2014/04/ciat_pb27_trinidad-and-tobago-assessing-the-impact-of-climate-change-on-cocoa-and-tomato.pdf https://cdkn.org/wp-content/uploads/2014/04/ciat_pb27_trinidad-and-tobago-assessing-the-impact-of-climate-change-on-cocoa-and-tomato.pdf https://doi.org/10.1016/s2468-2667(19)30102-1 https://doi.org/10.1016/s1473-3099(14)70948-x https://doi.org/10.1038/s41467-020-16010-4 https://doi.org/10.1080/0964056042000243195 https://www.theguardian.com/environment/2020/sep/10/humans-exploiting-and-destroying-nature-on-unprecedented-scale-report-aoe https://www.theguardian.com/environment/2020/sep/10/humans-exploiting-and-destroying-nature-on-unprecedented-scale-report-aoe https://www.theguardian.com/environment/2020/sep/10/humans-exploiting-and-destroying-nature-on-unprecedented-scale-report-aoe 7 hospedales july 2021. christian journal for global health 8(1) 18. almond rea, grooten m, petersen t. (eds). living planet report 2020 bending the curve of biodiversity loss [internet]. wwf, gland, switzerland. 2020. available from: https://www.wwf.org.uk/sites/default/files/202009/lpr20_full_report.pdf 19. francis. encyclical letter laudato si’ of the holy father francis on the care for our common home. [internet] 2015. available from: https://www.vatican.va/content/francesco/en/encyclic als/documents/papa-francesco_20150524_enciclicalaudato-si.html 20. speth g. gus speth calls for a new environmentalism [audio program]. living on earth; 2016 may 5. available from: https://loe.org/shows/segments.html?programid=15p13-00007&segmentid=6 21. n ceballos g, ehrlich pr, raven ph. vertebrates on the brink as indicators of biological annihilation and the sixth mass extinction. proceedings of the national academy of sciences. 2020 jun;117(24):1359613602. https://doi.org/10.1073/pnas.1922686117 22. nuccitelli d, masters j. the top 10 weather and climate events of a record-setting year [internet]. yale climate connection. 2020 dec 21. available from: https://yaleclimateconnections.org/2020/12/the-top10-weather-and-climate-events-of-a-record-settingyear/ 23. watts n, amann m, ayeb-karlsson s, belesova k, bouley t, boykoff m, et.al. the lancet countdown on health and climate change: from 25 years of inaction to a global transformation for public health. the lancet 2018 feb 10-16;391(10120):581-630. https://doi.org/10.1016/s0140-6736(17)32464-9 submitted: 15 july 2021, modified 28 july 2021, accepted 29 july 2021, published 30 dec 2021 competing interests: none declared. correspondence: dr. james hospedales, trinidad & tobago jameshospedales@earthmedic.com cite this article as: hospedales cj. caring for the earth for better health and well-being of all: addressing climate change as a planetary health emergency. christ j global health. july 2021; 8(1):3-7. https://doi.org/10.15566/cjgh.v8i1.575 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org https://www.wwf.org.uk/sites/default/files/2020-09/lpr20_full_report.pdf https://www.wwf.org.uk/sites/default/files/2020-09/lpr20_full_report.pdf https://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html https://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html https://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html https://loe.org/shows/segments.html?programid=15-p13-00007&segmentid=6 https://loe.org/shows/segments.html?programid=15-p13-00007&segmentid=6 https://doi.org/10.1073/pnas.1922686117 https://yaleclimateconnections.org/2020/12/the-top-10-weather-and-climate-events-of-a-record-setting-year/ https://yaleclimateconnections.org/2020/12/the-top-10-weather-and-climate-events-of-a-record-setting-year/ https://yaleclimateconnections.org/2020/12/the-top-10-weather-and-climate-events-of-a-record-setting-year/ https://doi.org/10.1016/s0140-6736(17)32464-9 mailto:jameshospedales@earthmedic.com https://doi.org/10.15566/cjgh.v8i1.575 http://creativecommons.org/licenses/by/4.0/ case report june 2022. christian journal for global health 9(1) acute suppurative thyroiditis in a post arteriovenous shunt infection patient ferdy royland marpaunga, aryati b, sidarti soehitac a department of clinical pathology, faculty of medicine, univeritas airlangga dr.soetomo hospital, surabaya, indonesia abstract acute suppurative thyroiditis (ast) is a rare clinical entity that must be treated immediately because of its morbidity, especially swelling in the thyroid area accompanied by fever. ast is often preceded by infection at another site; therefore, it is important to identify the source. a 40-year-old woman came to the dr. soetomo general hospital complaining of pain and swelling in the neck, difficulty swallowing, and fever. the patient suffered from chronic kidney disease. one week before, she had an infected arteriovenous hemodialysis shunt. laboratory results showed an increased ft4 (3.5 ug/dl) and a decreased tsh (0.015 uiu/ml), leukocytosis, and a raised c reactive protein (crp). thyroid ultrasound showed an abscess involving the entire left thyroid. thyroid fine needle biopsy showed ast. culture of the pus grew staphylococcus aureus. the thyroid tests supported the diagnosis of ast with hyperthyroidism; immediate treatment was indicated. three weeks after treatment, the patient was euthyroid and still had drainage of the wound. the ast was considered to be secondary to the hemodialysis av shunt infection. leukocytosis and increased crp levels supported the presence of inflammation and culture grew staphylococcus aureus. the patient improved with clindamycin therapy. to our knowledge, this is the first ast case preceded by hemodialysis av shunt infection. key words: acute suppurative thyroiditis, hyperthyroid, chronic kidney disease, arteriovenous shunt, haemodialysis introduction thyroiditis is inflammation of the thyroid that can be caused by an autoimmune disorder, as well as viral, bacterial, fungal, and other infections.1 acute suppurative thyroiditis (ast) is rare, accounting for only 0.1%–0.7% of all thyroid disorders. ast is more common in patients with hashimoto's thyroiditis and thyroid cancer. a predisposition is associated with the persistence of ducts originating from the 3rd or 4th bronchial sac which can lead to recurrent abscess. most infections spread to the thyroid gland via a piriform sinus shunt. the left lobe of the thyroid gland is more commonly affected. ast can be life-threatening with a mortality rate of marpaung, aryati & soehita 106 12% or more due to thyroid storm and sepsis.2 the diagnosis can be delayed due to atypical clinical features. ast is rare because of the bactericidal nature of colloidal materials, increased vascularity, and the presence of iodine. a thyroid abscess presents as a very painful swelling. the differential diagnosis for thyroid gland pain is subacute and chronic thyroiditis.3 patient information a 40-year-old woman was admitted to the hospital with the chief complaint of swollen neck pain for 2 days, accompanied by difficulty swallowing and fever. the patient had never had the same complaint before. one week previous, the patient had surgery due to infection in the av hemodialysis shunt. the patient had a history of chronic kidney failure (ckd) stage v for one month and underwent hemodialysis twice weekly. the patient had hypertension for about 7 years, but there was no history of diabetes mellitus or thyroid disorders. clinical findings (upon arrival to er) the patient was generally weak, but conscious (gcs 4-5-6), with blood pressure 110/70 mmhg, pulse of 92/minute, respiration rate of 20/minute, and axilla temperature of 38°c. other physical findings revealed left anterior swelling of neck which was warm and tender, size 4–5 cm, moving up and down when swallowing, and painful (figure 1). figure 1. swollen and painful left side of the neck of patient. diagnostic assessment the patient underwent laboratory testing including serial hematologic testing, clinical chemistry testing, and thyroid hormone function testing (tables 1–4). table 1. hematologic examination hematology day 1 (er) day 6 day 9 day 18 wbc (x 103/µl) 17.15 22.98 8.62 7.07 neu (%) 87.1 86.3 77.8 72.0 lym (%) 8.4 6.53 17.41 11.9 mono (%) 3.6 5.34 6.55 8.2 eos (%) 0.2 0.01 0.59 0.5 baso (%) 0.5 0.44 0.6 0.2 107 marpaung, aryati, soehita june 2022. christian journal for global health 9(1) rbc x 106/µl 4.08 4.030 4.126 3.95 hb (g/dl) 8.7 8.3 6.7 7.7 hct % 36.8 36.64 35.28 33.2 mcv (fl) 90.2 85.94 85.51 84.1 mch (pg) 30.2 30.43 30.93 29.9 mchc (g/dl) 33.5 35.41 36.17 35.5 rdw (%) 14.1 13.03 12.75 13.2 platelet (x103/µl) 100 121 114 128 table 2. clinical chemistry examination parameter day 1 day 6 day10 day 13 day 17 ref range na (mmol/l) 133 139 140 135 134 136–144 k (mmol/l) 5.1 4.1 3.5 4.9 3.6 3.8–5.0 cl (mmol/l) 100 99 105 104 103 97–103 ca (mg/dl) 7.2 8 8.6 8.4 8.5–10.1 pho (mg/dl) 6 6.1 5.6 2.5–4.9 alb (g/dl) 3.2 3.1 3.2 3.4 3.1 3.4–5.0 ua (mg/dl) 10.4 4.9 2.6–7.2 crp (mg/dl) 12 <5 table 3. thyroid plasma examination parameter day 1 day 8 day13 day 15 day 20 day 30 ref range ft4 (ug/dl) 3.5 3.73 1.8 1.68 1.21 1.10 0.89–1.76 tsh (uiu/nl) 0.015 0.015 0.02 0.018 0.02 0.59 0.55–4.78 antitpo (iu/ml) neg (27) <50: neg 50–75: bl >75: pos anti trab (iu/l) neg 0.00–1.73 table 4. immunology examination parameter day 5 day 7 ref range hbsag non reactive hiv non reactive ana tets 24.56 c3 (mg/l) 85 c4 (mg/dl) 49 marpaung, aryati & soehita 108 ultrasonography (usg) of neck showed an abscess involving the entire left lobe of the thyroid with a size of 3.54 x 2.2 x 5.49 cm. a smear from a fine needle aspiration biopsy (fnab) contained a distribution of lymphocytes and polymorphonuclear (pmn) cells as well as macrophage cysts against a broad erythrocyte background. the pathological diagnosis was acute suppurative thyroiditis (figure 2). culture of the pus grew staphylococcus aureus sensitive to gentamycin, ampicillin-sulbactam, oxacillin, cotrimoxazole, erythromycin, clindamycin, quinupristin-dalfopristin, levofloxacin, moxifloxacin, but resistant to ampicillin and tetracycline. figure 2. fnab results show an ast therapeutic interventions the patient was treated initially with ceftriaxone, 1g every 12 hours, then on day 12 changed to clindamycin oral, 300 every 12, when the culture and sensitivity results became available. the head and neck surgeon planned to perform incisiondrainage of the abscess after patient had become stable and had normal thyroid function. this patient also received amlodipine oral 10mg per day, paracetamol 500mg oral, thyrozol 10mg oral, propranolol 10mg oral, folic acid 1mg oral, and haemodialysis as scheduled 2 times/week. follow up and outcomes on follow up, the patient was clinically well with no fever. the patient’s abscess was drained at day 31. discussion abscess formation frequently occurs in children due to anatomic abnormalities such as piriform sinus fistulas. thyroid abscesses in adults are extremely rare and may be caused by foreign body trauma (fnab, fishbone) and anatomical pressure. hematogenous spread from distant sites is known to be the most common cause of thyroid infection, although the exact mechanism is unknown. the manifestation of thyroiditis is mostly local pain in the involved lobe, accompanied by pain and difficulty of swallowing. symptoms of fever and chills may occur depending on the virulence of the microorganism and the occurrence of sepsis. 1-2,4-8 primary thyroid abscess from ast is a rare type of head and neck infection because the thyroid gland is known to have infection-resistant mechanisms. thyroid protection includes a rich blood supply and lymphatic drainage, high iodine content of the gland which is bactericidal, separation of the gland from other neck structures by the fascial plane, and formation of hydrogen peroxide within the gland for thyroid hormone synthesis. ast is usually more painful than in patients with subacute thyroiditis. subacute thyroiditis usually displays as severe localized tenderness, but is less likely to be thyrotoxic (60% of patients).1 this patient had left neck lump pain followed by fever, and difficulty in swallowing. it was suspected that there had been hematogenous spread of bacteria creating thyroid infection because the patient had just had an av haemodialysis shunt transfer operation 1 week earlier. prior to the surgery, the patient experienced fever, chills, and the left av haemodialysis shunt was starting to have a 109 marpaung, aryati, soehita june 2022. christian journal for global health 9(1) red and painful swelling. the patient had had a pseudoaneurysm repair related to prior av shunt infection. the patient had leukocytosis and elevated crp that supported signs of inflammation. high ft4 levels and low tsh levels indicated a hyperthyroid condition. hyperthyroidism in thyroiditis may occur naturally over weeks to months. these patients should be treated immediately because ast is a lifethreatening condition (12% of mortality if not treated immediately). mortality may occur in result of thyroid storm and sepsis. thyroid storm develops when hyperthyroidism is not treated, resulting in symptoms of fever, increased pulse, blood pressure, nausea, vomiting, and agitation. ultrasound examination revealed an abscess in the thyroid gland or evidence of lobe enlargement, while fnab determined the presence of infection, done simultaneously with culture.1 the patient's ultrasound showed an abscess involving almost the entire left lobe of the thyroid with a size of 3.54 x 2, 2 x 5.49 cm. fnab results showed that the smear contained the distribution of lymphocytes and pmn cells and cyst macrophages with an erythrocyte background; no signs of malignancy were found. drainage-incision of the thyroid abscess was planned after euthyroid status had been achieved. basic incision and drainage is a necessary surgical procedure as therapy, but care must be taken to treat hyperthyroidism first to avoid postoperative thyroid storm and other unwanted metabolic effects. although this condition is rare (0–14%), the clinician avoided the possibility of a thyroid storm.9 therefore, in the early stages, the clinician recommends giving antibiotic and antithyroid therapy to treat thyrotoxicosis. appropriate antibiotics should be given accordingly to the causative organism. culture of the aspirate of this patient exhibited significant growth of staphylococcus aureus. the patient came to the hospital and received an injection of ceftriaxone 1gram intravenous daily for two days as empiric treatment. furthermore, after the results of the culture antibiogram were released, the patient's antibiotic was changed to clindamycin, 300 mg orally twice a day, starting on the 14th day. several previous case reports showed that the bacteria causing thyroid abscess was methicillin-resistant s. aureus (mrsa) which was not sensitive to ceftriaxone.10 the culture results in this patient showed sensitivity to oxacillin, indicating that this s. aureus was not mrsa. the oral therapy given was clindamycin, because this drug is safe for ckd patients. the patient also suffered from ckd which is able to cause immune system disorders. disorders can be in the form of systemic inflammation and immunosuppression.11 there is an increase in proinflammatory cytokines in ckd such as pentraxin, in addition to dysfunction of phagocytes, b and t cells.12-15 haemodialysis therapy is the key to improving the general condition and the patient’s immune system. the patient had incision and drainage done after thyroid function became normal. the prognosis is excellent with maintenance of normal thyroid function; however, post-thyroiditis thyroid function tests should be monitored to ensure that a thyroid disorder is not ongoing. to our knowledge, this is the first case report of suspected haemodialysis av shunt infection causing hematogenous spread to the thyroid organ leading to ast. conclusion the patient was diagnosed with ast that was probably caused by post-infectious av shunthaemodialysis. we recommend that cases of neck swelling and fever after infection with av haemodialysis shunt undergo a thorough thyroid testing, ultrasound, and fnab for early diagnosis of ast, and timely treatment because of its lifethreatening nature. references 1. brent g, larsen p, davis t. williams textbook of endocrinology. 13th ed. melmed s, polonsky ks, marpaung, aryati & soehita 110 larsen pr, kronenberg hm, editors. canada: elsevier; 2016. 442-5 p 2. paes je, burman kd, cohen j, franklyn j, mchenry cr, shoham s, et al. acute bacterial suppurative thyroiditis: a clinical review and expert opinion. thyroid. 2010 mar;20(3):247-55. http://doi.org/10.1089/thy.2008.0146 3. lamani yp, basarkod si, telkar sr, goudar b v, ambi u. 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update. toxins. 2012;4(11):962-90. https://doi.org/10.3390/toxins4110962 peer reviewed: submitted 27 sept 2021, accepted 19 jan 2022, published 20 june 2022 competing interests: none declared. correspondence: ferdy royland marpaung, indonesia. ferdyoke@gmail.com cite this article as: marpaung fr, aryati, soehita s. acute suppurative thyroiditis in post arteriovenous shunt infection patient. christ j global health. june 2022; 9(1):105-110. https://doi.org/10.15566/cjgh.v9i1.583 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://doi.org/10.1089/thy.2008.0146 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v9i1.583 about:blank abstract introduction patient information clinical findings (upon arrival to er) diagnostic assessment the patient underwent laboratory testing including serial hematologic testing, clinical chemistry testing, and thyroid hormone function testing (tables 1–4). table 1. hematologic examination table 2. clinical chemistry examination table 3. thyroid plasma examination table 4. immunology examination ultrasonography (usg) of neck showed an abscess involving the entire left lobe of the thyroid with a size of 3.54 x 2.2 x 5.49 cm. a smear from a fine needle aspiration biopsy (fnab) contained a distribution of lymphocytes and polymorphonuclear (pmn)... therapeutic interventions the patient was treated initially with ceftriaxone, 1g every 12 hours, then on day 12 changed to clindamycin oral, 300 every 12, when the culture and sensitivity results became available. the head and neck surgeon planned to perform incision-drainage... follow up and outcomes on follow up, the patient was clinically well with no fever. the patient’s abscess was drained at day 31. discussion conclusion references case reports july 2021. christian journal for global health 8(1) carcinoma of the breast in low resource setting: a surgical case series from rural india royson dsouzaa, anish jacobb, mrudula raoc, nandakumar menond a mbbs, ms, consultant surgeon, ashwini gudalur adivasi hospital, the nilgiris, tamil nadu, india b mbbs, ms, mch, assistant professor, department of endocrine surgery, christian medical college, vellore, india c mbbs, md, medical superintendent, ashwini gudalur adivasi hospital, the nilgiris, tamil nadu, india d mbbs, facs, dabs, director, ashwini health system and gudalur adivasi hospital, the nilgiris, tamil nadu, india abstract the burden of breast cancer has been on the rise world over and has become the most common cancer among women in urban india and the second most common cancer in rural women after carcinoma cervix. there is a considerable delay in presentation, associated with a lack of access to adequate and timely surgical intervention. consequently, most patients present to tertiary care centers in advanced or inoperable stages. many subsets of these patients can be managed adequately in resource-limited rural surgical centers. in this series of patients diagnosed with carcinoma breast, we have outlined comprehensive management possible in resource-constrained settings. the challenges in adhering to the standard of care and strategies to overcome these limitations have been discussed with a relevant review of the literature. key words: carcinoma of the breast, surgery, low resource, management, india introduction the lancet oncology commission’s projections for new cancers by 2030 worldwide are estimated to be 21.6 million of which 17.3 million will require surgery. of these, 10 million will be from low-and middle-income countries (lmics) like india. in lmics, three-quarters of the surgical burden will be from cancers of the breast, head and neck, esophagus, stomach, lung, cervix, and prostate.1 breast cancer is the most common cancer among women in high income countries.2 with the rising incidence of breast carcinoma the world over, it has become the most common cancer among women in urban india and the second most common cancer among rural women after carcinoma of the cervix.2–5 the various myths as well as the prevalent ignorance common in indian society are counterproductive in raising awareness about breast cancer.6 in addition, denial of the disease, fear of treatment, and social/financial issues contribute to the majority presenting late.4,5,7,8 this delay in presentation is especially true for patients coming from a lower socioeconomic status, and in addition to the above factors, there is a lack of access to adequate and timely surgical care for this subset of patients.4,9-11 the cases described in this series were managed at the association for health welfare in 79 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) the nilgiris (ashwini), a health network that directly serves approximately 20,000 tribal population spread across the nilgiris mountains of gudalur and pandalur in the state of tamil nadu, south india. there are five separate adivasi tribes living in nearly 350 hamlets. ashwini healthcare is decentralized with eight area health centres that have two community health nurses who conduct outreach clinics in villages, screening for cancers among other healthcare activities. if patients are diagnosed with a suspicious breast lump during screening, they are then referred to ashwini gudalur adivasi hospital for further management. the hospital has 50 well equipped beds with two operating rooms and facilities for ultrasound, plain radiography, laparoscopy, gastroscopy, and a laboratory and blood bank where the treatment is completely free. through these series of cases, we describe various clinical presentations of breast cancer and our management strategies in each case. consent was obtained from each patient for their case to be reported. clinical case series case 1 a 64-year-old woman presented with complaints of a painless mass in the left breast for two months that rapidly progressed in size. there was no history of nipple discharge or skin changes. she attained menopause at 50 years of age and had normal menstrual cycles prior. there was no family history of brca-associated malignancies. on examination, there was a mass in the upper quadrant of the left breast measuring 5x4 cm that had an irregular surface, hard consistency, and restricted mobility. there was no infiltration into the underlying pectoral muscles or the skin. there was a single mobile lymph node palpable in the left axilla. the right breast and axilla were unremarkable. with a clinical suspicion of carcinoma left breast, the patient underwent further evaluation. breast ultrasonogram (usg) showed an irregular hypoechoic mass in the left breast without axillary lymphadenopathy characterized as a birads 5 lesion. a core biopsy confirmed invasive carcinoma of the left breast. following this, the patient underwent upfront surgery. in view of the palpable axillary lymph node, a left modified radical mastectomy (mrm) was performed (figure 1). the final histopathology was consistent with invasive carcinoma of the left breast t2n0, immunohistochemistry (ihc) showing er and pr positivity while her2 neu was negative. the ki67 index was reported to be 7%. the patient received hormonal therapy alone with tamoxifen and was well on annual follow up. figure 1. left modified radical mastectomy specimen case 2 a 55-year-old woman presented with a history of a painless mass in the right breast that progressively increased in size over 2 months. there was no involvement of skin or nipple areola complex. she underwent a hysterectomy at 40 years of age for fibroid uterus. there was no family history of brca-associated malignancies. on examination, there was a mass in the upper quadrant of the right breast measuring 3x3 cm that was firm, irregular, and with restricted mobility. the right axillary lymph nodes were not palpable. the left breast and axilla were normal. an usg of the right breast showed a birads 5 lesion without axillary lymphadenopathy. a core biopsy was suggestive of mucinous carcinoma which was positive for er, pr, and negative for her2neu. as she had an early breast cancer with favorable ihc, she was offered 80 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) upfront surgery. due to the covid-19 pandemic and travel restrictions, mammography was not obtained, as the closest facility for the same was three hours away. the patient requested breast conservation surgery (bcs) and was motivated to undergo post-operative radiation therapy as well as frequent follow up. bcs was performed along with level 1 and 2 right axillary lymphadenectomy (figure 2). the histopathology confirmed mucinous carcinoma with adequate margins and absent lymph nodal metastasis (t2n0, er+, pr+, her2 neu -, ki67 index 7%). as a radiation therapy facility was not available at our hospital, she completed 25 cycles of radiation therapy at a cancer center and is on regular follow up on hormonal therapy without evidence of disease recurrence after 1 year. figure 2. breast conservation surgery with level 1 and 2 axillary lymphadenectomy case 3 a 45-year-old woman presented with complaints of a painful mass in the right breast for 3 months. on examination, she was severely emaciated and had features of systemic inflammatory response syndrome (sirs) with hypotension. there was an 8x6 cm ulceroproliferative growth occupying the entire right breast destroying the nipple areola complex. the growth had copious foul-smelling discharge and maggots. it was tender on palpation with superficial infection and was fixed to the chest wall. there were multiple right axillary lymph nodes palpable. her haemoglobin was 7.6g/dl, alp was 391u, and chest radiograph showed bilateral pleural effusion. the nature of disease and prognosis was explained to the patient’s family. in view of advanced disease and poor outcomes, they opted for non-escalation of treatment. the patient was offered best comfort care with local debridement and palliative chemotherapy and succumbed to the disease within a week. case 4 a 47-year-old woman with type 2 diabetes mellitus presented with a slowly progressive left breast lump for 6 months. there was no history of skin changes or nipple discharge. on examination, there was a 2x2 cm firm lump with restricted mobility in the upper outer quadrant of the left breast. it was free from the underlying muscle and 81 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) overlying skin. the left axillary nodes were not palpable. breast usg showed a solid, irregular lesion without axillary lymphadenopathy (figure 3). core biopsy suggested a non-specific chronic inflammatory lesion without evidence of malignancy. a lumpectomy was done but the final histopathology was consistent with invasive carcinoma. she then underwent a modified radical mastectomy, the histopathology reporting invasive ductal carcinoma t2n0 which was triple negative (tnbc) with ki67 index of 67%. she underwent adjuvant chemotherapy at a tertiary center and was well on follow up. figure 3. ultrasonography image of the left breast showing a solid irregular lump discussion the management of breast cancer has been rapidly evolving with an increased focus on multimodal therapy which includes surgery, radiation therapy, chemotherapy, targeted therapy, and hormonal therapy. working as general surgeons at a tribal secondary care hospital in india, with limited diagnostic facilities and nonavailability of an oncologist and a radiation therapist, we have made an attempt to describe how best such patients can be managed. screening and health education currently, breast cancer awareness programs in india are focused to cities and have not reached the rural areas.5,6 a rural surgeon caters to a defined population and is ideally suited to spearhead screening programs for the detection of common cancers in that geographic location.12 in addition, through these outreach programs, health education regarding breast cancer with special emphasis on risk factors, symptoms, and breast self-examination can be taught.3,4 ashwini integrated healthcare has dedicated community health nurses, village health volunteers, and animators who conduct outreach clinics where health education and screening are performed. they encourage patients to seek appropriate care when breast lumps are detected. the rapport they have with the local community help them educate the community with regards to the various myths as well as the prevalent ignorance that is common, building an awareness about breast cancer. in addition, they can help alleviate fear of the disease and its treatment as well as aid access to adequate and timely surgical care for this subset of patients. this has resulted in early detection of breast cancer in patients and treatment with curative intent. this may be a model that can be replicated in other rural areas for breast cancer screening and education. evaluation of breast lump the importance of clinical evaluation cannot be over emphasized in the diagnosis of carcinoma breast.13 this is even more important in rural areas where the options for second opinion and aid of advanced imaging are scarce. triple evaluation, that comprises clinical history and examination, imaging with ultrasound and mammography, and pathological tests with core biopsy have increased the overall diagnostic accuracy in detecting breast malignancies.14 mammography is not available at our hospital, necessitating reliance on ultrasonography for breast imaging. similarly, due to the lack of an in-house pathologist, core biopsy specimens need to be transported to the closest tertiary care center (5 hours away) for reporting, and the results are available only after 10–14 days. 82 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) these limitations cause a delay in the initiation of appropriate treatment. surgeon performed ultrasonography ultrasonography (usg) is a valuable addition to a general surgeon’s diagnostic acumen and is rapidly becoming an integral part of clinical practice.15,16 non-availability of a radiologist at our centre makes it crucial for the surgeon and family physician to perform usg. a rural surgeon should be competent to perform diagnostic ultrasound of the breast, thyroid, focused assessment with sonography in trauma (fast), and vascular systems.15 usg can often resolve the clinical dilemma of various breast lumps.17 moreover, it is a helpful tool in performing focused aspiration cytology or core biopsy. similarly, usg of the abdomen is the diagnostic modality of choice for evaluation of intraperitoneal metastasis. in case 2, bcs was performed after ruling out multifocal disease solely on usg. although mammography is crucial before planning a bcs, if circumstances do not allow for the same, a good usg evaluation can still be used.18 fnac, core biopsy, and immunohistochemistry fnac is an inexpensive, easily available, and easy to perform procedure that has a good sensitivity and specificity for detection of breast cancer. fnac has been the diagnostic procedure of choice for patients with breast lumps in the past. core biopsy increases diagnostic accuracy in addition to providing tissue for immunohistochemistry that, in turn, helps in prognosticating the disease.19 currently, the primary modality of treatment for patients with breast cancer is dependent on hormone receptor status. although these tests can be easily performed, the availability of a pathologist and procurement of core biopsy needles are a challenge in rural centers. as mentioned earlier, we do not have an inhouse pathologist and have to rely on the closest tertiary care center. core biopsy needles are procured as donations from tertiary care centers, which are re-used after adequate sterilization to minimize costs. in spite of the above hurdles, we perform core biopsies on all breast lumps as this is the standard of care the world over. multidisciplinary team (mdt) meeting the management of breast cancer is rapidly evolving. therefore, multidisciplinary, teambased meetings for appropriate management of patients with carcinoma of the breast have taken a big lead in recent years.20,21 this team consists of endocrine and breast oncosurgeons, radiologists, pathologists, medical and radiation oncologists, and breast care nurses.22 this is not possible or practical in rural hospitals where the surgeon must play a paramount role in diagnosis, staging, and planning treatment. however, with the advancement in technology and connectivity, online mdt meetings can be scheduled in collaboration with tertiary care centers that can help in planning optimal management for each patient.23 in our series, cases 2 and 4 were discussed in an mdt meeting with a tertiary care centre via emails and online meeting platforms and appropriate decisions were made. surgery for breast carcinoma mrm remains the most common procedure performed for breast cancer in india.10 with the evolution of chemotherapeutic agents, modalities for radiation, and hormone therapy, the extent of surgery has reduced considerably.22,24 however, adherence to adjuvant therapy remains questionable among patients from rural areas.4,8 this lack of adherence is a problem we face at our hospital as well. in addition, lack of a radiologist and reliance on usg of the breast performed by a surgeon for the assessment of the axillary nodal status has resulted in mrm being the most common surgery performed at our hospital for breast cancer. bcs in rural surgical centers is neither popular among our patients nor our surgeons. there is a significant disparity, with bcs being more often received by patients in urban areas, higher socioeconomic status, and in areas with better accessibility to cancer care.25 though multiple studies have showed similar oncological 83 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) safety between bcs and mrm, the need for post bcs radiation to the breast limits its acceptance in rural hospitals.26-27 as seen from our series, there is a small subset of patients motivated for bcs and willing to undergo adjuvant radiation even if they have to travel to another centre for the same. a lot depends upon the rapport between the surgeon, the patient, and the family and the counselling conducted. therefore, we feel that the onus is on the surgeon to identify and offer conservation to those who are motivated. in patients with early breast cancer and node negative axilla on clinical/imaging, sentinel lymph node biopsy (slnb) has emerged as the standard of care for the surgical assessment of the axilla. this may be performed either by a dual tracer technique or a single dye technique. methylene blue dye alone has been showed to be safe, simple, and cost-effective with acceptable identification and positivity rates. therefore, in this subset of patients, slnb with methylene blue dye alone should be offered for the assessment of axillary lymph node status.7,24,28,29 though we have not performed slnb in the cases presented, this is a future direction we hope to take. breast reconstruction after mastectomy mastectomy influences the patient’s emotional stability leading to fear, hopelessness, depression, and a negative attitude about their body.2 breast reconstruction is an integral part of management of carcinoma of the breast, as it restores positive body image and quality of life in the patients.9 although the emphasis on reconstruction is shown mostly by breast focussed surgeons, rural surgeons can very well adapt it.30 options like microvascular free flaps may not be possible in rural hospitals due to the lack of infrastructure. however, pedicled flaps like pectoralis major and latissimus dorsi myocutaneous flaps are still feasible. moreover, secondary care hospitals are not limited by time constraints and long waiting lists that are common problems in tertiary care centres.4 chemotherapy and radiation therapy systemic therapy has become the cornerstone in the management of breast cancer. the development of newer chemotherapeutic agents has resulted in improved prognosis and survival. in addition, targeted therapy has positively impacted the management of patients with her 2 positive breast cancers. though most secondary care centers lack the expertise to provide systemic/targeted treatment, all these modalities can be made available and administered in a rural setting with help from medical oncologists at other centres.31 closer co-operation must be fostered between medical oncologists and surgeons to tailor simpler, cheaper, and less toxic chemotherapy regimens for patients who, for various reasons, are unable to go to tertiary care centers. hormonal therapy that is relatively inexpensive can be offered with greater interest as it is easier to administer and likely to have better compliance. radiation therapy on the other hand requires dedicated infrastructure as well as a trained radiation therapist. one must be able to counsel patients who require radiation to attend therapy at available centers. monitory aid in our experience, often patients have declined adjuvant treatment following surgery or have not completed adjuvant therapy due to financial constraints. our patients face two major types of cost: firstly, the direct cost associated with adjuvant therapy, admission, investigations, and the non-medical costs like transport, food, and lodging. secondly, the indirect costs due to loss of productivity and labor losses of the patient and family are significant. these areas are where government or non-government organizations will need to lend financial support. there are multiple opportunities for financial aid available for cancer patients, and the primary care provider and the rural surgeon—should be aware of the same. they can play a major role in mobilizing financial aid for these patients. 84 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) palliative care as depicted in case 3, a rural surgeon should be equipped to manage patients with locally advanced/metastatic disease who present in poor general condition. these patients require best comfort care with psychological and social support for the family. conclusion providing standard care at rural surgical centers is very challenging due to the lack of resources and expertise. however, as depicted in our series and discussion, a rural surgeon can overcome these limitations and provide optimal treatment for patients with breast cancer. in 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oncol. 2017 may 12;(4):1–11. https://doi.org/10.1200/jgo.2016.008672 peer reviewed: submitted 20 april 2021, accepted 28 june 2021, published 30 july 2021 competing interests: none declared. correspondence: royson dsouza, ashwini gudalur adivasi hospital, india. roy6dsouza@gmail.com https://doi.org/10.1007/978-1-4939-1495-1_13m http://saspublisher.com/wp-content/uploads/2017/11/sjams-511a4366-4370.pdf http://saspublisher.com/wp-content/uploads/2017/11/sjams-511a4366-4370.pdf http://saspublisher.com/wp-content/uploads/2017/11/sjams-511a4366-4370.pdf https://doi.org/10.4103/ijpm.ijpm_885_19 https://doi.org/10.14694/edbook_am.2014.34.e461 https://doi.org/10.4103/0019-509x.104486 https://doi.org/10.4103/0019-509x.104486 https://www.researchgate.net/publication/343985693_the_zooming_rural_surgeons https://www.researchgate.net/publication/343985693_the_zooming_rural_surgeons http://ace.amegroups.com/article/view/5463 https://doi.org/10.1007/s13193-016-0535-z https://ro-journal.biomedcentral.com/articles/10.1186/s13014-017-0796-x https://ro-journal.biomedcentral.com/articles/10.1186/s13014-017-0796-x https://ro-journal.biomedcentral.com/articles/10.1186/s13014-017-0796-x https://doi.org/10.1371/journal.pone.0204364 https://doi.org/10.1186/1477-7819-9-19 https://doi.org/10.1111/jrh.12396 https://doi.org/10.1200/jgo.2016.008672 mailto:roy6dsouza@gmail.com 86 dsouza, jacob, rao & menon july 2021. christian journal for global health 8(1) cite this article as: dsouza r, jacob a, rao m, menon n. carcinoma of the breast in low resource setting: a surgical case series from rural india. christian journal for global health. july 2021; 8(1):78-86. https://doi.org/10.15566/cjgh.v8i1.539 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org https://doi.org/10.15566/cjgh.v8i1.539 http://creativecommons.org/licenses/by/4.0/ abstract introduction clinical case series discussion screening and health education evaluation of breast lump surgeon performed ultrasonography fnac, core biopsy, and immunohistochemistry multidisciplinary team (mdt) meeting surgery for breast carcinoma breast reconstruction after mastectomy chemotherapy and radiation therapy monitory aid palliative care conclusion references commentary july 2021. christian journal for global health 8(1) bridging the divide between health, social development and environmental interventions: an example from the leprosy mission james samuel pendera a programmes and advocacy officer – asia, the leprosy mission england and wales, united kingdom abstract there is historically a divide between health and social development practitioners versus environmentalists, with one side seen to prioritise people and the other seen to prioritize nature. however, the wellbeing of humans and that of the environment are inextricably linked. this paper will use leprosy, also known as hansen’s disease, as an example to show how disregard for the environment through anthropogenic caused climate change may threaten human health. additionally, it will outline, through the example of the leprosy mission england and wales and its partners, how environmental concerns can be integrated into health programmes with salutary outcomes for both health and environment. key words: leprosy, climate change introduction analyses of global challenges to biodiversity frequently pit other species’ requirements against those of humans. conservation prioritizations often address biodiversity targets without fully considering whether solutions leave room to meet people’s needs. conversely, analyses of economic development generally prioritize human advancement through continued economic growth while ignoring impacts on biodiversity.1 even promoting human health sometimes undermines environmental protection, with theories of health care ethics tending to be human-centred and not taking the environment into account. theories of environmental ethics may have little to say about human health.2 bakken et al trace the origin of such dualistic views of justice and ecology to the european enlightenment just over 200 years ago. western thought since the philosophers kant and hegel has tended to set nature in opposition to history and space in opposition to time. nature has been seen as a collection of objects governed by deterministic laws in a static or cyclic order; history is a dynamic, even progressive realm of self-conscious subjects capable of freely responding to moral laws. such a view has contributed to an either/or mentality regarding ecology and justice, making it difficult to 2 pender july 2021. christian journal for global health 8(1) see the dependence of history on nature, to situate the human self fully in its ecological context, or to apply moral concepts to human transactions with nature.3 this paper argues that these kinds of dualistic tradeoffs must give way to more convergent thinking. this dichotomy saw, for example, ernest fritschi, the director of the schieffelin research and training institute in karagiri, india, being criticized by his board who said that his goal and objectives should be to treat and to rehabilitate leprosy patients. money should not be diverted to other goals like farming and reforestation he was practising on the compound.4 however, for pragmatic reasons, there are signs of an emerging convergence. if preserving the environment benefits the welfare of communities, it is encouraged by health and social development practitioners. if improving the conditions of poor communities reduces pressure on endangered species or national parks, for example, it is promoted by conservationists. concerns of social developers and environmentalists have been brought together in agreements, including the 1992 earth summit,5 unced 2002 world summit on sustainable development,6 and the millennium development goals in 2000.7 the sustainable development goals in 2015 broke further ground in that they sought to integrate environmental and human developmental concerns across all the seventeen goals.8 according to the 2020 report of the lancet countdown on health and climate change, 50% of countries surveyed have now developed national health and climate change strategies or plans. however, in absolute terms, climate change continues to be framed in ways that pay little attention to its health dimensions.9 this does not encourage environmentalists to consider health nor health practitioners to consider environment and climate change. the importance of the environment to health yet, environmental action to prevent degradation, pollution, and climate change is vital to safeguard and improve the health of human beings, particularly those who reside in developing contexts in the “global south.” dr paul brand is credited with having established that leprosy is not the direct cause of the damage causing impaired function to the hands and feet observed in affected people. rather, the damage to extremities is self-inflicted, resulting from the loss of sensation and inability to feel pain.10 he further pioneered leprosy reconstructive surgery; yet, after devoting his life to the treatment of leprosy, he still stated: i would gladly give up medicine tomorrow if by so doing i could have some influence on policy with regard to mud and soil. the world will die from lack of pure water and soil long before it will die from a lack of antibiotics or surgical skill and knowledge. but what can be done if the destroyers of our earth know what they are doing and do it still? what can be done if people really believe that free enterprise has to mean absolute lack of restraint on those who have no care for the future?4 he had observed the impact of environmental degradation on the lives of those people affected by leprosy he was seeking to serve and realised their needs extended beyond the immediate cure for their disease and surgery to restore the function of their bodies. direct impact of climate change on leprosy climate change, more than any other area, has highlighted how lack of care for the environmental impacts on human health. the effects of climate change are being felt today, and future projections 2 pender july 2021. christian journal for global health 8(1) represent an unacceptably high and potentially catastrophic risk to human health. the implications of climate change for a global population of 9 billion people threatens to undermine the last half century of gains in development and global health.11 changing climatic conditions are increasingly suitable for the transmission of numerous infectious diseases.12 in terms of leprosy, a study in ethiopia found that a major factor that governs transmission of leprosy is the viability of mycobacterium leprae outside the human body in the thermal-hydrologic regime of the environment.13 in fact, a correlation between heat and humidity has long been suspected to be related to leprosy prevalence.14 however, a study in delhi, india found that although there were seasonal variations in exposure to leprosy from highly endemic pockets, the population was at risk of exposure to m. leprae irrespective of season.15 although climatic variables are related to and may influence transmission, they are not thought to be the main determinants of prevalence. rather, close contact with an existing untreated person with high leprosy bacterial loads is the main determining factor.16 indirect climate impacts on leprosy however, even for diseases such as leprosy, where climatic factors, particularly heat and humidity, influence transmission are not the main determining factors of prevalence. the indirect effects of climate change will increase poverty, more specifically undernutrition, hygiene, and sanitation which are key determinants of leprosy prevalence due to their impact on the immune system.16 the link between leprosy incidence and socioeconomic circumstances has been demonstrated because even before medical treatment became available, the disease vanished from europe, and it began to decline in post-war japan as poverty reduced.17 an association with unfavourable socioeconomic indicators including access to treated water, lower family income based on minimum wage, and more contact with other leprosy patients and the disease was demonstrated in brazil.18 leprosy bacteria has been found in soil and water around areas around poor, leprosy-affected communities in brazil and india.19 research in ethiopia has indicated that leprosy transmission may be related to adequacy and access to water, sanitation, and hygiene as well as to schistosomiasis co-infection.20 the literature strongly suggests the beneficial influence of adequate diet on the outcome of leprosy and the deleterious effect of a deficient diet.21 for example, a study in india shows undernutrition to be more common in people affected by leprosy than in those without leprosy.22 in another study in northwest bangladesh, seasonal food shortage during a “lean season” caused malnutrition, which, as an aspect of poverty, played an important role in the development of the clinical signs of leprosy.23 therefore, although the direct impacts of climate change on the leprosy bacteria, mycobacterium leprae, may not be likely to have a major or determining impact on leprosy prevalence, the indirect impact of climate change on the factors that increase susceptibility of vulnerable populations to developing clinical leprosy are likely to be significant. these factors include: greater poverty caused by increasingly frequent disasters such as drought, floods, and cyclones which destroy livelihoods and increase food insecurity; increases in mean seasonal temperatures and rainfall patterns over growing seasons which reduce harvests; as well as a higher disease burden among susceptible communities from other diseases that are increasing due to climatic factors that reduce immunity.24 climate change induced migration due to changing seasonal river flows, flooding, sea level rise, increasing salinity in coastal soils, and powerful cyclones threaten to displace millions in leprosy endemic countries like bangladesh.25 drought related migratory movements in brazil have already been suspected to have introduced leprosy into new 2 pender july 2021. christian journal for global health 8(1) areas.26 climate related natural disasters should be expected to influence the distribution of leprosy worldwide through migration and the concentration of internally displaced people into crowded slums or camps. increased vulnerability due to climate change in addition to influencing the factors that increase leprosy prevalence, climate change will also affect people already affected by leprosy who may be plunged into further poverty. the 3-4 million people living with visible impairments due to leprosy27 are the most stigmatised and faced with further barriers due to their disability. leprosy is predominantly “a disease of poverty;” so people affected by leprosy are often already from marginalised communities, located in remote locations, of low caste, ethnicity, or religion. even once cured, former patients may continue to face extreme stigma and marginalisation, expelled from families and communities, and pushed into less desirable locations, more prone to disaster or less fertile for cultivation. therefore, climate impacts such as poorer agricultural yields and increasingly frequent extreme events leading to “natural” disasters will disproportionately affect them. as a marginalised group, they will be also less likely to receive adequate relief and rehabilitation after such an event.28 marginalised communities less integrated with mainstream society and with fewer financial assets are also more likely to be reliant on natural resources, such as rivers for drinking water, rain-fed agriculture, wild game or fish, firewood, and material for handicrafts. environmental degradation and climate change that reduces or damages their resource base will, therefore, disproportionately impact those in the most marginalised and poorest communities with already reduced health outcomes including those affected by leprosy. this is the experience of the leprosy mission. for example, the coastal province of cabo delgado in northern mozambique is the poorest province and has the highest proportion of leprosy and lymphatic filariasis cases in the country. it is increasingly drought prone and was hit by cyclone idai in 2019. leprosy colonies in mumbai, india are located along storm drains that flood annually, and 4000 leprosy affected farmers in northwest bangladesh were impacted by unprecedented river flooding in 2017 that flooded houses, destroyed crops, and killed livestock. insufficient rain in north-eastern myanmar, meanwhile, led to rice harvests on farms of “leprosy villages” failing in 2020 as rainfall patterns change. experience of the leprosy mission england and wales contrary to holding a position that is either people or environment, the leprosy mission england and wales recognises the impact of environmental degradation and climate change on communities affected by leprosy and the importance of assisting them in climate change adaptation and resource management. it believes that in god’s creation all things have value to god and, as a result, signed the jamaica declaration of the lausanne movement, which states: . . . informed and inspired by our study of the scripture—the original intent, plan, and command to care for creation, the resurrection narratives, and the profound truth that in christ all things have been reconciled to god . . . creation care is an issue that must be included in our response to the gospel, proclaiming and acting upon the good news of what god has done and will complete for the salvation of the world. this is not only biblically justified, but an integral part of our mission and an expression of our worship to god for his wonderful plan of redemption through jesus christ. therefore, our ministry of reconciliation is a matter of great joy and 2 pender july 2021. christian journal for global health 8(1) hope and we would care for creation even if it were not in crisis.28 although with a core mission to reduce leprosy transmission and to transform the lives of people affected by leprosy, it is recognised that as a christian organisation, the leprosy mission england and wales should seek to reduce its impact on the environment. therefore, its environmental policy has recently been updated and actions to reduce impact small and large are being implemented. this includes offsetting flights (which are difficult to eliminate as our project work is all overseas). the first initiative using the offsetting funds was to equip the leprosy hospital in naini, india with solar panels, which also provided a cheaper, more sustainable power source, instead of coal-based power from the grid or diesel power from the back-up generator that produce greenhouse gases. within the uk, actions have included phasing out plastic envelopes for our newsletter mailings in favour of potato starch ones which are biodegradable and changing our electricity supplier to one obtaining electricity and gas from renewable sources. in its interventions, outcomes that will conserve the environment as well as improve the lives of people affected by leprosy are being sought out. in nepal, the new hospital building under construction will utilise biogas and solar panels to provide hot water for the facility. in mozambique, an approach called “farming god’s way,”29 using biblical references on good stewardship and creation care to encourage communities to adopt “conservation agriculture” promoting good husbandry practises that conserve and improve the soil has been promoted. this improves the yields of local crops as well as introduces new ones and improves food security in the drought prone coastal areas of cabo delgado province. this has been recommended as an effective means of communitybased climate change adaptation.30 another intervention has been the promotion of “system of rice intensification”31 in shan state, myanmar. this agricultural technique keeps the rice paddy moist rather than waterlogged, plants are evenly spaced, and organic inputs given. it reduces methane emissions, a powerful greenhouse gas, chemical inputs are not required, and yields are increased.32 leprosy mission beneficiaries reported dramatically improved harvests even in the first year of using this method, with some farmers doubling production, enabling them to sell a surplus and give a tithe to the church for the first time in their lives. increased snail pests on the crops on the drier paddies were even seen as a bonus as they were consumed as food. other leprosy mission interventions that support people affected with leprosy as well as benefit the environment include the following: promotion of organic farming methods in sri lanka and myanmar, use and conservation of wild “vegetable” plants for improved nutrition in sri lanka, and tree planting around leprosy communities in niger. conclusion people depend on the environment for their health and wellbeing, so it is vital that health focused personnel and organisations integrate environmental action alongside community health and development. environmentally focused organisations that have included community health interventions within their programmes include a rocha uganda, promoting bio-sand water filters and fireless cookers on the edge of a biodiverse urban wetland in kampala34 and plateau perspectives working on environmental protection in mountainous regions in asia, improving people’s resilience and quality of life including co-funding nine clinics and health worker training in tibet.34 with climate change acting as a risk multiplier reducing health outcomes, it is vital that there is an integration of health, development, and environmental concerns in grassroots projects. this is even more pertinent for christian individuals and agencies as bradshaw of world vision explains: 2 pender july 2021. christian journal for global health 8(1) christian development cannot be complete without a concern for the environment, as in contrast to the dualistic western worldview that separates health and development practitioners from environmentalists. all the elements of creation participate in god’s redemptive work through christ. environmental components must be integrated into the many issues such as health that address wholistic christian development’s concern for sustaining life.35 environmental concerns do not so obviously interlink with the goal of “defeating leprosy and transforming lives” of the 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https://www.kirkensnodhjelp.no/contentassets/c1403acd5da84d39a120090004899173/2010/nca_what-is-climate-change-its-impacts-and-possible-community-based-responses-in-bangladesh.pdf https://www.fmreview.org/climatechange/pender https://pubmed.ncbi.nlm.nih.gov/26964429/ http://tiempo.sei-international.org/newswatch/comment110107.htm http://tiempo.sei-international.org/newswatch/comment110107.htm http://lwccn.com/about/jamaica-call-to-action/ https://www.farming-gods-way.org/ 2 pender july 2021. christian journal for global health 8(1) working group ii to the fifth assessment report of the intergovernmental panel on climate change. cambridge, united kingdom, new york, ny, usa: cambridge university press; 2014 [cited 2021 apr 23]. p 1203. available from: https://www.ipcc.ch/site/assets/uploads/2018/02/ar5_ wgii_spm_en.pdf 31. sri international network and resources center [internet]. available from: http://sri.ciifad.cornell.edu/ 32. selvaraju r. system of rice intensification (sri) [internet]. fifth annual investment days. rome, italy; 2013 dec 17 [cited 2021 april 23]. climate, energy and tenure division (nrc), fao. available from: http://www.fao.org/fileadmin/templates/tci/pdf/inves tment_days_2013/17_december/1c._system_of_ric e_intensification__sri__-_selvaraju.pdf 33. a rocha uganda [internet]. available from: https://uganda.arocha.org/ 34. plateau perspectives [internet]. http://plateauperspectives.org/en/about/ 35. bradshaw b. bridging the gap: evangelism, development and shalom. monrovia, california: marc; 1993. peer reviewed: submitted 30 april 2021, accepted 12 july 2021, published 30 july 2021 competing interests: none declared. correspondence: james samuel pender, the leprosy mission, england and wales. jamesp@tlmew.org.uk cite this article as: pender js. bridging the divide between health, social development and environmental interventions: an example from the leprosy mission. christ j global health. july 2021; 8(1):__ https://doi.org/10.15566/cjgh.v8i1.543 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org https://www.ipcc.ch/site/assets/uploads/2018/02/ar5_wgii_spm_en.pdf https://www.ipcc.ch/site/assets/uploads/2018/02/ar5_wgii_spm_en.pdf http://sri.ciifad.cornell.edu/ http://www.fao.org/fileadmin/templates/tci/pdf/investment_days_2013/17_december/1c._system_of_rice_intensification__sri__-_selvaraju.pdf http://www.fao.org/fileadmin/templates/tci/pdf/investment_days_2013/17_december/1c._system_of_rice_intensification__sri__-_selvaraju.pdf http://www.fao.org/fileadmin/templates/tci/pdf/investment_days_2013/17_december/1c._system_of_rice_intensification__sri__-_selvaraju.pdf https://uganda.arocha.org/ http://plateauperspectives.org/en/about/ mailto:jamesp@tlmew.org.uk https://doi.org/10.15566/cjgh.v8i1.543 about:blank poetry june 2022. christian journal for global health 9(1) the conqueror’s creed: a declaration and prayer of christian scripture for those in pain emily h. garmona a md, fasa, clinical associate professor of anesthesiology, texas a&m health science center college of medicine, baylor scott & white medical center, temple, tx, usa i submit myself to the lord’s will. i affirm that i am a child of the most high god. i was bought with a price. pain does not own me; christ owns me. i refuse to allow pain to give the enemy a foothold for temptation or doubt. i take captive my pain so i may fulfill the good works god prepared in advance for me to do. when i feel hopeless, i will boldly declare the promise that i can do all things through christ who gives me strength. dear god, grant me the strength i need to conquer each day. holy spirit, comfort me in my affliction. open my eyes to others who are suffering, that i may comfort them with the comfort i have received. help my testimony bring glory to you, encourage others, and be a witness for your power and faithfulness. please give me a heart that delights in difficulties. for when i am weak, then i am strong. i ask all of this through your son, jesus christ, who suffered on earth as none other before or since. amen peer reviewed: submitted 9 may 2021, accepted 16 jun 2022, published 20 jun 2022 competing interests: none declared. correspondence: emily h. garmon, temple, tx, usa emily.garmon@bswhealth.org cite this article as: germon eh. the conqueror’s creed: a declaration and prayer of christian scripture for those in pain. christ j global health. june 2022; 9(1):125. https://doi.org/10.15566/cjgh.v9i1.655 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:emily.garmon@bswhealth.org https://doi.org/10.15566/cjgh.v9i1.655 about:blank short communication / field report dec 2022. christian journal for global health 9(2) engaging the local church to tackle stunting in indonesia: a case study in nias island fotarisman zaluchua a mph, phd, lecturer, universitas sumatra utara, indonesia background stunting, the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation occurs globally, including in indonesia.1,2 based on the latest data (2021), the percentage of stunting among underfive children in indonesia is 24.4 percent, only down by 3.3 percent from the condition in 2019, even though the president of the republic of indonesia has issued instructions to reduce this figure to 14 percent by 2024.3,4 the magnitude of this stunting figure puts indonesia as the country with the largest stunting burden in southeast asia and in the top five in the world.5 stunting due to nutritional deficiencies and other factors is a recognized outcome of deficiencies in the vulnerable first 1000 days of a child’s life. local faith communities are being recognized as key resources of education and social protection for this stage of the life cycle.6 stunting leads to poor outcomes in overall health, neurobehavioral and cognitive development, and educational and economic attainment later in life.7 in 2021, we, myself and a team from the university of north sumatra, indonesia, organized stunting education for pregnant women and mothers of children under five years in the nias islands, the outer islands of north sumatra province in indonesia. these islands are inhabited by about 900,000 people; as many as 96 percent of the population identify as christian (protestant and catholic) believers.8 approaches and techniques we invited the main local church, banua niha keriso protestan (bnkp), to cooperate in the program. in the early stages of the activity, we invited the leadership of the bnkp synod. to the church leaders, i explained that stunting could affect future church ministry. those who suffer from stunting today are those who in the next 1520 years may not be able to become leaders in the church. they may be inhibited from serving as satua niha keriso (elders of the church), as pastors, or even teachers in sunday schools. in addition, they may be restricted economically from becoming donors to the church. in my explanation, i described how stunting could affect future health, learning, and income. those who experience stunting may lack good educational quality because they are often sick and miss class time at school. they might also be less productive and unable to get good jobs. later, when they could become servants in the church or active church members, it is the church that will suffer if the stunting problem is not prevented. the prevention of stunting at this time by the church is critical, since the church has a very significant influence in the nias islands where the prevalence of stunting is the highest in north sumatra province—between 25 and 48 percent.3 the cooperation of local church leaders made it easy to organize activities. the bnkp then decided to help carry out this activity, asking local church leaders to support the activity by pregnant women and under-five mothers through women’s organizations in the church. the bnkp church zaluchu 24 dec 2022. christian journal for global health 9(2) assigned the diakonia commission at the synod level to assist our activities. first, educational activities always began with worship led by local pastors. the community was gathered by the church in the church building. the involvement of church leaders to invite the community was very important because, socioculturally, the community still has a positive perception of the church. the implementation of activities generally ran very smoothly. second, our educational activities are in the nias language. the rural areas of nias islands are underdeveloped. even among the program participants, there are still those who have never been to school at all. early marriage among women is very high, a consequence of patriachal tradition. however, in such a situation, as i was born as a niasan, it is easy for me to explain the material in the participants local language. third, we provided materials and delivery techniques using a local approach. as a tribe with a different subculture compared to other tribes in indonesia, we had to use material that was culturally easy to understand. for pictured teaching materials, we show typical nias ornate, women’s clothing (figure 1). this cultural design appeals to participants and motivates them to see and listen. figure 1. when we teach stunting to participants, we use dance or maena. maena is a typical nias dance that is sung at wedding parties. in the wedding context, maena is danced together with the members of the community who attend the party, both from the bridegroom’s and the bride’s side. the rhythm of maena is usually very pleasant, easy to remember, and contains sentences containing moral messages. we then composed the lyrics of the maena with stunting education messages using dance that is familiar to the participants. five songs were created to be used during the training. when we asked participants to create maena songs 25 zaluchu dec 2022. christian journal for global health 9(2) themselves, they did so. these dances were performed each time we offered the training, reflecting the knowledge they received from us. routinely, meetings took place weekly for eight times. at the end of a meeting, we distributed a calendar to the participants. the calendar contained the selected training pictures (figure 2) including the maena verses we taught them. our hope was that participants would remember the lessons they had received. figure 2. reflection the most important feature of these activities was the role of the church in addressing health problems. before this, the bnkp church had never thought about the problem of stunting. at the same time, the government program was very limited because of budget constraints and because such programs were usually designed without considering a local approach. if left unsolved, stunting is very concerning especially because christians are a majority in the nias islands. the church’s willingness to shift slightly out of their “traditional norm” of spiritual and theological affairs was a big step. we were fortunate to have local church leaders who were willing to cooperate and get involved in the work of overcoming stunting. our explanation of how the future of the church could be potentially affected was a very important early opening conversation to the church leaders. in the future, churches around the world will face health problems. covid-19 is a recent example. some churches have responded by being zaluchu 26 dec 2022. christian journal for global health 9(2) involved in vaccination activities. in different parts of the world, there are different patterns of disease. there are many problems that must be overcome that require the church. even if it is unfamiliar territory, the church must be willing to care for the health of church members and show a willingness to heal as the lord jesus once did. in the future, involving the church can have a wide-reaching impact. every denomination has local churches. bnkp itself has more than 1000 branch churches in nias islands and in indonesia. if well engaged, they can tackle stunting and other health problems. this involvement may well require cooperation with parties outside the church to plan and implement to have a real impact. our experience doing stunting education featured a local approach. such communication channels can be developed by the church to teach god’s word. we developed teaching materials using typical nias ornaments, including maena, as an educational channel to increase education effectiveness. local approaches promoted development of two-way communication between reseachers and the subjects of education efforts. there may be an impression that the church does not care about local circumstances where the church is located. this can be the consequence of traditional, one-way teaching, as in some ways of preaching. in fact, every church finds itself in a certain cultural context. the church needs to see the potential of the culture in which it is located. the church must hear the “voice” conveyed through the existing local culture, so the church can respond to it, even use it, for the purpose of service. the church is challenged to be more creative for the benefit of the communities served in order to know god better and to be healthier and more prosperous. instead of educational institutions being mere sources of scientific information, the church can be the greatest source of knowledge about people’s social life. every day, every week, and every year the church is close to society and serves the community. the local church is not born by chance and is given the opportunity by god to solve local health problems within local contexts. the visual representation of the activity can be accessed here: https://youtu.be/l9bg_9xaroc references 1. who. who child growth standards [internet]. who; 2009. available from: https://www.who.int/tools/child-growth-standards 2. who. chapter 1. stunted growth what is it? in: stunting in a nutshell [internet]. 2015. available from: https://www.who.int/multimedia/details/stunting-in-a-nutshell-chapter1# 3. ministry of health. indonesia nutrititonal status study [hasil studi status gizi indonesia]. ministry of health; 2021. available from: https://www.litbang.kemkes.go.id/buku-saku-hasilstudi-status-gizi-indonesia-ssgi-tahun-2021/ 4. republik indonesia government. presidential decree no. 72/ 2021 about stunting reduction acceleration.; 2021. available from: https://peraturan.bpk.go.id/home/details/174964/pe rpres-no-72-tahun-2021 5. titaley cr, ariawan i, hapsari d, muasyaroh a, dibley mj. determinants of the stunting of children in indonesia : a multilevel analysis of the 2013 indonesia basic health survey. nutrients. 2019;11:1160. https://doi.org/10.3390/nu11051106 6. lundie re, hancox dm. the local church and the first thousand days of a child’s life: a mixed methods study from south africa. christ j glob heal. 2020;7(3):6-22. https://doi.org/10.15566/cjgh.v7i3.323 7. victora cg, adair l, fall c, hallal pc, martorell r, richter l, et al. maternal and child undernutrition: consequences for adult health and human capital. lancet. 2008;371(9609):340-57. http://doi.org/10.1016/s0140-6736(07)61692-4 8. indonesia statistics board north sumatra province. population in north sumatra based on religion in 2020. 2021 [cited 2022 jun 20]. available from: https://sumut.bps.go.id/statictable/2021/04/21/2289/j umlah-penduduk-menurut-kabupaten-kota-danagama-yang-dianut-2020.html. https://youtu.be/l9bg_9xaroc https://www.who.int/tools/child-growth-standards https://www.who.int/multi-media/details/stunting-in-a-nutshell-chapter1 https://www.who.int/multi-media/details/stunting-in-a-nutshell-chapter1 https://www.litbang.kemkes.go.id/buku-saku-hasil-studi-status-gizi-indonesia-ssgi-tahun-2021/ https://www.litbang.kemkes.go.id/buku-saku-hasil-studi-status-gizi-indonesia-ssgi-tahun-2021/ https://peraturan.bpk.go.id/home/details/174964/perpres-no-72-tahun-2021 https://peraturan.bpk.go.id/home/details/174964/perpres-no-72-tahun-2021 https://doi.org/10.3390/nu11051106 https://doi.org/10.15566/cjgh.v7i3.323 http://doi.org/10.1016/s0140-6736(07)61692-4 https://sumut.bps.go.id/statictable/2021/04/21/2289/jumlah-penduduk-menurut-kabupaten-kota-dan-agama-yang-dianut-2020.html https://sumut.bps.go.id/statictable/2021/04/21/2289/jumlah-penduduk-menurut-kabupaten-kota-dan-agama-yang-dianut-2020.html https://sumut.bps.go.id/statictable/2021/04/21/2289/jumlah-penduduk-menurut-kabupaten-kota-dan-agama-yang-dianut-2020.html 27 zaluchu dec 2022. christian journal for global health 9(2) submitted 5 may 2022, revised 19 june 2022, accepted 20 june 2022, published 20 dec 2022 competing interests: none declared. correspondence: dr. fotarisman zaluchu, indonesia fotarisman.zaluchu@usu.ac.id cite this article as: zaluchu f. engaging the local church to tackle stunting in indonesia: a case study in nias island. christ j glob health. dec 2022; 9(2):23-7. https://doi.org/10.15566/cjgh.v9i2.649 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:fotarisman.zaluchu@usu.ac.id https://doi.org/10.15566/cjgh.v9i2.649 about:blank background references original article does universal health insurance act as a driver of increased life expectancy? evidence from selected emerging economies sabina ampon-wirekoa, zhou lulinb, henry asante antwic, ebenezer wireko brobbeyd, arielle doris kachiee a ma, phd(c) jiangsu university, zhenjiang, china b professor of public management, dean of school of management, jiangsu university, zhenjiang, china and head of governing board of social health insurance in jiangsu province (prc) c phd, post-doctoral fellow of the institute of health insurance and social medicine, jiangsu university, zhenjiang, china d ma, tutor at manso-amenfi senior high school, amenfi, ghana e phd(c), jiangsu university, zhenjiang, china abstract background: the world currently has experienced an unimaginable increase in life expectancy rate (ler). there are many factors that influence ler, including faith and forgiveness. however, an ongoing argument among scholars is whether health insurance is partly ascribed to the historical forces that drive the surge in ler among emerging countries. the study seeks to investigate the long-run effect of universal health insurance (uhi) on ler among 15 selected emerging countries spanning from 2000 to 2015. methods: using the panel unit root, panel cointegration, panel fully modified least squares (fmols), and employing the dynamic ordinary least square (dols) as a robust check, the study analyzed connections between the study variables. results: the outcome of the results showed that uhi, physician ratio, healthcare expenditure, and educational factors are positive contributors to increasing life expectancy, while economic growth remained negatively significant in the selected emerging economies. conclusion: this study showed that improved education, increased physician ratio, increasing health expenditures, and universal insurance coverage were correlated with increased life expectancy in emerging economies. in order to promote healthy lives of its citizens, a move toward uhi coverage is suggested since it increases the life expectancy rate among emerging nations. key words: universal health insurance, life expectancy, emerging countries, fully modified least squares introduction a healthy body with a sound state of mind supports a successful life. according to deaton, it is difficult for billionaires to enjoy life to the fullest without good health.1 while all workers need a healthy life in order to actively function, a healthy life offers children a sound academic life that enables active participation in many other activities both at school and home.2 nevertheless, 53 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) some developing nations fail to offer their citizens an ideal opportunity for healthy living. emerging nations are those countries that invest in industrial capacity for production. they are moving away from an economy that depends on the export of raw materials and on agricultural activities. in many emerging countries, health financing is characterized by high out-of-pocket (oop) spending for health care. people who are not able to afford health care avoid visits to health facilities and delay or postpone seeking medical attention.3 consequently, the world health organization (who) embraces policies that mobilize more resources for health and enhance attainment of quality health care delivery, particularly among low income countries.4 these policies are reinforced by the world bank as a technique to achieve universal health coverage.5 the world is currently experiencing an increase in life expectancy rate (ler). however, an ongoing discourse among scholars, technocrats, and policy makers is whether health insurance is partly ascribed to the historical forces that drive the increase in ler among emerging countries. jakovljevic et al. noted that the speedy increase in life expectancy echoes the overall influence of an operational healthcare system and policies within a country.8 some researchers, such as deaton and xiong et al.,9 tend to concentrate on health insurance and accessibility of health care universal capital while duku et al.10 and yang11 focus on perception and quality of universal health insurance (uhi). wilper et al.12 explore the effects of health insurance on mortality rate in the united states using a survey and concluded a negative association between health insurance and death rate. a study by anderson et al.13 also established that health insurance helps promote protection for financial risk, equal access, and equity in health financing among the taiwanese. anderson et.al.,13 in a survey, examined the influence of health insurance coverage on the utilization of medicare service and concluded that expanding insurance for healthcare will lead to a substantial surge in care provided to new uninsured members. employing a regional census and cancer registry data for 1987–1993, lee-feldstein et al.14 examined relationships between diagnosis, survival experience, and treatment and health insurance among breast cancer patients. they established that health insurance will lead to the utilization of health services. ekman reviewed articles on the impacts of community-based health insurance on the mobilization of resources and providing financial protection among the lowincome countries.15 the author discovered that health insurance provides some financial protection by reducing oop spending. kilbourne,16 examining the impact of health insurance on population health, deduced a positive connection between health insurance and healthrelated outcomes. another line of study explored the effect of health insurance on the usage of mammography among cancer patients, but failed to establish a positive effect for insurance coverage.17 several independent variables, such as governance, accessibility to safe water, oop payments, urbanization, nutritional outcomes, and geographical status, have been established to significantly affect life expectancy.18, 19, 20 others confirmed that adult and infant mortality, socioeconomic status, disease control interventions, and life style were related to longevity.21,23 toussaint et.al.6 examined multiple types of forgiveness as predictors of mortality and potential psychosocial, spiritual, and health mechanisms of the effects of forgiveness on longevity. data from a nationally representative sample of united states’ adults ages 66 and older measured forgiveness, health, religiousness/spirituality, and socio-demographics. the study reports reduced mortality with understanding god's unconditional forgiveness and increased mortality with conditional forgiveness toward others. several scriptures from the holy bible (psalm. 91:16; job 5:26, 42:17; proverb 3:2; zechariah 8:4; isaiah 65:22; 1 peter 3:10) also consider longevity as a sign of righteousness/justice and god’s blessings. mccullough et al.7 examined the relationship between devoutness and longevity. psychological 54 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) investment in religion was associated with the delay of death in the terman sample. survival differences were largely attributable to crosssectional and prospective between-class differences in personality traits, social ties, health behaviors, and mental and physical health. in contrast to existing analyses of these other factors for life expectancy, only a few studies examined the long term role of uhi on health outcomes among 183 emerging nations,24 nepal,23 and the united states.25 though attaining universal health coverage is a target of the sustainable development goals (sdgs), no study focused on the role of uhi on life expectancy in emerging nations.26 in the existence of such a knowledge gap, this study focuses on a panel of thirteen selected emerging countries. previous studies have concentrated on cross sectional survey and times series analysis. this study is novel as it uses a panel data set, allowing comparisons to be made across countries and regions, especially where the emerging countries are the fastest growing nations, and also serve as mentors for other developing nations.27 again, the present study attempts to identify a causal association between uhi and life expectancy, and this will provide new discussion on financial pressures and the potential for health reform. furthermore, the employment of cross-sectional dependence (cd) and homogeneity tests allows appropriate econometrics methods that avoid spurious results. finally, panel fully modified least squares (fmols) and dynamic ordinary least square (dols) analyses are employed to estimate the long run relationship between the variables as these methods provide efficient results in the presence of endogeneity. figure 1. time series pattern of universal health insurance among emerging countries 2000–2015 figure 1 shows universal health insurance coverage among 13 emerging countries between 2000 and 2015. the percent (%) of current health expenditure offering quality health care to all citizens is plotted over time. there has been gradual increase among a number of countries, with turkey leading the group while pakistan and malaysia performed poorly. 55 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) figure 2. annual health care expenditures us$ (2010) figure 2 offers a comparison between emerging countries in their efforts to promote quality health care. during 2015, argentina had the highest rate of public health cost as compared to russia, south africa, indonesia, thailand, iran, columbia, mexico, china, turkey, malaysia, egypt, and pakistan. figure 3. life expectancy rates over time among emerging countries 2000–2015 figure 3 shows life expectancy is measured as the average number of years remaining for an individual at any given age centered on the year of birth. argentina stands out as the star performer with south africa being the worst among the group. 56 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) materials and methods data the study extracted data from the world development indicators28,29 and the global health observatory data30 covering the period 2000 to 2015 because data are only available within these periods. we studied the association between uhi, life expectancy, health care expenses, number of physicians to population ratio, literacy rate, and economic growth from the thirteen selected countries to explore individual effects of uhi among emerging economies. table 1 describes the variables studied, their abbreviations, the unit of the variable used, and the sources of the variable data. table 1. name and definition of variables abbreviation variable name unit source ler life expectancy age-at-death world development indicator (2015) uhi universal health insurance % of current health expenditure global health expenditure database (2015) phy number of physicians physician per unit of population world development indicator (2015) gdpc gross domestic product per capita % current us $ world development indicator (2015) litr literacy rate % of the population aged 15 years and over who have completed high school barro and lee (2015) hce current health care expenditures per capita in ppp international dollars constant 2010 us$ world development indicator (2015) source: world development indicator (2015), unicef (2015), & barro and lee (2015) supplementary table 1 shows the mean, minimum, skewness, standard deviation, kurtosis, and jarque-bera test of the variables. life expectancy has the highest mean whilst physician ratio had the lowest mean value indicating life expectancy as a critical variable in emerging economies. universal health insurance has the highest standard deviation. the distribution of physician data displays a positive value for excess kurtosis, called leptokurtic, which indicates a sharp peak in the distribution. the jarque-bera test (the difference between the kurtosis and skewness of each variable) shows a normal distribution for all variables. supplementary table 1. descriptive analysis ler lit phy uhi hce gdpc mean 73.95367 27.22165 1.807018 23.87273 5.510032 12.30082 median 75.64550 24.85000 1.235000 25.19484 5.790293 10.92078 maximum 81.73600 61.40000 42.00000 60.09808 7.053359 18.25497 minimum 55.09700 10.40000 0.014000 0.558896 2.931237 9.181529 57 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) std. dev. 5.869973 9.792527 3.528317 17.68763 0.965980 3.006685 skewness -1.402444 0.985828 9.252645 0.288523 -0.983915 0.750643 kurtosis 4.690461 4.138422 97.57425 1.957425 3.237716 2.013499 jarque-bera 100.1005 48.37870 86676.19 13.25282 36.66938 30.11911 probability 0.000000 0.000000 0.000000 0.001325 0.000000 0.000000 sum 16565.62 6097.650 404.7720 5347.491 1234.247 2755.383 sum sq. dev. 7683.819 21384.27 2776.131 69766.01 208.0851 2015.955 model specification the study is grounded on “demand for health” proposed by grossman,31 where health is regarded by the individual as a necessary product and other factors, such as income and education, from which happiness is gained. according to the production function of health, citizens and states become healthy by consuming health care services. to analyze the impact of uhi on life expectancy, the study begins with a panel model expressed as: (1) 𝑌𝑖𝑡 = 𝛼𝑖 + 𝜑1𝑋𝑖𝑡 + 𝑣𝑖𝑡 where y is the dependent variable (ler), x is the independent variable, 𝜑 the vector coefficients of independent variables, 𝛼𝑖 the intercept which represents the country, and 𝑣 signifies the error term. in limiting the equation to the study objective, we formulate equation 2: (2) 𝐿𝐸𝑅𝑖𝑡 = 𝛼𝑖𝑡 + 𝜑11𝑈𝐻𝐼𝑖𝑡 + 𝜑2𝐻𝐶𝐸𝑖𝑡 + 𝜑3𝐺𝐷𝑃/𝑐𝑎𝑝𝑖𝑡 + 𝜑4𝐿𝐼𝑇𝑅𝑖𝑡 +𝜑5𝑃𝐻𝑌𝑖𝑡 + 𝑣𝑖𝑡 where ler represents expectancy rate, 𝐿𝐼𝑇𝑅 represents literacy rate, hce stands for healthcare expenditure, 𝛼 the intercept which represents the country, 𝜑 the vector coefficients, 𝐻𝐿𝑇𝐸𝑋𝑃 denotes public health care expenses, 𝑃𝐻𝑌 is the number of physician per population, uhi is universal health insurance, 𝐺𝐷𝑃𝑐 is the gdp per capita, and 𝑣 is the error term. econometric method employing panel data in empirical studies has merits and demerits. one major advantage of a panel study is spatial dependence, that is, the propensity for variables to influence each other and to possess similar attributes and heterogeneity. recent literature on the influence of health insurance on health status using panel data analysis employed first-generation econometric technique. the first-generation econometric technique assumes cross-sectional independence and homogeneity in the panel data sets. however, such an assumption could lead to spurious results in cases where the data are cross-sectionally dependent and heterogeneous. however, if second generation econometric procedure is used, weaknesses related to panel data are considered and adjusted. the study, therefore, proceeded with the preliminary test preliminary results a preliminary test of the data for cross sectional dependence, homogeneity, panel unit root, and cointegration was undertaken. cross-sectional dependence and homogeneity test before testing for integration (unit root) among the study variables, a cd) test was performed. this will provide the basis for the selection of subsequent econometric tests. table 2 shows test results for cd. the null hypothesis was not supported at the 1% significance level indicating that cross-sections were not independent. the homogeneity test 58 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) assessed uniformity of the cross sections using adjusted delta tilde tests, according to pesaran and yamagata. 32 the null statement of homogeneity was rejected at a 5% significance level, an indication that, the coefficients are heterogeneous. this enabled the researchers to select the appropriate unit root methods and estimation techniques for the study. table 2. crosssectional dependence and homogeneity test results crosssectional dependence test (null hypothesis: there is cross sectional independence) cd-testc variable lnler 29.14735 (0.0000) lnhce 78.07571 (0.0000) lnlitr 4.890231 (0.0000) lngdpc 9.441241 (0.0000) lnuhi 6.984736 (0.0000) lnphy 9.441241 (0.0000) homogeneity test results test statistic p-value delta_tilde 163 (0.0000)*b delta_tilde adj 5.722 (0.0000)* notes. ap-values are in parenthesis. b*represents 1% significance level. ccd-test denotes cross-section dependence test. panel cadf and cips unit root tests subsequent to testing for homogeneity, we conducted cross-section augmented dickey-fuller (cadf) and cross-section augmented ips (cips) tests by pesaran,33 as shown in table 3. the previous test results for cross-sectional and homogeneity require utilization of the secondgeneration techniques to produce robust results. thus, the use of the traditional unit root technique could lead to invalid results. the selection of cadf and cips unit root tests obviate this risk. the cadf and cips test results show reliable and effective cross-dependence and heterogeneity between the countries studied. the findings confirm that there is non-stationarity with the data at levels. however, they became stationary at their first difference; thus, the data are considered stable during the lag one period. the null hypothesis is rejected because there was stability among the series. 59 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) table 3. unit root test and results cadf cips variable at level at 1st difference at level at 1st difference lnler [-1.966] [-3.828]*** [-2.488] [-3.255]*** lnuhi [-1.439] [-3.006]*** [-1.414] [-3.006]*** lngdpc [-2.142] [-3.542]*** [-2.572] [-2.84]*** lnhce [-1.978] [-2.975]*** [-2.65] [-4.174]*** lnlitr [-1.179] [-2.351]** [-1.768] [-3.777]** lnphy [-2.096] [-1.870]** [-1.527] [-4.415]** notes. ** and *** designate statistically significant at 5% and 1%, respectively, while figures in brackets signify and t–statistics of variables respectively. cointegration test table 4 gives the results of the kao34 and pedroni35 cointegration tests. the null hypothesis of no cointegration is rejected at the 5% significance level. table 4. panel cointegration test results cointegration test kao cointegration test t-statistics prob. adf-statistics -2.80079 0.0025* pedroni residual cointegration test common ar coefficients (within – dimensions) statistic prob. panel v-statistic -0.145 (0.000) * panel rho-statistic 2.325 (0.990) panel pp-statistic -4.491 (0.000) * panel adf-statistic -4.702 (0.000) * individual ar coefficients statistic prob. group rho-statistic 4.490 (0.885) group pp-statistic -0.913 (0.041) * group adf-statistic -1.940 (0.026) * note. *designates statistically significant at 5%, while the figures in parenthesis denote probability values results from panel fmols and dols analysis the fmols and the dols techniques were employed to determine the long-term relationship between the panel data. the results are shown in table 5. uhi and ler are significantly and positively related. a unit increase in uhi (% of current health expenditure) will increase life expectancy by 1.478% and 0.028% (fmols, dols respectively) in the studied countries, as indicated. in addition, the coefficient from the fmols and 60 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) dols assessment of government hce is positive and significant. as the per capita income of these emerging countries have increased in recent years, so has the government expenditure on health. economic growth is significantly negative in the fmols analysis. using the dols analysis as a robust check on this result reveals a positive relationship. a unit increase in economic growth will reduce life expectancy at birth by 0.5%. the physician to population ratio was also positive in the fmols estimation procedures. an estimated 1% increase in physician to population ratio will result in an increase in life expectancy of 1.021%. inversely, the findings of the dols coefficient established a negative relationship between physician to population ratio and life expectancy. the literacy rate in this study has a positive relationship with life expectancy. coefficients from both fmols and dols estimations indicate that a unit increase in literacy will lead to an increase in life expectancy of 0.066 and 0.003 years, respectively, in the emerging economies. table 5. panel fmols and panel dols results for emerging countries note. ***, **, * designate significance level of 1%, 5%, and 10%, respectively. granger causality test for an in-depth understanding of the direction of the association between public health costs and its determinants, the study used the dumitrescu and hurlin36 granger causality test. the results are shown in table 6. there is a bidirectional causal relationship between life expectancy and economic growth, health care expenditure and life expectancy, education and life expectancy, literacy rate and economic growth, uhi and economic growth, and uhi and health care expenditure. unidirectional causality was found between uhi and ler, physician to population ratio and literacy rate, and uhi and physician to population ratio. again, the dumitrescu-hurlin granger causality test also revealed an independent causal relationship between literacy rate and health care expenditure. (a) panel fmols results (b) panel dols results variable coefficient t-stat variable coefficient t-stat lnuhi 0.308*** 22.971 lnuhi 0.009*** 37.382 lnhce 1.478*** 5.331 lnhce 0.028*** 4.129 lngdpc -1.572** -2.429 lngdpc 0.002** 2.023 lnphy 1.021** 3.317 lnphy -0.005* -1.781 lnliter 0.066*** 8.735 lnlite 0.003*** 13.749 r2 0.673 r2 0.913 adj r2 0.703 adj r2 0.970 61 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) table 6. dumitrescu-hurlin granger causality test hypothesis: prob. conclusion gdpc does not homogeneously cause le 0.000** bidirectional causality between gdpc and le hce does not homogeneously cause le 0.000** * bidirectional causality between hce and le liter does not homogeneously cause le 0.000** * bidirectional causality between liter and le phy does not homogeneously cause le 0.000** * bidirectional causality between phy and le uhi does not homogeneously cause le 0.000** * bidirectional causality between uhi and le hce does not homogeneously cause gdpc 0.024** bidirectional causality between hce and gdpc liter does not homogeneously cause gdpc 0.001** * bidirectional causality between liter and gdpc phy does not homogeneously cause gdpc 0.020** bidirectional causality between phy and gdpc uhi does not homogeneously cause gdpc 0.001** * bidirectional causality between uhi and gdpc liter does not homogeneously cause hce 0.101 independent causality uhi does not homogeneously cause hce 0.000** * bidirectional causality between uhi and hce phy does not homogeneously cause liter 0.211 unidirectional causality between phy and liter uhi does not homogeneously cause liter 0.002** * bidirectional causality between hce and gdpc note. *, **, and *** denote rejection of null hypothesis at 1%, 5%, and 1%, respectively discussion universal health insurance the fmols-estimated model suggests that uhi positively influences life expectancy in these emerging countries. one reason could be that uhi lessens the monetary cost of accessing healthcare services. it would then improve the accessibility of health resources for poor households. uhi may provide the public sector with extra resources that can be used to increase the number and quality of services for the general public. uhi gives opportunity for registered individuals to access health facilities at their time of need. it, therefore, improves access to hospital or other medical attention at the earliest stage of a disease and helps prevent complications that might result in a preventable death. uhi also protects individuals from oop expenses and financial burdens, thereby enhancing the utilization of healthcare services. this finding is in line with seppehri, sarma, and simpson37 study about vietnam and ranabhat et al.23 this outcome agrees with a recent study by woolhandler and himmelstein38 indicating a reduction in mortality among the insured group and shorter survival rates among the uninsured. health care expenditure again revealed a positive relationship with life expectancy. this suggests that the provision of medical equipment, health facilities, essential drugs, and training of health staff are crucial in achieving better health 62 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) status in these emerging countries. these findings corroborate with farag et al.39 in which outcomes from 133 lower and upper income nations support the idea that government funds for healthcare systems enhance population health. moreover, economic growth appears to cause a decrease in life expectancy among these emerging countries. it is likely that a low percentage of gdp is invested in disease prevention and treatment, training of health providers, and the purchase of health equipment as the economy develops. economic growth can possibly have a negative effect on longevity through overconsumption of unhealthy food coupled with a more sedentary lifestyle with industrialization. this does not imply that the progression of the economy is insignificant, but greater attention should be paid to its potential adverse effects. the study agrees with ang 40 in the united states. in addition, brenner41 and weil42 found economic growth associated with deteriorating health leading to untimely death. however, it opposes the findings of gonzalez and quast43 who established that an increase in economic growth results in greater longevity. literacy literacy rate among the emerging nations was found to increase life expectancy. this may be because more years of schooling results in positive behavioral change and encourages a healthy lifestyle. in considering this outcome, higher educational levels may be highly correlated with overall socioeconomic status, which would be a major determinant of health status. individuals with higher educational levels are also less likely to exhibit depression, anxiety, and stress that can lead to untimely death. other studies on the relation between education and life expectancy have been carried out. in examining an indirect correlation between education and long life, friedman et al.44 observed that personality traits which induce one to achieve higher educational levels are connected to increased longevity. however, the causality runs in both directions because poor health will prevent the individual from pursuing education. these findings corroborate with hahn and truman 45 and morrisroe et al.46 the findings are not supported by inaba,47 whose study found no relationship between education and poor health outcome (depression) in japan. physician: population ratio finally, another area of the study focuses on the effect of physician ratio on life expectancy. life expectancy is positively explained by increased physician to population ratio among these emerging nations. the implication is that a surge in the number of physicians who help patients practice healthy behaviors and avoid excessive smoking and drinking are likely to help their patients prolong their lives. also, an increase in the number of physicians enables early detection and treatment of diseases to prevent unavoidable death. this confirms the findings of oberg and frank.48 following the empirical findings of this study, we propose that governments should intensify their support for health services because the health care indicators are mutually dependent. increasing health care expenditure alone without improvement in other sectors will not translate into healthy life for their citizens. conclusion the poor often delay and postpone seeking medical care even when they suspect signs with known symptoms of poor health in order to prevent becoming bankrupt. while political, geographical, environmental, faith, forgiveness, and other social determinants have been used in explaining the trend of longevity, our study investigated the longterm effect of uhi on life expectancy among thirteen emerging countries. econometric procedures known to be robust and providing better statistical interpretations regarding heterogeneity and spatial dependence were deployed. the results show that uhi, physician ratio, health care expenditure, and educational factors are positive contributors to increased life expectancy at birth in the selected emerging 63 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) economies while economic growth remained negatively significant. education should be prioritized among emerging economies to help people change risky behaviors to healthy ones in order to improve population health and increase life expectancy. expanding the healthcare work force is another approach that leads to increased life expectancy. the study justifies shifting away from oop charges to uhi. this means concentrating on risk pooling and enabling financial protection from the healthy-wealthy to sick-vulnerable groups could lead to enhanced population health. this will help achieve sdg 3.2, which seeks 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sloan m. depression in the united states and japan: gender, marital status, and ses patterns. soc sci med. 2005;61:2280-92. https://doi.org/10.1016/j.socscimed.2005.07.014 48. oberg e, frank e. physicians' health practices strongly influence patient health practices. bmj. 2009;39(4):290. https://doi.org/10.4997/jrcpe.2009.422 peer reviewed: submitted 1 feb 2020, accepted 3 june 2020, published 30 june 2020 competing interests: none declared. acknowledgements: we desire to express our profound gratitude to the national science foundation of china grant no. 71974079 (grant no. 71974079) for their support. we also wish to render our sincere gratitude to the institute of healthcare management and social medicine for making available their facilities for this extended period of research. we also do acknowledge that a section of this study has been presented at the 2nd international conference on medical and about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 66 ampon-wireko, zhou, antwi, brobbey, teguom june 2020. christian journal for global health 7(2) health science, july 26-27, 2019 conference in melbourne, australia. similarly, we are indebted to mr. ampon-wireko for his valuable suggestions on the preliminary draft of this manuscript. correspondence: sabina ampon-wireko, zhenjiang, china. amponwirekosabina@gmail.com cite this article as: ampon-wireko s, lin zl, antwi ha, brobbey ew, tetgoum adk. does universal health insurance act as a driver of increased life expectancy? evidence from selected emerging economies. christian journal for global health. june 2020; 7(2):52-66. https://doi.org/10.15566/cjgh.v7i2.347 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank family conflict – the major underlying influence in suicide attempts in northern bihar, india. original article family conflict – the major underlying influence in suicide attempts in northern bihar, india. sangeeta naira, lois joy armstrongb, philip finnyc aclinical psychologist, department of medicine, duncan hospital, a unit of emmanuel hospital association bresearch co-ordinator, epidemiology and research dept, duncan hospital, a unit of emmanuel hospital association cconsultant physician/endocrinologist, duncan hospital, a unit of emmanuel hospital association abstract suicide attempts in north india are generally underreported but have been considered to be rising. the number of admissions due to attempted suicide at duncan hospital, north bihar, rose from 82 in 2007 to 419 in 2011. a structured interview and the who (world health organization) major (icd-10) depression inventory were completed by 157 suicide-attempt survivors. immediate relatives were also interviewed. only 23% of patients came from india; 77% of patients came from nepal. the highest incidence was in the age group 16-20 years. females have higher rates in the 21-30 year age group (p=0.012), but after 30 years of age, the number of males becomes higher than the females (p=0.048); 81.5% of the respondents were below the age of 30 years. pesticide poisoning was the major mode of attempted suicide (94.3%). using the who major (icd-10) depression inventory, 28 of the participants suffered from depression (17.7%). ninety people (56.9%) admitted to previous thoughts of suicide, and nine (5.7%) people had attempted suicide previously. hindus made up 84.0% of the respondents. almost 50% of respondents only carried out their religious rituals on an occasional basis or not at all. 70.2% had not completed education beyond primary school, and 49.7% earned less than rs10,000 per month (us$200). eighty percent of the participants stated conflicts with family members led to the attempted suicide. relatives did not expect the attempted suicide in 97.4% of cases. knowledge of the suicide of a neighbour, friends, or relative influenced 77.0% of the participants to attempt suicide. efforts to prevent suicide attempts and deaths need to be multifaceted. banning the most poisonous pesticides and improving poison storage in the community must be encouraged. prevention, early intervention and treatment all are required in a suicide prevention plan. the lack of psychiatrists necessitates that other professionals and trained non-professionals be utilised in the mental health team. holistic care should include cultural aspects like shame as well as physical, psychosocial, and spiritual issues. special interventions need to be aimed at training adolescents in stress management and conflict resolution and mentoring adolescents to become part of strong, caring families.   introduction suicide is a worldwide phenomenon, and whether it is a fatal or nonfatal suicide attempt, it has repercussions on the family, the extended family, and wider community. india is no exception. shame has always been associated with suicide, but in cultures where shame and honour play a larger cultural role than in the western world, suicide has its own unique characteristics. it leads to the problem of suicide being hidden and underestimated. this is especially so in the teeming millions of north india. the state of bihar had a population of 104 million in the 2011 census and a population density of 1100 people per square kilometre.1 with the current 25% growth rate, this is now much higher.1 bihar is on the fertile gangetic plain and has an 89% rural population, predominantly farmers.1 although productive farming land, it is prone to flooding because of the many rivers running down from nepal, across the plain, and into the ganges river. the religion figures from the 2011 census are not yet available, but in the 2001 census, hindus made up 79% of the population of bihar followed by 16.5% muslims and 0.064% christians.2 in rural bihar, the literacy rate is 59.78% with female literacy lagging behind at 44.3%.1 the figure for the timely completion of primary school education for the state is 23%.3 only 21% of primary school teachers had completed tenth standard of education. 3 bihar follows uttar pradesh in being the state with the second largest number of people below the poverty line. however, as a percentage of the population, bihar is the highest.4 in east champaran district where duncan hospital is located, 21.3% of people have access to electricity, 93.5% use firewood/crop residue/cow dung as fuel for cooking, 61.2% have a phone/mobile phone, and 8.8% possess a computer. 5 it is these types of figures, along with a history of poor administration and law enforcement, which have given bihar the reputation of being the most backward state in the country. in general, health facilities in bihar are severely under resourced.6,7 the number of psychiatrists per 100,000 population has been studied, and, overall, india has a 77% deficit in the number of psychiatrists. bihar is the third most badly serviced state with a deficit of 96.62%.8 at the time of the study, there were no psychiatrists in the district of east champaran (5 million people) and no evidence of a district mental health plan. in india, there are many reports of rising suicides and particularly high rates reported in the affluent states of india such as kerala and tamil nadu.9-11 in maharashtra and andhra pradesh, farmer suicides are a particular problem and frequently relate to financial crises.12 in north india, especially bihar, there is little data, and lack of reporting may be influencing the reported low rates in these regions.13 around the world, there are many reports of rural suicide rates being higher than urban. some of the reasons given are the instability of farming income due to climate change and natural disasters, increased access to pesticides and firearms, social isolation, higher population of indigenous communities, and decreased access to health care and, specifically, psychiatric care.14-16 in india, radhakrishnan reports urban suicides to be higher than rural, using national crime records bureau (ncrb) data, with the reasons given being social isolation and over-crowding.17 in the million death study, rural suicides are reported to be higher than urban with the reasons suggested to be higher availability of pesticides and poorer access to medical care.18 the discrepancy between these two indian reports may be that there are poorer reporting systems in rural india. duncan hospital is a 230 bed hospital and community health facility at raxaul, east champaran district, bihar. it began in 1930 on the indo-nepal border to serve patients from both india and nepal. it is a secondary level referral centre with basic specialities and is part of the larger non-governmental organisation, emmanuel hospital association. at the time of the study, there were two physicians who took a special interest in mental health and a clinical psychologist. duncan hospital recorded 82, 126 and 202 admissions due to attempted suicide in the years 2007, 2008, and 2009. of these 410 patients, 403 patients ingested poisons (predominantly pesticides), and seven attempted hanging (unpublished hospital data). an audit of poisoning cases was carried out from 1 february 2011 to 31 january 2012 that included 418 attempted suicides by poisoning and one attempted hanging. these poisoning cases constituted 9.5% of all the medical inpatients. of those who took poisons, 9.5% died due to fatal complications. the age group with the highest frequency was 16-20 years, and there were slightly more females than males (52.1%: 47.9). (unpublished hospital data) after collecting a year of clinical data, expanded understanding of the psychological and sociological issues involved in attempted suicide in this region was needed. current literature seems to have variation across the country regarding influencing factors, and as there was no published literature from this region, we hoped to determine what factors were relevant for north bihar. the aim of this was to help us develop relevant hospital and community services with appropriate personnel to treat mental health issues and prevent suicides. materials and methods patients admitted to duncan hospital for attempted suicide were interviewed by a clinical psychologist (ma[clinical psychology], msc[applied psych]). these interviews were carried out after medical treatment was completed and verbal consent obtained from the patient. verbal consent was used because of the sensitivity of the issue and a reluctance of people to talk if written consent was required. patients who did not survive or were discharged early or against medical advice were unable to be interviewed. one or two close relatives of the patient were also interviewed. at the time of the interview, the psychologist also provided counselling for the patient and their relatives. patient and close relative interviews were done using a questionnaire looking at demographic and socio-economic factors and a series of questions related to social factors and reasons for suicide. the who major (icd-10) depression inventory was also completed to assess for depression among the attempted suicide cases.19 the beck depression inventory was pilot tested, but was found to be too difficult to be used due to the complexity of ideas and words used. the data from the questionnaire was coded and put in ms excel and analyzed. vassarstats online was used for obtaining p values for differences of proportions and for confidence intervals.20 95% two-tailed measurements were applied. approval for this study was obtained from emmanuel hospital association research and ethics committee (proposal number 80). results between 16 may 2012 and 13 march 2013, there were 372 suicide attempts (368 poisonings and 4 hangings) of which 32 persons died in hospital. one hundred and fifty-eight of these suicide-attempt survivors were approached for interview. one interview was not completed due to problems with language. one psychologist was available to conduct the interviews during regular working hours. although attempts were made to keep people for interview and counselling, many left prior to being seen. demographic data 77.7% of the patients came from nepal (n=122) with the remainder, 22.3%, being from india (n=36). females (n= 85, 54.1%) presented more often than males (n=73, 45.9%). the highest incidence in the 5-year age interval was 16-20 years. gender ratio changes through the age groups. no significant difference exists under the age of 20 (p=0.26), but in the 21-30 age group, females predominate (p=0.012). after 30 years of age there are significantly more males than females. (p=0.048). 81.5% of the respondents were below the age of 30 years. (figure 1) figure 1. age interval and gender of suicide attempt patients 71.5% of the respondents were married (n=113). 63.7% respondents were living in joint families (n=100), 35.7% in nuclear families (n=56), and 1.8% (students) were living away from home (n=2). one hundred and twelve of our respondents had not completed primary education (70.2%). the most common occupation was housewife (n=59, 37.6%). students were the second largest group (n=34, 21.6%). male respondents had a variety of occupations, the top three being: agriculture workers (n=18, 11.5%), skilled labourers (n=14, 8.9%), and business owners (n=13, 8.3%). (figure 2) figure 2. education completion 49.7% of respondents had a monthly income of 10,000 indian rupees [us$200] or less (n=78). 27.4% earned between 10,000-19,999 indian rupees [us$200-400] per month (n=43), and 9.5% earned above 20,000 indian rupees [us$400] per month (n=15). 14.0% of respondents, mostly women, did not know their average monthly income (n=22). 9.5% of respondents said they had debt (n=15). (fig 3) figure 3. occupation of respondents hindus made up 84.0% of the participants (n=132). muslims were 15.2% (n= 24) and 1.3% of the group (n=2) were buddhist. frequency of practice of religious rituals varied, with 38.2% who practiced them daily (n=60) and 14.0%, two to three times per week (n=22). 30.6% practiced their religious rituals only at major festivals (n=48), and 17.8% did not practice them at all (n=28). women were more likely to practice their religion than men; of those who never practiced their religion, 67.8% were male, and of those who practised their religion daily, 70.0% were female. when asked about how meaningful/helpful their religious practices were to them, 17.2% said it was very meaningful (n=27), 59.2% said somewhat helpful (n=93), and 24.0% said it was not helpful at all (n=38). suicide incident data of the interview population, 148 attempted suicide by ingestion of poison, usually pesticide (94.3%), nine respondents took an overdose of medication (5.7%), and one attempted hanging (0.63%). one hundred and twenty of the respondents stated that a family conflict was the reason they had attempted suicide (80.2%). this includes spouse, in-laws, and other family members. (table 1). when the issue of family conflict was separated according to gender, women had significantly more problems with family conflict than men (p=0.0042). on sub group analysis, it was also noted that conflict with in-laws was more for women (p=0.001) while conflict with other family members was significantly more for the men (p=0.0004). conflict in marriage was also more for women than men but was not statistically significant (p=0.22). table 1: stated reasons for attempting suicide reasons for attempting suicide total % with 95% ci conflict between husband & wife 52 32.9 (26.1-40.1) conflict with other family members 47 29.7 (23.17 – 37.3) conflict with in laws 27 17.1 (12.023.7) suspicion of extramarital affair 10 6.3 (12.0 – 23.7) insult 4 2.5 (0.99 – 6.33) exam failure 3 1.9 (0.65-5.43) did not reveal reason 3 1.9 (0.65-5.43) under influence of alcohol 3 1.9 (0.65-5.43) forced marriage 2 1.27(0.35-4.5) bereavement of family member 2 1.27(0.35-4.5) lost large amount of money 1 0.63 (0.11-3.5) sickness/anxiety 1 0.63 (0.11-3.5) neighbor suggested her that her husband was going to remarry 1 0.63 (0.11-3.5) total 157 of the people who were married, 25.9% reported they had a poor relationship with their spouse, and 28.7% reported they had a poor relationship with their in-laws. 36.9% of respondents felt that they were harassed (n=58), and 7.5% of respondents stated alcohol was a cause of quarrelling in the home more than twice a week (n=12). mental health using the who major (icd10) depression inventory, it was observed that 17.7% of the respondents were suffering from depression (n=28). nine met the criteria of mild depression, nine of moderate depression, and ten of severe depression. assessment by the medical team found two participants who were psychotic. eleven people stated they had chronic medical illnesses (7.0%). nine respondents had attempted suicide previously (5.7%), and 90 participants admitted to having previous suicidal thoughts (57.3%). one hundred and twenty-one of the respondents were influenced to attempt suicide because of having heard about someone in their neighbourhood, friends, or family who had previously attempted suicide (77.0%). six were influenced by the television (3.8%), and thirty-one did not know what influenced them (19.6%). response by the relatives one or two close relatives of the respondents were also interviewed using a structured questionnaire. 97.4% of the relatives stated that the news about the person attempting suicide was unexpected. fourteen relatives did not want to continue with the questionnaire at this point (8.9%). seven relatives had noted some clues that the person might consider suicide, (4.4%) and four had heard some expression of suicidal thoughts (2.5%). thirty-nine of the relatives had noted the person who attempted suicide had been sad in the previous few days (24.8%). discussion demographics and socio economics over 80% of the suicide attempt respondents in this study were under 30 years of age. although this finding is similar to the million death study of suicides in india, where 70% of the suicides deaths were in the 16 to 30 age group, an even larger percentage in the under 30 age group is described here.18 although the 16-20 age group had the highest rates, there were more cases in the 21-30 age group than the 11-20 age group. although our data is on suicideattempt survivors rather than deaths, it highlights the impact made on this economically productive age group. the very high rates in the 16-20 year age group are of great concern as is the fact we also have had suicide attempts down to 10 years of age. aaron et al in tamil nadu also had their highest rates in the 10-19 year age group.12 in bihar, the majority of young people leave school early, begin working at a young age, and get married as early as thirteen years of age. they are forced to take on the challenges of complex life situations in their early teens before they develop adult logical thinking skills. data relating to age and gender varies throughout india, according to whether suicides or suicide attempts are being measured.21,22 the million death study reported more deaths for men than women, but the average age at which the suicide attempt occurs is younger for women than for men.18. this has been in a number of other studies as well. 21,22 other researchers have used age intervals rather than average age, perhaps due to the fact that many indians do not know their age accurately. however, the common finding of higher rates for women in the 15-30 age group and higher rates for men over the age of 30, as in the data of this study, would be another way of expressing the same phenomena.10,23 some of the reasons given for the high number of suicides in young women concern marriage issues: arranged marriages, dowry, adjustment of moving to the husband’s home, infertility, unable to produce a boy child, domestic violence, harassment by in-laws, and the pressure to stay in an unhappy marriage. 17,21 another reason might be that women have very little voice in decision making in many of these issues. given the age of the respondents in this study, most should have completed primary education. the fact that 70.2% had not completed any education beyond primary level education highlights that respondents have very little education. the rate of timely completion of primary school in bihar is 25% which compares well to the study data seen here.3 lack of education decreases the options which a person is able to access when looking for support in times of crisis. fifty-two percent of the respondents had an income of less than 10,000 rupees (us$ 200) per month, but, surprisingly, very few people gave lack of finances as their reason for suicide. lack of finances may have contributed to the family conflict in more situations, but the topic of the conflict was not elicited. the bihar department of agriculture states that 81% of the workforce is involved in agriculture production while this study has only 11.5% of respondents who were farmers or farmer labourers.24 this proportion is significantly different (p< 0.0002), suggesting that farmer suicide is not a major problem in this region. exam failure and academics also do not seem to be a major problem for this region. although 22% of the respondents were students, only three gave exam failure as their reason for attempting suicide. the general term, family conflict, may hide some cases. academic pressure was the equal third topic mentioned in the focus group discussions (fgds) in the qualitative work of the author (unpublished ma thesis, 2013). there were also a couple of subjects in the study who wanted to study but were not allowed to, or not able to, due to finances. family conflict eighty percent of respondents stated the reason for suicide as conflict within the family. other studies have recognised this before, but this is the highest rate of family conflict documented.10,17,21,22 family conflict needs to be sensitively explored in further studies to try and understand the reason for the conflict and to find the point where communication breaks down so that one of the parties feels the only way out is to end their life. manorajitham et al. used the collective term “psychosocial stress” to describe the major risk factor for suicide.25 ongoing family conflict and psychosocial stress may well overlap in these definitions, but the difference in terminology makes it difficult to compare the two studies. suicide is frequently considered the only option for a person wanting to leave a family in conflict. divorce or separation, although permitted, carries with it a huge burden of shame, not just for the individual but for their present family and for their family of origin as well. shame, plus the lack of facilities such as safe houses or shelters, leaves very few options. even if a woman leaves her husband’s home (where she lives after marriage) and returns to her family home, she will be frequently returned to her husband’s home, the place of conflict, to prevent shame for both of the families. training adolescents in life skills relating to coping with stress, conflict management, and encouraging healthy family relationships are good preventative measures to be considered. an emphasis on forgiveness and reconciliation are two important principles that the christian faith has to offer in helping people with family conflict. mental health fifty-seven percent of the respondents stated they had had previous suicidal thoughts and ten percent of this group had attempted suicide previously. to the best of our knowledge, no other indian literature has recorded such high rates of prior suicidal thoughts. even with this high rate, most relatives of the suicide-attempt survivors found the suicide attempts unexpected. behaviours suggesting a person might be considering suicide were rarely noticed. education about expressed thoughts and behaviours people show, prior to attempting suicide, is a tool for preventing suicide in the western world.26 this could also be used to educate families and lay people in india, but first there needs to be research to ascertain if there is any cultural variation in behaviours which people express when considering suicide in india and whether there might be differences between rural and urban areas. psychosis was rare, but 18% of the respondents had depression according to the who major depression (icd-10) inventory. this proportion might have been higher. the psychologist conducting the test found this tool missing some cases of mild depression when compared to clinical assessment. this rate of mental health disorder is similar to what is seen in other parts of india which is between 20-40%. 24, 27 these data are different from those reported in western literature where mental health disorders exist in 91% of suicide deaths.28 the part alcohol contributes to the problem of suicide use may have been underestimated in this study. the annual health survey 2010-2011, bihar (2012) showed that east champaran had the highest rate of people habitually drinking alcohol of any district in the state(14.9%).5 one of the authors (unpublished ma thesis, 2013) found alcohol abuse was frequently mentioned in the fgds in their study. the use of a questionnaire may not have been the best way to get people to admit to the use or abuse of alcohol. the psychologist conducting the who icd-10 inventory found that the language was difficult for people with low literacy to understand, even though it was the simplest tool found. religion and culture the proportion of hindus in this study is higher than the state data, and the number of muslims is slightly less, but this is not significant (p=0.18). the fact there are no christians in the study reflects the low percentage of christians in this part of india and the larger number of buddhists reflects the proximity to nepal where there are more buddhists. the three major religions of india, hinduism, islam, and christianity, all teach that suicide (as per the context used here) is not acceptable. muslims and christians both say that god is the one who gives life and is the only one entitled to end life. islam and some parts of the christian community in india are very strong in declaring that suicide is a sin. the practice of seeing people who attempt suicide as people who need assistance rather than need condemnation also exists among christians. in buddhism, there is no clear cut teaching.29 although, at first, it may appear that hinduism might allow suicide because it simply means going on to the next life, this is not a correct understanding. human life is seen as the highest form of life and to cut that short would be considered bad karma and would send a person back to a lower form of life. each cycle of life is allotted a certain amount of time. if this is cut short prematurely, then the person will become ghost/wandering spirit (bhoot) until the allotted time for them to move onto the next life.30 sati, the outlawed practice of a widow joining her dead husband on the funeral pyre, may also be seen as suicide, but the cultural and social issues here are somewhat different. hinduism does have some acceptable forms of suicide that are considered self-sacrifice rather than suicide: agnipravesa — offering of the body to fire, prayopravesa — offering of the body to air, and samadhi — offering of the body to the earth. these ascetic religious practices can only be carried out when a person has reached a high level of spirituality and has no responsibilities in this life.30 however, these practices are far removed from the life of the average rural indian. here, the issue of shame related to suicide will play a much larger influence. hindu writings also have stories where suicide is glorified in situations where someone seeks to avoid shame or disgrace.17 hindi movies have also frequently portrayed suicide as an option for avoiding a situation of shame. the issue of shame plays a large part in suicide, and it is imperative to understand this when considering prevention and intervention in suicides in india. shame related issues also explain the large number of nepali patients seen in this study. in both india and nepal, attempted suicide requires reporting to the police. the principle behind this is that it is the role of the state to protect people from taking their own lives, just as it is their role to protect people from taking the lives of others.31 to avoid this police report, the nepali people come to india for treatment, and some indians go across to nepal, while others give nepali addresses. this also contributes to the ongoing problem of under-reporting of suicides as families seek to find ways to avoid the shame suicide brings on the whole family. until a person attempting suicide is seen as someone in need of help, instead of a person to be prosecuted, under reporting will continue. religiosity, rather than religion, is also important to consider and needs further examination. this study shows almost 50% either carry out their religious practices on an occasional basis or not at all. many do not find their religious practices meaningful. lack of religious faith was seen to be a risk factor for suicide by manorajitham.25 religious rituals usually point to a deeper meaning of beliefs. however, hinduism is not a creedal religion and is more concerned about the correct practice of rituals.32 when people are in distress, the practice of rituals without deeper meanings may not be sufficient to provide them with the inner resources they need to prevent them from attempting suicide. other factors related to suicide attempts the vast majority of suicide attempts occur by people consuming pesticides in contrast to south india where hangings, self-immolation, and drowning are more common. the most recent publication from the haryana, north india, reports poisonings as 41.1%, hangings as 36.8%, and burns as 14.7%.22 no other data from bihar is available for comparison. with a 92% rural population in east champaran district, the easy availability and lack of safe storage of pesticides in this farming community could well explain the high rates of pesticide poisonings.1 reasons for the low number of hanging and drowning suicides could include: 1) open wells are not common — the water table in bihar is high and so closed tube wells largely suffice, 2) flimsy house structures with no fans (and no electricity) do not provide the strong support needed for a hanging, 3) a high population density of 1100 persons per square kilometre and open housing does not permit sufficient privacy to allow hanging.1 the media is often portrayed as an influence in putting the thought of suicide in people's minds. this appeared to be only a minor influence in this study. movie halls are sparse in this rural area and television is lacking. however, “the local community grapevine” — the influence of knowing a neighbour or relative who has attempted suicide, is a major influence. when suicide prevention measures are being planned, this method of communication needs to be used to spread good messages instead of bad ones. continued research and interventions interventions are needed at many levels. at the level of public health, one of the interventions would be to ban class i and ii pesticides. this was done with good effect in sri lanka.33 manorajitham et al. argue for a need to address the underlying causes of human suffering, including poverty, economic inequality, and lack of social justice.24 although this could help alleviate psychosocial stress, it does not explain why the highest rates of suicide are in the southern, more socio-economically advanced states of india. practical measures, such as secure storage of pesticides at a household or community level, can be initiated.34 here in bihar, where housing structures are very basic and lockable cupboards are unknown, education regarding safe storage of poisons would decrease the rates of both deliberate and accidental poisonings. although suicides in india are frequently considered to be impulsive in nature, it does not mean that a longer underlying history is irrelevant. the high rate of previous suicidal thoughts and the presence of poor family relationships suggest that the final family conflict may be “the straw that breaks the camel’s back.” further investigation needs to be done to find the culturally appropriate cues indicating that people are considering suicide. teaching families, teachers, and community health workers to be alert for suicidal behaviour could allow early interventions to prevent suicide. the implementation of mental health services needs to be holistic in a number of ways. first, while there is desperate need for psychiatrists, well trained family practitioners, social workers, mental health community nurses, specially trained community health volunteers, traditional healers, and religious leaders can all participate in providing care and community education.35-38 second, preventative teaching, as well as interventional care, needs to be holistic. topics such as alcohol abuse, domestic violence, and the value of women must be included. third, people need to be treated not just from a biological perspective but as physical, social, psychological, and spiritual individuals, relating within their family, community, and the environment.38, 39 a major focus of preventative work needs to be with young people. training in life skills, such as handling relational conflict and stress particularly in family situations, could be used in both school settings and in the community. the value of every human life, especially the value given to women, is an intrinsic characteristic of the christian faith. using these values as a basis for intervention provides a sense of worth and hope to those badly in need of it. there is also an important role to be played in mentoring young people through their teenage years and into healthy families. building strong, caring families is an essential intervention in decreasing the problem of suicide in india. references bihar population census 2011. 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[internet] [cited 2015 february 2]. available from: http://thinkingaboutsuicide.org/ peer reviewed competing interests: none declared. correspondence: lois armstrong, duncan hospital, a unit of emmanuel hospital association, india loisjarmstrong@gmail.com cite this article as: nair s, armstrong lj and finny p. family conflict – the major underlying influence in suicide attempts in northern bihar, india. christian journal for global health (april 2014), 2(1):23-34. © nair s, et al. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ field reports nov 2014. christian journal for global health, 1(2):81-88. through the valley of the shadow of death – surviving the dreaded ebola disease adaora chinenye okoli-igonoh a a md, first consultants medical centre, lagos, nigeria on the night of sunday july 20th, 2014, patrick sawyer was wheeled into the emergency room at first consultants medical centre, obalende, lagos, with complaints of fever and body weakness. the doctor on call admitted him as a case of malaria and took a full history. knowing that mr. sawyer had recently arrived from liberia, the doctor asked if he had been in contact with an ebola patient in the last couple of weeks, and mr. sawyer denied any such contact. he also denied attending any recent funeral ceremony. blood samples were taken for full blood count, malaria parasites, liver function test, and other baseline investigations. he was admitted into a private room and started on antimalarial drugs and analgesics. that night, the full blood count result came back as normal and not indicative of infection. the following day, however, his condition worsened. he barely ate any of his meals. his liver function test result showed his liver enzymes were markedly elevated. we then took samples for hiv and hepatitis screening. at about 5:00 p.m., he requested to see a doctor. i was the doctor on call that night, so i went in to see him. he was lying in bed with his intravenous (i.v.) fluid bag removed from its metal stand and placed beside him. he complained that he had stooled about five times that evening, and he wanted to use the bathroom again. i picked up the i.v. bag from his bed and hung it back on the stand. i told him i would inform a nurse to come and disconnect the i.v. so he could conveniently go to the bathroom. i walked out of his room and went straight to the nurses‘ station where i told the nurse on duty to disconnect his i.v. i then informed my consultant, dr. ameyo adadevoh about the patient‘s condition, and she asked that he be placed on some medications. the following day, the results for hiv and hepatitis screening came out negative. as we were preparing for the early morning ward rounds, i was approached by an ecowas official who informed me that patrick sawyer had to catch an 11 o‘clock flight to calabar for a retreat that morning. he wanted to know if it would be possible to be discharged. i told him it wasn‘t, as he was acutely ill. dr. adadevoh also told him the patient could certainly not leave the hospital in his condition. she then instructed me to write very boldly on his chart that on no account should patrick sawyer be allowed out of the hospital premises without the permission of dr. ohiaeri, our chief medical consultant. all nurses and doctors were duly informed. during our early morning ward round with dr. adadevoh, we concluded this was not malaria, and the patient needed to be screened for ebola viral disease. she immediately started calling laboratories to find out where the test could be carried out. she was eventually referred to professor omilabu of the luth virology reference lab in idi-araba whom she called immediately. prof. omilabu told her to send blood and urine samples to luth straight away. she tried to reach the lagos state commissioner for health but was unable to contact him at the time. she also put calls across to officials of the federal ministry of health and national centre for disease control. 82 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. dr. adadevoh, at this time, was in a pensive mood. patrick sawyer was now a suspected case of ebola, perhaps the first in the country. he was quarantined, and strict barrier nursing was applied with all the precautionary measures we could muster. dr. adadevoh went online, downloaded information on ebola, and printed copies which were distributed to the nurses, doctors, and ward maids. blood and urine samples were sent to luth that morning. protective gear, gloves, shoe covers, and facemasks were provided for the staff. a wooden barricade was placed at the entrance of the door to keep visitors and unauthorized personnel away from the patient. despite the medications prescribed earlier, the vomiting and diarrhea persisted. the fever escalated from c to c. on the morning of wednesday 23rd july, the tests carried out in luth showed a signal for ebola. samples were then sent to dakar, senegal for a confirmatory test. dr. adadevoh went for several meetings with the lagos state ministry of health. thereafter, officials from lagos state came to inspect the hospital and the protective measures we had put in place. the following day, thursday 24th july, i was again on call. at about 10:00 p.m., mr. sawyer requested to see me. i went into the newly created dressing room, donned my protective gear, and went in to see him. he had not been cooperating with the nurses and had refused any additional treatment. he sounded confused and said he received a call from liberia asking for a detailed medical report to be sent to them. he also said he had to travel back to liberia on a 5:00 a.m. flight the following morning, and he didn‘t want to miss his flight. i told him that i would inform dr. adadevoh. as i was leaving the room, i met dr. adadevoh dressed in her protective gear along with a nurse and another doctor. they went into his room to have a discussion with him and, as i heard later, to reset his i.v. line which he had deliberately removed after my visit to his room. at 6:30 a.m., friday 25th july, i got a call from the nurse that patrick sawyer was completely unresponsive. again, i put on the protective gear and headed to his room. i found him slumped in the bathroom. i examined him and observed that there was no respiratory movement. i felt for his pulse; it was absent. we had lost him. i certified patrick sawyer‘s death. i informed dr. adadevoh immediately, and she instructed that no one was to be allowed to go into his room for any reason at all. later that day, officials from the word health organization (who) came and took his body away. the test in dakar later came out positive for the zaire strain of the ebola virus. we now had the first official case of ebola virus disease in nigeria. it was a sobering day. we all began to go over all that happened in the last few days, wondering just how much physical contact we had individually made with patrick sawyer. every patient on admission was discharged that day and decontamination began in the hospital. we were now managing a crisis situation. the next day, saturday 26th july, all staff of first consultants attended a meeting with prof. nasidi of the national centre for disease control, prof omilabu of luth virology reference lab, and some officials of who. they congratulated us on the actions we had taken and enlightened us further about the ebola virus disease. they said we were going to be grouped into high risk and low risk categories based on our individual level of exposure to patrick sawyer, the ―index‖ case. each person would receive a temperature chart and a thermometer to record temperatures in the morning and night for the next 21 days. we were all officially under surveillance. we were asked to report to them at the first sign of a fever for further blood tests to be done. we were reassured that we would all be given adequate care. the anxiety in the air was palpable. the frenetic pace of life in lagos, coupled with the demanding nature of my job as a doctor, means that i occasionally need a change of environment. as such, one week before patrick sawyer died, i had gone to my parents‘ home for a retreat. i was still staying with them when i re83 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. ceived my temperature chart and thermometer on tuesday29th of july. i could not contain my anxiety. people were talking ebola everywhere – on television, online . . . everywhere. i soon started experiencing joint and muscle aches and a sore throat, which i quickly attributed to stress and anxiety. i decided to take malaria tablets. i also started taking antibiotics for the sore throat. the first couple of temperature readings were normal. every day i would attempt to recall the period patrick sawyer was on admission — just how much direct and indirect contact did i have with him? i reassured myself that my contact with him was quite minimal. i completed the anti-malarials, but the aches and pains persisted. i had loss of appetite and felt very tired. n friday 1st of august, my temperature read a high . c. as i type this, i recall the anxiety i felt that morning. i could not believe what i saw on the thermometer. i ran to my mother‘s room and told her. i did not go to work that day. i cautiously started using a separate set of utensils and cups from the ones my family members were using. on saturday 2nd of august, the fever worsened. it was now at c and would not be reduced by taking paracetamol. this was now my second day of fever. i couldn‘t eat. the sore throat was getting worse. that was when i called the helpline and an ambulance was sent with w.h.o. doctors who came and took a sample of my blood. later that day, i started stooling and vomiting. i stayed away from my family. i started washing my plates and spoons myself. my parents, meanwhile, were convinced that i could not have ebola. the following day, sunday 3rd of august, i got a call from one of the doctors who came to take my sample the day before. he told me that the sample they had taken was not confirmatory, and they needed another sample. he did not sound very coherent, and i became worried. they came with the ambulance that afternoon and told me that i had to go with them to yaba. i was confused. couldn‘t the second sample be taken in the ambulance like the previous one? he said a betterqualified person at the yaba centre would take the sample. i asked if they would bring me back. he said ―yes.‖ even with the symptoms, i did not believe i had ebola. after all, my contact with sawyer was minimal. i only touched his i.v. fluid bag just that once without gloves. the only time i actually touched him was when i checked his pulse and confirmed him dead, and i wore double gloves and felt adequately protected. i told my parents i had to go with the officials to yaba, and i would be back that evening. i wore a white top and a pair of jeans, and i put my ipad and phones in my bag. a man opened the ambulance door for me and moved away from me rather swiftly. strange behavior, i thought. they were friendly with me the day before, but that day, not sono pleasantries, no smiles. i looked up and saw my mother watching through her bedroom window. we soon got to yaba. i really had no clue where i was. i knew it was a hospital. i was left alone in the back of the ambulance for over four hours. my mind was in a whirl. i didn‘t know what to think. i was offered food to eat, but i could barely eat the rice. the ambulance door opened and a caucasian gentleman approached me but kept a little distance. he said to me, ―i have to inform you that your blood tested positive for ebola. i am sorry.‖ i had no reaction. i think i must have been in shock. he then told me to open my mouth, and he looked at my tongue. he said it was the typical ebola tongue. i took out my mirror from my bag and took a look, and i was shocked at what i saw. my whole tongue had a white coating, looked furry, and had a long, deep ridge right in the middle. i then started to look at my whole body, searching for ebola rashes and other signs as we had been recently instructed. i called my mother immediately and said, ―mummy, they said i have ebola, but don‘t worry, i will survive it. please, go and lock my room now; don‘t let anyone inside and don‘t touch anything.‖ she was silent. i cut the line. 84 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. i was taken to the female ward. i was shocked at the environment. it looked like an abandoned building. i suspected it had not been in use for quite a while. as i walked in, i immediately recognized one of the ward maids from our hospital. she always had a smile for me but not this time. she was ill, and she looked it. she had been stooling a lot too. i soon settled into my corner and looked around the room. it smelled of faeces and vomit. it also had a characteristic ebola smell to which i became accustomed. dinner was served – rice and stew. the pepper stung my mouth and tongue. i dropped the spoon. no dinner that night. dr. david, the caucasian man who had met me at the ambulance on my arrival, came in wearing his full protective ‗hazmat‘ suit and goggles. it was fascinating seeing one live. i had only seen them online. he brought bottles of water and oral rehydration solution (ors), which he dropped by my bedside. he told me that 90 percent of the treatment depended on me. he said i had to drink at least 4.5 litres of ors daily to replace fluids lost in stooling and vomiting. i told him i had stooled three times earlier and taken imodium tablets to stop the stooling. he said it was not advisable, as the virus would replicate the more inside of me. it was better, he said, to let it out. he said good night and left. my parents called. my uncle called. my husband called, crying. he could not believe the news. my parents had informed him, as i didn‘t even know how to break the news to him. as i lay on my bed in that isolation ward, strangely, i did not fear for my life. i was confident that i would leave that ward someday. there was an inner sense of calm. i did not for a second think i would be consumed by the disease. that evening, the symptoms fully kicked in. i was stooling almost every two hours. the toilets did not flush so i had to fetch water in a bucket from the bathroom each time i used the toilet. i then placed another bucket beneath my bed for the vomiting. on occasion, i would run to the toilet with a bottle of ors, so that as i was stooling, i was drinking. the next day, monday 4th of august, i began to notice red rashes on my skin, particularly on my arms. i had developed sores all over my mouth. my head was pounding so badly. the sore throat was so severe i could not eat. i could only drink the ors. i took paracetamol for the pain. the ward maid across from me wasn‘t doing so well. she had stopped speaking. i couldn‘t even brush my teeth; the sores in my mouth were so bad. this was a battle for my life, but i was determined i would not die. every morning, i began the day with reading and meditating on psalm 91. the sanitary condition in the ward left much to be desired. the whole ebola thing had caught everyone by surprise. the lagos state ministry of health was doing its best to contain the situation, but competent hands were few. the sheets were not changed for days. the floor was stained with greenish vomitus and excrement. dr. david would come in once or twice a day and help clean up the ward after chatting with us. he was the only doctor who attended to us. there was no one else at that time. the matrons would leave our food outside the door; we had to go get the food ourselves. they hardly entered in the initial days. everyone was being careful. this was all so new. i could understand. was this not how we ourselves had contracted the disease? mosquitoes were our roommates until they brought us mosquito nets. later that evening, dr. david brought another lady into the ward. i recognized her immediately as justina ejelonu, a nurse who had started working at first consultants on the 21st of july, a day after patrick saywer was admitted. she was on duty on the day patrick reported that he was stooling. while she was attending to him that night, he had yanked off his drip, letting his blood flow almost like a tap onto her hands. justina was pregnant and was brought into our ward bleeding from a suspected miscarriage. she had been told she was there only on observation. the news that she had contracted ebola was broken to her the 85 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. following day after results of her blood test came out positive. justina was devastated and wept profusely — she had contracted ebola on her first day at work. my husband started visiting but was not allowed to come close to me. he could only see me from a window at a distance. he visited so many times. it was he who brought me a change of clothes and toiletries and other things i needed because i had not even packed a bag. i was grateful i was not with him at home when i fell ill, or he would most certainly have contracted the disease. my retreat at my parents‘ home turned out to be the instrumentality god used to shield and save him. i drank the ors fluid like my life depended on it. then i got a call from my pastor. he had been informed about my predicament. he called me every single day morning and night and would pray with me over the phone. he later sent me a cd player, cds of messages on faith and healing, and holy communion packs through my husband. my pastor, who also happens to be a medical doctor, encouraged me to monitor how many times i had stooled and vomited each day and how many bottles of ors i had consumed. we would then discuss the disease and pray together. he asked me to do my research on ebola since i had my ipad with me and told me that he was also doing his study. he wanted us to use all relevant information on ebola to our advantage. so i researched and found out all i could about the strange disease that has been in existence for 38 years. my research, my faith, my positive view of life, the extended times of prayer, study, and listening to encouraging messages boosted my belief that i would survive the ebola scourge. there are five strains of the virus, and the deadliest of them is the zaire strain, which was what i had. but, that did not matter. i believed i would overcome even the deadliest of strains. infected patients who succumb to the disease usually die between 6 to 16 days after the onset of the disease from multiple organ failure and shock caused by dehydration. i was counting the days and keeping myself well hydrated. i didn‘t intend to die in that ward. my research gave me ammunition. i read that as soon as the virus gets into the body, it begins to replicate really fast. it enters the blood cells, destroys them, and uses those same blood cells to aggressively invade other organs where they further multiply. ideally, the body‘s immune system should immediately mount up a response by producing antibodies to fight the virus. if the person is strong enough, and that strength is sustained long enough for the immune system to kill off the viruses, the patient is likely to survive. if the virus replicates faster than the antibodies can handle, however, further damage is done to the organs. ebola can be likened to a multi-level, multi-organ attack, but i had no intention of letting the deadly virus destroy my system. i drank more rs. i remember saying to myself repeatedly, ―i am a survivor, i am a survivor.‖ i also found out that a patient with ebola cannot be re-infected, and they cannot relapse back into the disease as there is some immunity conferred on survivors. my pastor and i would discuss these findings, interpret them as it related to my situation, and pray together. i looked forward to his calls. they were times of encouragement and strengthening. i continued to meditate on the word of god. it was my daily bread. shortly after justina came into the ward, the ward maid, mrs ukoh, passed on. the disease had gotten into her central nervous system. we stared at her lifeless body in shock. it was a whole 12 hours before officials of w.h.o. came and took her body away. the ward had become the house of death. the whole area surrounding her bed was disinfected with bleach. her mattress was taken and burned. to contain the frequent diarrhea, i had started wearing adult diapers, as running to the toilet was no longer convenient for me. the indignity was quite overwhelming, but i did not have a choice. my faith was being severely tested. the situation was desperate enough to break anyone psychologically. dr. ohiaeri also called us day 86 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. and night, enquiring about our health and the progress we were making. he sent provisions, extra drugs, vitamins, lucozade, towels, and tissue paper; everything we needed to be more comfortable in that dark hole we found ourselves. some of my male colleagues had also been admitted to the male ward two rooms away, but there was no interaction with them. we were saddened by the news that jato, the ecowas protocol officer to patrick sawyer who had also tested positive, had passed on days after he was admitted. two more females joined us in the ward: a nurse from our hospital and a patient from another hospital. the mood in the ward was solemn. there were times we would be awakened by the sudden, loud cry from one of the women. it was either from fear, pain mixed with the distress, or just the sheer oppression of our isolation. i kept encouraging myself. this could not be the end for me. five days after i was admitted, the vomiting stopped. a day after that, the diarrhea ceased. i was overwhelmed with joy. it happened at a time i thought i could no longer stand the ors. drinking that fluid had stretched my endurance greatly. i knew countless numbers of people were praying for me. prayer meetings were being held on my behalf. my family was praying day and night. text messages of prayers flooded my phones from family members and friends. i was encouraged to press on. with the encouragement i was receiving, i began to encourage the others in the ward. we decided to speak life and focus on the positive. i then graduated from drinking only the ors fluid to eating only bananas, to drinking pap, and then bland foods. just when i thought i had the victory, i suddenly developed a severe fever. the initial fever had subsided four days after i had been admitted, and then, suddenly, it showed up again. i thought it was the ebola. i enquired from dr. david who said fever was sometimes the last thing to go, but he expressed surprise that it had stopped only to come back on again. i was perplexed. i discussed it with my pastor who said it could be a separate pathology and possibly a symptom of malaria. he promised he would research if indeed this was ebola or something else. that night as i stared at the dirty ceiling, i felt a strong impression that the new fever i had developed was not as a result of ebola but malaria. i was relieved. the following morning, dr. ohiaeri sent me antimalarial medication which i took for three days. before the end of the treatment, the fever had disappeared. i began to think about my mother. she was under surveillance along with my other family members. i was worried. she had touched my sweat. i couldn‘t get the thought off my mind. i prayed for her. hours later, on twitter, i came across a tweet by w.h.o. saying that the sweat of an ebola patient cannot transmit the virus at the early stage of the infection. the sweat could only transmit it at the late stage. that settled it for me. it calmed the storms that were raging within me concerning my parents. i knew right away it was divine guidance that caused me to see that tweet. i could cope with having ebola, but i was not prepared to deal with a member of my family contracting it from me. soon, volunteer doctors started coming to help dr. david take care of us. they had learned how to protect themselves. among the volunteer doctors was dr. badmus, my consultant in luth during my housemanship days. it was good to see a familiar face among the care-givers. i soon understood the important role these brave volunteers were playing. as they increased in number, so did the number of shifts increase and, subsequently, the number of times the patients could access a doctor in one day. this allowed for more frequent patient monitoring and treatment. it also reduced care-giver fatigue. it was clear that lagos state was working hard to contain the crisis. sadly, justina succumbed to the disease on the 12th of august. it was a great blow, and my faith was greatly shaken as a result. i commenced daily bible study with the other two female patients, and we would encourage one another to 87 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. stay positive in our outlook, though in the natural, it was grim and very depressing. my communion sessions with the other women were very special moments for us all. on my 10th day in the ward, the doctors, having noted that i had stopped vomiting and stooling and was no longer running a fever, decided it was time to take my blood sample to test if the virus had cleared from my system. they took the sample and told me that i shouldn‘t be worried if it comes out positive as the virus takes a while before it is cleared completely. i prayed that i didn‘t want any more samples collected from me. i wanted that to be the first and last sample to be tested for the absence of the virus in my system. i called my pastor. he encouraged me, and we prayed again about the test. on the evening of the day justina passed on, we were moved to the new isolation centre. we felt like we were leaving hell and going to heaven. we were conveyed to the new place in an ambulance. it was just behind the old building. time would not permit me to recount the drama involved with the dynamics of our relocation. it was like a script from a science fiction movie. the new building was cleaner and much better than the old building. towels and nightwear were provided on each bed. the environment was serene. the following night, dr. adadevoh was moved to our isolation ward from her private room where she had previously been receiving treatment. she had also tested positive for ebola and was now in a coma. she was receiving i.v. fluids and oxygen support and was being monitored closely by the who doctors. we all hoped and prayed that she would come out of it. it was so difficult seeing her in that state. i could not bear it. she was my consultant, my boss, my teacher, and my mentor. she was the imperial lady of first consultants, full of passion, energy, and competence. i imagined she would wake up soon and see that she was surrounded by her first consultants family, but sadly it was not to be. i continued listening to my healing messages. they gave me life. i literally played them hours on end. two days later, on saturday the 16th of august, the who doctors came with some papers. i was informed that the result of my blood test was negative for ebola virus. if i could somersault, i would have, but my joints were still slightly painful. i was free to go home after being in isolation for exactly 14 days. i was so full of thanks and praise to god. i called my mother to get fresh clothes and slippers and come pick me up. my husband couldn‘t stop shouting when i called him. he was completely overwhelmed with joy. i was told, however, that i could not leave the ward with anything i brought in with me. i glanced one last time at my cd player, my valuable messages, my research assistant (a.k.a., my ipad), my phones, and other items. i remember saying to myself, ―i have life; i can always replace these items.‖ i went for a chlorine bath, which was necessary to disinfect my skin from my head to my toes. it felt like i was being baptized into a new life as dr. carolina, a who doctor from argentina poured the bucket of chlorinated water all over me. i wore a new set of clothes, following the strict instructions that no part of the clothes must touch the floor or the walls. dr. carolina looked on, making sure i did as instructed. i was led out of the bathroom and straight to the lawn to be united with my family, but first i had to cut the red ribbon that served as a barrier. it was a symbolic expression of my freedom. everyone cheered and clapped. it was a little but very important ceremony for me. i was free from ebola! i hugged my family as one who had been liberated after many years of incarceration. i was like someone who had fought death face-to-face and had come back to the land of the living. we had to pass through several stations of disinfection before we reached the car. bleach and chlorinated water were sprayed on everyone‘s legs at each station. as we made our way to the car, we walked past the old isolation building. i could hardly recognize it. i could not believe i slept in that building for 10 days. i was free! free 88 okoli-igonoh nov 2014. christian journal for global health, 1(2):81-88. of ebola. free to live again. free to interact with humanity again. free from the sentence of death. my parents and two brothers were under surveillance for 21 days, and they completed the surveillance successfully. none of them came down with a fever. the house had been disinfected by lagos state ministry of health soon after i was taken to the isolation centre. i thank god for shielding them from the plague. my recovery after discharge has been gradual but progressive. i thank god for the support of family and friends. i remember my colleagues who we lost in this battle. dr. adadevoh my boss, nurse justina ejelonu, and the ward maid, mrs. ukoh were heroines who lost their lives in the cause to protect nigeria. they will never be forgotten. i commend the dedication of the w.h.o. doctors, dr. david from virginia, usa, who tried several times to convince me to specialize in infectious diseases, dr. carolina from argentina who spoke so calmly and encouragingly, and mr. mauricio from italy who always offered me apples and gave us novels to read. i especially thank the volunteer nigerian doctors, matrons, and cleaners who risked their lives to take care of us. i must also commend the lagos state government and the state and federal ministries of health for their swift efforts to contain the virus. to all those prayed for me, i cannot thank you enough. and to my first consultants family, i say a heartfelt thank you for your dedication and for your support throughout this very difficult period. i still believe in miracles. none of us in the isolation ward was given any experimental drugs or so-called immune boosters. i was full of faith yet pragmatic enough to consume as much ors as i could, even when i wanted to give up and throw the bottles away. i researched on the disease extensively and read accounts of the survivors. i believed that even if the mortality rate was 99%, i would be part of the 1% who survived. early detection and reporting to hospital is key to patient survival. please do not hide yourself if you have been in contact with an ebola patient and have developed the symptoms. regardless of any grim stories one may have heard about the treatment of patients in the isolation centre, it is still better to be in the isolation ward with specialist care than at home where you and others will be at risk. i read that dr. kent brantly, the american doctor who contracted ebola in liberia and was flown out to the united states for treatment was being criticized for attributing his healing to god when he was given the experimental drug zmapp. i don‘t claim to have all the answers to the nagging questions of life. why do some die and some survive? why do bad things happen to good people? where is god in the midst of pain and suffering? where does science end and god begin? these are issues we may never fully comprehend on this side of eternity. all i know is that i walked through the valley of the shadow of death and came out unscathed. this account was first published in bellanaija 15 sept 2014. competing interests: none declared. cite this article as: okoli-igonoh ac. from the valley of the shadow of death – surviving the dreaded ebola disease. christian journal for global health (nov 2014), 1(2):81-88. http://dx.doi.org/10.15566/cjgh.v1i2.44 © okoli-igonoh ac. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.15566/cjgh.v1i2.44 http://creativecommons.org/licenses/by/3.0/ original article june 2022. christian journal for global health 9(1) effect of epidural ketamine on pain after total knee arthroplasty: a randomized double-blind placebo controlled clinical trial litha mary mathewa, leejia mathew b, verghese cherianc, alice davidd a mbbs, da, dnb, consultant, anesthesia department, believers church medical college, kerala, india b mbbs, md, dip pal med, consultant, anesthesia department, believers church medical college, kerala, india c mbbs, md, ffarcsi, professor of anesthesiology, penn state health college of medicine, usa d msc., phd, head of medical research, epidemiology & biostatistics, believers church medical college, kerala, india abstract background and aims: managing the pain after a total knee arthroplasty (tka) is essential for early mobilization and rehabilitation, which plays a crucial role for better clinical outcomes. epidural infusion of local anesthetic and opioids provides good pain relief but can lead to side effects such as hypotension, motor weakness and respiratory depression. the objective of this study was to evaluate if epidurally administered ketamine could provide postoperative analgesia, thereby, reducing the dose of epidural infusion and the need for rescue analgesia. methods: thirty patients undergoing tka under epidural anesthesia were randomized to receive 0.5% bupivacaine (group i) or 0.5% bupivacaine + ketamine (0.5mg/kg) (group ii) as their primary anesthetic. at the end of the surgery, an infusion of 0.1% bupivacaine + fentanyl (1μg/ml) was started through the epidural catheter at 5ml/h. the rate was adjusted every 2 hours, depending on the pain experienced by the patient. if, despite rate adjustment, the patient graded the pain as 5 or more, morphine 5mg intramuscularly could be administered as the rescue analgesic. results: the dose of epidural infusion in the postoperative period between the 2 groups was comparable. rescue analgesia was needed in 5 (35%) group i and 8 (53%) group ii patients. an analysis of the subset of patients using the kaplan-meier curves, showed that most of the patients from group i needed the rescue dose at the sixth hour. few of the group ii patients also needed rescue analgesia at the sixth hour but their rate of needing rescue analgesic was gradual, lasting up to 18 hours. conclusion: this study showed that the addition of a single dose of ketamine (0.5mg/kg) did not improve postoperative analgesia after tka. however, it may have some benefit in a select subset of patients. key words: epidural, ketamine, pre-emptive analgesia, total knee arthroplasty, postoperative pain mathew, mathew, cherian & david 78 introduction total knee arthroplasty (tka) is often followed by pain, requiring analgesics in the post operative period to facilitate early mobilization and rehabilitation.1 one of the techniques of providing post-operative analgesia in these patients is the administration of a local anesthetic through an indwelling epidural catheter. however, this technique could be associated with hypotension, blockade of motor function, and tachyphylaxis.2 various additives such as opioids, alpha 2 agonists,3 midazolam,4 and ketamine5 have been shown to reduce the dose of bupivacaine thereby retaining effective analgesia with reduced dose-related side effects.6 identification of opiate receptors in the spinal cord has led to widespread use of intra spinal opioids for postoperative pain management;7 however, this is associated with side effects such as nausea, vomiting, pruritus, urinary retention, and delayed respiratory depression.8 the understanding of the role of n-methyl-daspartate (nmda) receptors in pain modulation has prompted the use of nmda receptor antagonists such as magnesium and ketamine to control postoperative pain.9 ketamine, administered intrathecally or epidurally, targets the nmda receptors located within the dorsal horn10 and has been found to be effective in controlling postoperative pain.11 this study was undertaken to assess if addition of ketamine to epidurally administered bupivacaine, improves postoperative analgesia after tka surgery. methods this randomized, double-blind, placebocontrolled study was approved by the institutional research and ethics committee (irb min no. 5491). all asa (american society of anesthesiologists) physical status 1 or 2 patients scheduled for elective tka were eligible to be enrolled in this study. patients with spinal abnormalities, pre-existing neuropsychiatric illness, chronic pain syndromes, or those with any contraindication to epidural anesthesia or use of ketamine were excluded from participation. the study was explained to all eligible subjects and a written consent was obtained from all those who volunteered. in the operating room, after establishing standard monitors and administering intravenous fluids, an epidural catheter was placed by the anesthesiologist on record, who was blinded to the randomization. the participants were randomized to one of two groups. group i received 10ml of 0.5% bupivacaine and group ii received 10ml of 0.5% bupivacaine + ketamine (0.5 mg/kg body weight). the anesthesiologist was permitted to administer aliquots of 0.5% bupivacaine to achieve sensory block for surgical anesthesia. the patient’s vital parameters were monitored every 5 min for the duration of the surgery. at the end of the surgery, an infusion of 0.1% bupivacaine + fentanyl (1μg/ml) was started through the epidural catheter at 5ml/h. the rate was adjusted every 2 hours, depending on the pain experienced by the patient as assessed by a 11-point numerical rating scale (0–10). if despite rate adjustment, the patient graded the pain as 5 or more, morphine 5 mg, intramuscularly, was administered as the rescue analgesic. all patients were monitored for 48 hours after surgery for pain relief, sedation, incidence of vivid dreams or hallucinations, and sleep disturbances. sedation level was measured as 0 – awake, 1 – responds to verbal call, 2 – responds to tactile stimulus, 3 – unresponsive. patient satisfaction was also measured using a 6-point nrs (0–5) at 48 hours. the epidural administration of bupivacaine and fentanyl was continued for 48 hours. randomization and statistical analysis prior to the start of the study, a computer generated random list, in blocks of 10, was generated and serially numbered sealed envelopes containing the group number were created. the envelope was 79 mathew, mathew, cherian & david june 2022. christian journal for global health 9(1) opened after the epidural was sited and an anesthesiologist, not involved in the study, was asked to load the study drug and hand it over to the anesthesiologist who sited the epidural. the means of each group were compared using student’s t-test. the proportions were compared using chi square test and the fisher’s exact test was used whenever the expected cell values were less than five. a p-value less than 0.05 was considered to be statistically significant in all the above tests. time to the first rescue analgesia was compared using the log rank test and graphically represented using kaplan meier curves. results thirty patients scheduled for tka were randomized to either group i (bupivacaine) or group ii (ketamine + bupivacaine). one patient in group i had to be withdrawn because of failure to achieve adequate surgical anesthesia with epidural and had to be administered general anesthesia. the flow chart according to the consort guidelines for rct is given in figure 1. the baseline characteristics of patients in the two groups were comparable. see table 1. postoperative pain was well controlled in all the study patients. the dose of bupivacaine and fentanyl administered epidurally was comparable between the two groups. see table 2. despite adjusting the infusion rate of the epidural solution, eight subjects in the ketamine group and five in the control group needed additional analgesic in the form of morphine (5mg) intramuscularly, but this was not statistically significant. among those who needed it, the average time to rescue analgesia was on an average 3h later in the ketamine group. see table 3. a further analysis of the subset of patients who needed rescue analgesia was done using the kaplan-meier curves. most of these patients from group i needed the rescue dose at the sixth hour. although few of the group ii patients also needed rescue analgesia at the sixth hour, their rate of needing rescue analgesic was gradual, lasting up to 18 hours. see figure 2. this difference was not statistically significant as measured by the log-rank test (p=0.1564). the blood pressure, the heart rate and the oxygen saturation were stable and comparable between the two groups. during the postoperative period the incidence of complications such as nausea and vomiting, urinary retention and paresthesia was comparable between the two groups as was the level of sedation (p >0.05). none of the patients complained of hallucinations or vivid dreams. patient satisfaction at 48 hours was not statistically different. see table 4. mathew, mathew, cherian & david 80 figure 1. flow chart of recruitment analyzed (n= 14)  excluded from analysis (n=0) allocated to standard care (group i) (n=15)  received standard care (n= 14)  did not receive standard care (reason: failure to achieve adequate surgical anesthesia) (n=1) follow-up analyzed (n= 15)  excluded from analysis (n=0) analysis lost to follow-up (n= 0) discontinued intervention (n=0) lost to follow-up (n=0) discontinued intervention (n= 0) enrollment allocation randomized (n= 30) excluded (n= 6)  not meeting inclusion criteria (n= 6)  declined to participate (n= 0)  other reasons (n= 0) assessed for eligibility (n=36) allocated to intervention (group ii) (n= 15)  received allocated intervention (n= 15)  did not receive allocated intervention (n= 0) 81 mathew, mathew, cherian & david june 2022. christian journal for global health 9(1) table 1. baseline characteristics of group i (bupivacaine) compared to group ii (bupivacaine plus ketamine) group i (n=14) group ii (n=15) p value male n (%) 3 (21.4%) 7 (46.7%) 0.2 age (years) (mean + sd) 58.4 ± 9.0 60.0 ± 7.8 0.6 weight (kg) (mean + sd) 59.0 ± 9.0 61.9 ±9.0 0.4 height (cm) (mean + sd) 153.9 ± 6.2 155.9 ± 6.2 0.4 volume of 0.5% bupivacaine administered to achieve surgical analgesia (ml) (mean + sd) 19.6 ± 5.9 20.9 ± 2.8 0.5 onset of anesthesia in minutes (mean + sd) 8.2 + 1.4 7.3 + 1.8 0.1 duration of surgery in minutes (mean + sd) 150. 7 ± 54.4 137.7 ± 44.2 0.5 table 2. post-operative requirement of bupivacaine and fentanyl infusion dose (ml) time since surgery group (n = 14) group ii (n = 15) p value 6 hours 29.1 + 6.1 30.5 +2.5 0.4 12 hours 62.4 + 12.4 64.9 + 8.8 0.5 24 hours 134.1 + 28.2 138.1 + 18.1 0.7 48 hours 261.3 + 36.1 271.4 + 35.7 0.5 table 3. post-operative requirement of rescue analgesics (ml) group i (n=14) group ii (n=15) p value number of patients requiring rescue analgesia 5 (35.7%) 8 (53.3%) 0.3 time to first dose among those who received rescue analgesia mean + sd 7.4 + 2.6 (n-5) 10.4 + 4.4 (n-8) 0.2 mathew, mathew, cherian & david 82 table 4: postoperative subjective assessment complications group i (n = 14) group ii (n = 15) p value nausea/vomiting 1 (7.1%) 4 (26.7%) 0.16 urinary retention 2 (14.3%) 0 (0.0%) 0.13 paresthesia 0 (0.0%) 1 (6.7%) 0.32 catheter displacement 1 (7.1%) 1 (6.7%) 0.97 sedated at 6 hours (>1) 3 (21.4%) 5 (33.3%) 0.47 pain at 6 hours 2.9 + 1.3 3.3 + 1.5 0.72 patient satisfaction 8.2 + 1.1 8.1 + 1.0 0.71 figure 2. kaplan meier curve comparing those who received rescue analgesia in group i (bupivacaine) and group ii (bupivacaine + ketamine) 83 mathew, mathew, cherian & david june 2022. christian journal for global health 9(1) discussion the surgical technique and the postoperative management of tka have evolved since its inception over 50 years ago. epidural infusion of local anesthetic with adjuvant analgesic medication used to be an accepted mode of analgesia for this procedure. due to the associated motor weakness, attempts were made to reduce the concentration of the local anesthetic, while changing the adjuvants to minimize side effects. in developed countries, pain management strategy has moved from epidural infusion of local anesthetic to continuous selective nerve block with or without infiltration of the local tissue with a solution containing a mixture of ropivacaine, epinephrine, ketorolac, and saline which is infiltrated around the knee joint by the surgeon after skin closure. transition to minimally invasive surgical technique which causes limited tissue injury and associated pain may have contributed to this change in pain management. moreover, the offer of a “bundle package” by the insurance companies incentivized reducing the hospital stay. with improved home nursing care, it was cheaper for the insurance company to manage pain at home using infusion pumps to deliver local anesthetics into catheters placed in proximity to peripheral nerves. however, in developing countries, where community-based healthcare facility is nascent, and poor hygiene and low socio-economic conditions preclude the use of sophisticated infusion pumps in a home setting, techniques such as epidural analgesia and care in a hospital ward for a couple of days are still very common, practical, and affordable. a continuous infusion of local anesthetic through an epidural catheter is a well-established technique of providing postoperative analgesia. however, to reduce the motor blockade, the concentration of local anesthetic is kept low and opioids are added to complement the analgesic action. the addition of opioids can cause side effects such as pruritus, sedation and respiratory depression.8 in many developing countries, the limited availability of opioid medications, the paucity of monitoring devices and inadequate staffing have prompted efforts to reduce the dose of opioids in the postoperative period and add a nonopioid based regimen for postoperative analgesia.12 ketamine, readily available even in smaller towns, in low doses has been shown to be an effective analgesic with negligible hallucinogenic or respiratory depression effects.9 this study was an attempt to see if addition of a low dose of ketamine given epidurally, along with the initial dose of local anesthetic as part of the anesthetic for tka, would reduce the dose of epidural infusion over 48 hours needed to control pain after the surgery. as explained above, a 48-hour infusion is still in practice in resource poor settings. the study showed that addition of ketamine (0.5mg/kg) to bupivacaine given epidurally, did not reduce the requirement of the infusion of 0.1% bupivacaine + fentanyl (1μg/ml), administered epidurally, for postoperative analgesia. this is consistent with the findings of the study done by weir et al.13 they added 3 different doses of ketamine (0.3 mg/kg, 0.5 mg/kg & 0.67 mg/kg) to 0.5% bupivacaine for epidural anesthesia in patients undergoing tka and concluded that a single bolus injection of ketamine had no effect on the quality or duration of epidural analgesia. they concluded that since drug binding to the nmda receptor occurs slowly, a bolus dose of ketamine may not provide adequate exposure of the drug to the receptor for maximal effect and speculated that a continuous infusion may prove more effective. similarly, yanli et al., in a placebo-controlled clinical trial added 25 mg ketamine to 20 ml of 0.5% bupivacaine administered epidurally to patients undergoing lower abdominal or orthopedic surgery. there was a small but significant decrease in onset time to anesthesia and a slightly higher segmental blockade in the ketamine group, but there was no difference regarding postoperative analgesic requirements.14 in contrast to the above studies, himmelseher et al. used a mixture of s(+) ketamine and ropivacaine in a patient-controlled epidural analgesia (pcea) system and showed better control of postoperative mathew, mathew, cherian & david 84 pain.5 s(+) ketamine has a four times higher affinity for nmda receptors and twice the analgesic potency compared to racemic ketamine. in our study, due to the non-availability of s (+) ketamine, racemic ketamine was used. the pcea system was not used either. rescue morphine was given intramuscularly since it was considered to be safer than intravenous in a ward with minimal nursing personnel and monitoring facilities. the analysis of those patients who needed rescue analgesia suggests a slight prolongation in analgesia among those who received ketamine (figure 2). therefore, a larger initial dose or an infusion of ketamine in the postoperative period may benefit even this subset. however, this study was not powered enough to delineate the characteristics of such patients. nmda receptors maintain neuroplasticity and hyperalgesia after a painful stimulus, as shown by both electrophysiological and behavioral studies carried out in animals.13-15 hence, blockade of nmda receptors preemptively might inhibit central sensitization to pain induced by tissue trauma and inflammation. ketamine, an nmda receptor blocker, has been shown to be effective in opioid dependent patients as well as those with chronic pain.9 the concept of preemptive analgesia suggests that the administration of an analgesic or local anesthetics before incision, might reduce the barrage of nociceptive stimulus induced by surgical trauma and, thus, the intensity of postoperative pain.16, 17 ketamine has been shown to provide better postoperative analgesia after laparoscopic hysterectomy when administered before the surgical incision.18, 19 ozyalcin et al., in a randomized, double blinded and placebo-controlled study, demonstrated that ketamine given epidurally compared to intramuscular was more effective in reducing perioperative analgesic requirements, hyperalgesia and touch allodynia after thoracotomy.20 ketamine has been shown to improve postoperative analgesia in patients undergoing spine surgery and who have chronic pain and are opioid tolerant.21, 22 other modalities of pain control after tka include administering local anesthetic through a peripheral nerve catheter placed in the adductor canal or infiltrating it into the periarticular tissue. a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy and safety of local infiltration anesthesia versus epidural analgesia for postoperative pain control in tka23, has demonstrated that local anesthesia provides an equivalent efficacy in pain control with an increase in the range of motion and a reduction of the occurrence of nausea and length of hospital stay. however, the advantage of epidural is that it can be used as the primary anesthetic as well. this study did not show any increase in the incidence of any side effects attributed to ketamine, such as increased sedation, hallucinations or vivid dreams. nor was there any increase in complications such as nausea, vomiting, urinary retention, or paresthesia. similarly, there was no difference in the level of satisfaction with the perioperative care between the two groups. conclusion although this study failed to show that the addition of a single dose of ketamine (0.5mg/kg) improved postoperative analgesia after tka, it may have some benefit in a select subset of patients. a larger sample size would be needed to identify those patients. perhaps the use of s-ketamine or addition of ketamine in the epidural infusion 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rfk, lim j, chan mtv, gin t, chiu wky. preoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery. anesth analg. 2004;98(4):1044-9. http://doi.org/10.1213/01.ane.0000105911.66089.5 19. abdel-ghaffar me, abdulatif ma, al-ghamdi a, mowafi h, anwar a. epidural ketamine reduces post-operative epidural pca consumption of fentanyl/bupivacaine. can j anaesth. 1998;45(2):103-9. http://doi.org/10.1007/bf03013246 20. ozyalcin ns, yucel a, camlica h, dereli n, andersen ok, arendt-nielsen l. effect of preemptive ketamine on sensory changes and postoperative pain after thoracotomy: comparison of epidural and intramuscular routes. br j anaesth. 2004;93(3):356-61. http://doi.org/10.1093/bja/aeh220 21. park pj, makhni mc, cerpa m, lehman ra, lenke lg. the role of perioperative ketamine in postoperative pain control following spinal surgery. j http://doi.org/10.1034/j.1399-6576.2001.450805.x http://doi.org/10.1097/00000542-200002000-00012 http://doi.org/10.1007/bf03012706 http://doi.org/10.1097/00000539-200105000-00040 http://doi.org/10.1097/00000542-199307000-00010 http://doi.org/10.1097/00000542-199307000-00010 http://doi.org/10.1093/bja/54.5.479 http://doi.org/10.1213/01.ane.0000108501.57073.38 http://doi.org/10.1097/00000542-197301000-00003 http://doi.org/10.1097/00002508-200309000-00006 http://doi.org/10.1002/14651858.cd012538.pub2 http://doi.org/10.1093/bja/80.3.299 http://doi.org/10.1111/j.1365-2044.1996.tb07662.x http://doi.org/10.1111/j.1365-2044.1996.tb07662.x http://doi.org/10.1016/s0304-3940(98)00217-1 http://doi.org/10.1016/s0304-3940(98)00217-1 http://doi.org/10.1016/0304-3959(93)90219-f http://doi.org/10.1016/0304-3959(88)90286-2 http://doi.org/10.1016/0304-3959(88)90286-2 http://doi.org/10.1213/01.ane.0000105911.66089.5 http://doi.org/10.1007/bf03013246 http://doi.org/10.1093/bja/aeh220 mathew, mathew, cherian & david 86 spine surg. 2020;6(3):591-7. http://doi.org/10.21037/jss-19-306 22. loftus rw, yeager mp, clark ja, brown jr, abdu wa, sengupta dk, et al. intraoperative ketamine reduces perioperative opiate consumption in opiatedependent patients with chronic back pain undergoing back surgery. the journal of the american society of anesthesiologists. 2010;113(3):639-46. 23. li c, qu j, pan s, qu y. local infiltration anesthesia versus epidural analgesia for postoperative pain control in total knee arthroplasty: a systematic review and meta-analysis. j orthop surg res. 2018;13(1):112. http://doi.org/10.1186/s13018-0180770-9 peer reviewed: submitted 18 mar 2022, accepted 31 may 2022, published 20 june 2022 competing interests: none declared. correspondence: leejia mathew, believers church medical college hospital, kerala, india. leejia.philip@gmail.com cite this article as: mathew lm, mathew l, cherian v, david a. effect of epidural ketamine on pain after total knee arthroplasty: a randomized double-blind placebo controlled clinical trial. christ j global health. june 2022; 9(1):77-86. https://doi.org/10.15566/cjgh.v9i1.641 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://doi.org/10.21037/jss-19-306 http://doi.org/10.1186/s13018-018-0770-9 http://doi.org/10.1186/s13018-018-0770-9 about:blank https://doi.org/10.15566/cjgh.v9i1.641 about:blank introduction methods randomization and statistical analysis results discussion conclusion references conference report nov 2014. christian journal for global health, 1(2):98-100. ccih annual conference explores best practices in christian global health kathy erb a a director of communications, christian connections for international health approximately 150 attendees from the u.s, africa, asia and europe attended the christian connections for international health (ccih) 28th annual conference at marymount university in arlington, va. june 20-23, 2014 to share experiences and best practices, and join in christian fellowship. the theme of the conference was transforming lives: christians in global health, with four sub-themes digging deeper into the work of christians. the sub-themes were strength in partnerships; excellences in practices; compassionate care in crisis; and voice for the vulnerable. gil odendaal, ph.d., d. min., vice president of integral mission at world relief kicked off the 28th annual conference on june 20 with an inspiring discussion of what it means to integrate "word and deed" and how christians working in global health need to strive to bring healing to body and spirit. dr. odendaal shared his experiences growing up under apartheid in south africa and how that influenced his calling to serve. he also challenged participants to evaluate how their churches were being inclusive and encouraging participation by all in god’s kingdom. the following plenary session, strength in partnerships, featured the work of three christian organizations who use partnerships to deliver care and health services. emily sarmiento, child sponsorship program director, compassion international, described the organization’s partnership model working with implementing churches and sponsors. ms. sarmiento explained that the 99 erb nov 2014. christian journal for global health, 1(2):98-100. model encourages local partners to work with each other for greater impact in releasing children from poverty. debbie dortzbach, director of health and social development, world relief, presented world relief’s program in turkana, kenya which involves partnership with wheaton bible church and other partners to empower vulnerable farmers by training them on irrigation systems and how to marketing practices. lara villar, vice president for strategy and organizational performance, catholic medical mission board (cmmb), explained how cmmb’s champs (children and mothers partnerships) program encourages large scale social change from better cross sector coordination rather than isolated interventions by individual organizations. the plenary session, awakening our voice: advancing excellence in christian global health, was moderated by doug fountain, vice president, operations support, medical teams international and featured panelists tom davis, mph, chief program officer, feed the children; todd nitkin, md, mph, senior advisor, monitoring and evaluation, medical teams international; and anne peterson, md, mph, director, public health program, ponce school of medicine and health sciences. the panel discussed differentiating doing “right” from doing “good,” meaning that christians need to ensure their programs are achieving their intended goals through proper measurement and monitoring and evaluation, as well as the concepts of stewardship and accountability practices and maintaining a sense of humility in our work. the challenge of maintaining christian values while serving in demanding professions and in diverse locations and settings was explored in the plenary session, living out your faith in your work. moderator pamela mukaire, dr.ph., loma linda university questioned panelists ron mataya, md, associate professor of global health, loma linda university school of public health; jonathan quick, md, mph, president and ceo, management sciences for health; anbrasi edward, ph.d., mph, johns hopkins school of public health; and kathy griffith , grants office in community-based primary health care, united methodist committee on relief. panelists shared personal testimony on the importance of their spirituality and maintaining a balance with their professional lives. rick santos, president and ceo, ima world health moderated a session on compassionate care in crisis. melissa crutchfield, associate general secretary, united methodist committee on relief (umcor); nicole hark, deputy director for asia and the middle east, lutheran world relief; and william sage, consultant to faith-based organizations shared their experiences working with fbos responding in crises. a theme that emerged during the panel was the natural connection between fbos and churches in communities, which makes them powerful partners and is an advantage for fbos responding to crises. the importance of engaging local community organizations to facilitate the transition from relief and recovery to development after a crisis was also discussed. the final plenary session featured reverend david beckmann, president, bread for the world, who spoke on the biblical basis for advocacy. according to rev. beckmann, many christians, especially in the u.s., do not understand that they have a responsibility to help change laws and structures in a way that will provide opportunity for people in need. he discussed jesus’ statement of “the judgment of the nations” which is judgment of not only individual actions, but also of nations and we all have the responsibility to be involved in public policy and advocate for the protection of those in need. view videos of sessions and copies of powerpoint presentations on june 23, the day following the final conference sessions, nearly 40 conference participants went to capitol hill for ccih’s annual advocacy day. they visited 26 congressional offices and discussed the importance of global health programs and shared stories of the impact of chrishttp://www.ccih.org/2014-annual-conference-presentations http://www.ccih.org/2014-annual-conference-presentations 100 erb nov 2014. christian journal for global health, 1(2):98-100. tians working in global health. see report of advocacy day ending extreme poverty: the challenge for christians in global health the theme of the 2015 ccih conference is ending extreme poverty: the challenge for christians in global health and is expected in june 2015. watch www.ccih.org over the coming months for updates. correspondence: kathy erb, ccih, 1329 shepard drive, suite 6 sterling, va, 20164 usa 703-444-8250 kathy.erb@ccih.org cite this article as: erb k. ccih annual conference explores best practices in global health. christian journal for global health (nov 2014), 1(2):98-100. © erb k. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.ccih.org/ccih-news-july-august-2014#advocacy http://www.ccih.org/ccih-news-july-august-2014#advocacy http://www.ccih.org/ mailto:kathy.erb@ccih.org http://creativecommons.org/licenses/by/3.0/ original article associations of multisite pain with mental ill health among women in north india nathan john grillsa, prerana singh b, pamela anderson c a mbbs, mph, dphil, associate professor and public health physician, nossal institute of global health, university of melbourne; public health foundation of india (faculty); community health global network, senior research advisor, australia india institute b msw, mph, project officer, emmanuel hospital association. c research associate, nossal institute for global health, the university of melbourne abstract physical triggers of multisite body pain (msp) have typically been the focus of treatment regimens for msp in lowand middle-income countries (lmics). we explored the non-physical dimension of msp, particularly the presence of mental ill health and other possible risk factors. we conducted a case-control study among 140 female participants in north india in early 2019. we used structured interviews to assess pain and validated mental health questionnaires to determine presence of depression and psychological distress. statistical analyses of msp, mental health, and demographic data found strong associations between msp and depression and psychological distress. marital status (women who had been widowed, separated, or unmarried) was the only demographic factor found to have a significant association with the experience of msp. we conclude that non-physical factors such as mental health need to be considered by treating practitioners and included within national treatment guidelines in lmics such as india. key words: pain, mental health, women, india, widowhood, multisite musculoskeletal pain, depression, psychological distress disorder points of interest • multisite pain has long-term impacts but is poorly understood, particularly in lmics. • treatments for multisite pain typically address physical symptoms, whereas nonphysical aspects of its aetiology may be important. • our study notes a significant association between women reporting multisite pain and marital status (i.e., singleness in some form). grills, singh & anderson 34 • in high-income settings, studies have indicated associations between mental health conditions and musculoskeletal pain. • among women in north india, we confirm the positive association between mental ill health—namely depression and psychological distress—and multisite pain. • we note that potentially dangerous treatment regimes, such as long-term use of nonsteroidal anti-inflammatory medications, are often used when the aetiology is poorly understood. introduction multisite pain (msp) is a prevalent condition with far-reaching impacts. a global study estimated that six to 34 percent of the populations in 17 countries suffered from the condition.1 msp was predictive of disability, especially when occurring around the neck, back, and upper limbs.2,3 for low-and middle-income countries (lmics), the incidence of msp is rapidly growing: as of 2015, neck and back pain climbed from the top twelfth in 1990 to the fourth cause of disabilities in lmics.4 in india, where this study was conducted, msp is often described as “whole body pain” by patients. despite its serious long-term health impact, msp is often inadequately treated or managed, especially in lmics, partly due to the lack of clear aetiology and partly because causes of the msp often have been understood in the light of physical triggers such as ergonomics or occupational stressors, heredity, or physical injuries.5,6 notwithstanding the frequent acceptance of this biophysical approach, studies have shown that many cases of multisite body pain cannot be wholly attributed to damage to tissues or other specific physical causes.7 the growing understanding of the intricate relationship between mind and body has seen more studies devoted to the non-physical dimension of msp. mental disorders, for instance, are among some of the common ailments that involve physical pain. studies have found that people with musculoskeletal pain likely have concomitant mental health problems.1, 8-11 the association between pain and mental disorders may be due to the shared risk factors, which include female gender, older age, low socioeconomic status (ses), and adverse life events.8,10,12 globally, women were found to have more years lived with disability due in part to higher prevalence of major depressive disorder in addition to higher prevalence of anaemia, migraines, and alzheimer’s disease.13 the impact of msp and depression in lmics requires further study. although the psychological dimension of msp and chronic pain has attracted growing attention among public health and medical researchers, most of the studies are conducted in high-income countries like germany, norway, france, and the uk.9,11,14,15 very few studies have focused on those in lmics who experience multisite body pain and none specifically on women. to address this, we examined (1) the association between msp and mental health among women in rural north india and (2) the possible risk factors of msp. ethics approval was obtained from the community health global network (chgn) uttarakhand cluster on 23 november 2018. methods study design and setting we conducted a case-control study between february and july 2019 in tehri garhwal district in uttarakhand, north india. a total of 140 participants were recruited into the study, of which 70 were cases and 70 controls. the participants were selected through a screening survey undertaken in community health clinics. cases and controls we defined msp, the disease of interest, as currently experiencing physical pain in more than three sites. given that older age is a wellrecognised risk factor, we matched each case with a similarly aged control. we arbitrarily used seven years each side of the case age, but our analysis 35 grills, singh & anderson june 2022. christian journal for global health 9(1) showed minimal difference between the ages of the cases and controls. for every case we recruited, the very next female patient without msp and aged within seven years was recruited as a control. cases and controls were recruited at the same clinics in the study district. all female patients aged 18 years or above were eligible to be enrolled in the study. data collection, variables of interests, and definitions through a structured interview, our trained researchers/interviewers identified cases by asking questions about the number of sites they were currently experiencing pain. we collected demographic and socio-economic data with a short questionnaire which contained questions regarding participants’ age, education, marital status, family size, parity (number of children), household income, occupation, decision-maker in the household, and type of housing. we collected data on mental health using the patients’ health 9 questionnaire (phq-9) and the self-reported questionnaire 20 (srq-20), both of which have been validated and widely used for determining the presence of depression and psychological distress, respectively.16 validated english and hindi versions of both screening tools were administered by our researchers as hindi was widely accepted and understood in this area. depression status was determined by the total score of the phq-9 in which the questions touch on participants’ level of interest in doing things, feeling down or depressed, difficulty sleeping, energy levels, eating habits, selfperception, ability to concentrate, speed of functioning, and thoughts of suicide. responses range from “0” (not at all) to “3” (nearly every day). using the srq-20, we assessed patients for presence or absence of psychological distress. this 20-question instrument asks respondents about symptoms and problems likely to be present in those with psychological distress. the response was binary (yes/no), and all 20 items were scored as “0” or “1.” the score of “1” indicates that the symptom was present during the past month while a score of “0” indicates that the symptom was absent. participant consent participants were briefed verbally about the study objectives based on a plain language statement that was also provided to the participants. we obtained written consent from all participants via a consent form translated into hindi, which most women in this area could sufficiently comprehend. the contents of the plain language statement and the consent form were read aloud and explained prior to seeking written consent, or verbal consent if they were unable to sign their name (this was then recorded by the researcher). statistical analysis we presented all categorical and binary data as percentages of the total number of participants and/or of the number of participants in their respective group. age, annual income, average daily hours of household work, family size, phq9 total score, and srq-20 total score were presented in mean and standard deviations or median and interquartile range in case of skewed distributions. we analysed the data as unmatched casecontrol data as this would be more appropriate given the sample size and the minimal matching in our study. we transformed the two exposure numerical variables into binary variables for tests of association between mbsp and depression and psychological distress. for diagnosis of depression, we followed (17)’s physicians’ guidelines, which suggested the following cutpoints based on phq-9 total scores: • minimal depression (0 to 4), • mild depression (5 to 9), • moderate depression (10 to14), • moderately severe depression (15 to19), • severe depression (20 to 27). given the narrow range of total scores and the absence of patients with severe depression in our sample, we combined minimal, mild, and moderate depression as one category, which gives a binary outcome of min/mild/moderate depression vs. moderately severe depression. for psychogrills, singh & anderson 36 logical distress, respondents were classified either as “normal” (total srq-20 score ≤12) or with “psychological distress” (total srq-20 score >12). we tested the associations between whole body pain and mental health variables (depression and psychological distress), as well as socioeconomic variables using the chi-square test. we also examined the link between depression and selected socio-economic risk factors such as total number of children, hours of housework, and annual income. strengths of association were measured in odds ratio using epitab for casecontrol studies. all statistical analyses were conducted using stata v.14.18 tests were twosided with statistical significance at 0.05. results we recruited 140 female participants between february and july 2019 in tehri garhwal district in uttarakhand, north india. all 140 respondents gave consent to the survey (100 percent response rate) of which 70 (cases) had msp and 70 did not have the condition. socio-demographic profile of all respondents table 1 summarises the characteristics of major demographics and mental health conditions of all respondents. the average age of all participants was 39.3 years, ranging from 23 years to 62 years. the median age was 40 years in the case and 38 years in the controls. approximately 73 percent (n=102) of the respondents were either housewives or farmers. nearly 70 percent of all participants had no more than five years of education, of which half had no schooling at all. on average, these women worked for more than seven hours daily on household chores. all but two of them lived in owned houses, as opposed to rented. table 1. demographic features of all participants (n=140) variable categories count % education never been to school 48 34.29 1–5 years 48 34.29 6–9 years 21 15.00 10–12 years 15 10.71 college 8 5.71 marital status married 123 87.86 separated 3 2.14 widowed 13 9.29 unmarried 1 0.71 type of family joint 46 32.86 nuclear 94 67.14 number of boys nil 12 8.63 1 to 2 97 69.78 3 to 4 26 18.71 5 to 7 4 2.88 number of girls nil 30 21.58 1 to 2 75 53.96 3 to 4 30 21.58 5 to 6 4 2.88 type of housing pucc (permanent) 114 81.43 kuccha (temporary) 26 18.57 occupation wage worker 32 23.02 shop owner 5 3.60 farmer 49 35.25 housewife 53 38.13 housing own house 138 98.57 rented house 2 1.43 37 grills, singh & anderson june 2022. christian journal for global health 9(1) table 1. demographic features of all participants (n=140) (cont’d) variable mean sd min max age 39.32 8.70 23 62 annual income (irp) 76,581.63 57,224.09 10,000 360,000 average daily hours of household work 7.24 2.42 2 13 number of family members 6.43 2.76 1 17 phq9† (based on total score) 8.2 4.77 0 18 srq20‡ (based on total score) 9.78 3.59 1 20 note. † patient health 9 questions for measuring depression ‡ self-reported 20 questions for identifying psychological distress whole body pain and mental disorders table 1 shows that both the average phq-9 and srq-20 scores of all respondents were below the parameters for moderately severe depression (total phq-9 score <20) and psychological distress (total srq-20 score <12). however, in individuals with the disease of interest (msp), average srq20 score was 54 percent higher (mean=11.9; sd=2.7) than in those without msp (mean=7.7; sd=3.2). similarly, participants with msp scored more than double on average phq-9 (mean=11.4; sd=3.8) when compared with their non-msp counterparts (mean=5; sd=3.2). table 2. distributions of exposure variables by msp status case (n=70) count (%) control (n=70) count (%) exposure variable category row total phq moderately severe† 17 (24.29%) 1 (1.43%) 18 min/mild/moderate‡ 53 (75.71%) 69 (98.57%) 122 sqr20 psychological distress§ 33 (47.14%) 5 (7.14%) 38 normal¶ 37 (52.86%) 65 (92.86%) 102 note. † moderately severe: phq total >14 § psychological distress: srq total >12 ‡ min/mild/moderate: phq total ≤ 14 ¶ normal: srq total ≤ 12 moderately severe depression was 17 times more prevalent in those with msp (table 2). similarly, nearly seven times as many individuals with msp also had psychological distress when compared with non-msp subjects. the proportions of both exposures (depression and psychological distress) were significantly different according to pain status (depression: p<0.001; psychological distress: p<0.0001). we detected an association between msp and depression. the odds of having moderately severe depression were 22 times higher in those with msp than in those without (95 percent ci 3.21 to 937.8, p<0.001). likewise, we observed a link between msp and psychological distress. the odds of having psychological distress in patients with msp were 12 times higher than those in the control group (95 percent ci 3.9 to 40.6, p<0.0001). other possible risk factors of all socio-economic and demographic variables, marital status was the only factor found to be associated with msp (table 3). the odds of being widowed, separated, or unmarried were about four times higher (95 percent ci: 1.07; 16.6, p=0.02) in those with msp than in those without. grills, singh & anderson 38 table 3. associations between main socio-economic factors and msp status variable categories case control row total odds ratio (95% ci) p-value education never been to school 23 (47.92%) 25 (52.08%) 48 0.88 (0.41; 1.88) 0.72 grade 1 to college 47 (51.09%) 45 (48.91%) 92 marital status widowed, separated, or single 13 (76.47%) 4 (23.53%) 17 3.76 (1.07; 16.59) 0.02 married 57 (46.34%) 66 (53.66%) 123 type of family nuclear 52 (55.32%) 42 (44.68%) 94 1.93 (0.89; 4.22) 0.07 joint 18 (39.13%) 28 (60.87%) 46 number of girls 3 or more 17 (50%) 17 (50%) 34 1.02 (0.44; 2.38) 0.96 0 2 52 (49.52%) 53 (50.48%) 105 no. of children no children 4 (66.67%) 2 (33.33%) 6 2.09 (0.29; 23.75) 0.39 1 or more 65 (48.87%) 68 (51.13%) 133 type of house temporarykuccha 15 (57.69%) 11 (42.31%) 26 1.46 (0.57; 3.84) 0.38 permanent pucca 55 (48.25%) 59 (51.75%) 114 occupation housewife 27 (50.94%) 26 (49.06%) 53 1.09 (0.52; 2.28) 0.81 other occupations 42 (48.84%) 44 (51.16%) 86 decision maker self 17 (58.26%) 12 (41.38%) 29 1.59 0.27 others 49 (47.12%) 55 (52.88%) 104 hours of household work 7 hours or more 36 (52.94%) 32 (47.06%) 68 1.59 (0.68; 3.75) 0.25 2–6 hours 17 (41.46%) 24 (58.54%) 41 annual income 40,000 irp or less 13 (48.15%) 14 (51.85%) 27 1.2 (0.45; 3.2) 0.69 more than 40,000 irp 31 (43.66%) 40 (56.34%) 71 house ownership rented 1 (50%) 1 (50%) 2 1 (0.01; 79.62) 1 owned 69 (50%) 69 (50%) 138 discussion the present study demonstrates an association between msp and depression among female patients in a small village clinic in rural north india. those who had msp had higher odds of having moderately severe depression than those without. similarly, the odds of psychological distress were significantly higher in those with msp than in those without pain. when exploring possible socio-economic risk factors that might be associated, we found that marital status was related to msp. women who were not married, divorced, or widowed, had higher odds of having moderately severe depression than those who were married. the same finding was true for psychological distress. 39 grills, singh & anderson june 2022. christian journal for global health 9(1) msp-mental disorder associations our study findings affirm the hypothesis that msp is associated with depression and psychological distress. the odds of having moderately severe depression were 22 times higher in those with msp than in those without. although different in magnitude, our study results in rural north india are consistent with studies done in other contexts that confirm a link between msp and mental disorders1,8-11 in a population-based study involving 17 countries worldwide, gureje and colleagues (2008) found a strong association between psychological disorders and msp across cultures. the odds of having a mood disorder and anxiety in those with msp were almost four times than in those without. coggon and colleagues also demonstrated a moderate to strong association between mental health status and multisite musculoskeletal pain.8 most of the cited studies took place in urban areas among various occupation groups mostly in european countries. the present study is unique in exploring these associations in rural clinics in north india. however, in the other studies the screening tools for main exposures (depression and psychological distress) and definition of disease outcome (msp) are not the same across these studies, which limits the comparison of odds ratios. despite the association between msp and mental disturbances, a causal relationship cannot be established based on the case-control methodology. whether msp is a risk factor for or an outcome of mental health issues in women is worthy of further investigation. kroenke and colleagues (19) demonstrated a bi-directional causal relationship in which the severity of chronic widespread pain was predictable of the severity of mental diseases, and vice versa.19 some longitudinal studies, however, indicated that low mood led to the subsequent development of pain while also predicting the severity and persistence of pain.20-23 specifically, it has been suggested that the number of pain sites increased progressively with the severity of mental health disorders.8 the limited sample size prevented us from exploring a dose-response relationship, and we treated msp as a binary variable. none of the women experiencing msp were found to be severely depressed, although 24 percent of them had moderately severe depression. this was not surprising since those with very severe or pronounced symptoms of mental disturbances might either be seeking help elsewhere or be too unwell to consult a practitioner. what is concerning is that msp patients may not be aware of their mild to moderately severe mental health disease, thereby missing out on timely and appropriate intervention. in fact, less severe depression may go unnoticed over a long period due to poor mental health literacy in india.24 in our sample, all but one of the women with msp had at least minimal, mild, or moderate symptoms of depression. even if patients with msp are aware of their mental distress, stigmatisation of mental illness often results in a reluctance to seek medical treatment.25 the role of socio-demographic factors while msp was strongly associated with depression and psychological distress, our study found that only marital status, among all socioeconomic risk factors, was related to the msp status. women with msp had much higher odds of having any form of singleness, i.e., not married, widowed, or divorced. ascertainment of a causal path between singleness and msp could not be established due to the inherent limitation of casecontrol studies. mixed results have been published in recent literature. a small study conducted in an urban area of karnataka, north india, found that those who were married had much higher odds of suffering from chronic pain than the unmarried study subjects (or 34.9, ci 2.71 to 102.3, p= 0.006).26 however, our finding was consistent with that of a 14-year, prospective study in norway: singleness due to separation or divorce was associated with higher number of pain sites.10 important questions such as whether and why the association between singleness and msp is more pronounced in some cultural contexts also merit further exploration. although msp was associated with marital status in the present study, it was not found to be linked with any other socio-economic factors. many studies affirmed the relations between msp grills, singh & anderson 40 and occupation, education and number of dependent children or parity.10,21,27,28 one possible explanation of our different findings is the sample size of the present study, which had insufficient power to detect associations with all demographic variables. the odds of msp were higher in most risk groups; however, these associations were not statistically significant. moreover, these differences may be due to the fundamental differences in terms of study and contextual settings, case definitions, and target populations. further research and policy recommendations presently, the exact pathway msp is connected to mental health is still unclear. some experts suggest a somatisation presenting as msp as an explanation. that is, patients complaining of somatic pain could be suffering from psychiatric issues (often termed psychosomatic pain), particularly in cultural contexts where mental disease is stigmatised.21 in a study of patients with major depressive episodes, chowdhury and colleagues (2001) reported that 48 percent said physical pain and other somatic symptoms were the most troubling problems, not the psychological complaints. it is important for patients and physicians to both be aware of the possible connection between pain and mental health. failure to identify the psychological dimension of pain in some patients may hamper the effectiveness of pain alleviation and exacerbate mental health problems. more concerningly, in a context where medication overuse and polypharmacy are common, failing to recognise psychosomatic pain can lead to unnecessary, and often dangerous, treatments ranging from prolonged use of potent anti-inflammatories to unnecessary procedures and injections.29-31 alternatively, a confirmation of association between mental health and msp in our study should not necessarily imply that patients who show both symptoms must be demonstrating psychosomatic pain syndromes. screening on somatising tendency using validated measures such as the brief symptom inventory (bsi) would be beneficial to our understanding of the complex relationship between mental health and msp.32 more importantly, to fully grasp the aetiology of msp, we need well-designed longitudinal studies in rural india where medical resources are scarce and mental health disorders and msp are prevalent. our study has several limitations. the presence of wide confidence intervals suggests that a sample size was insufficient to detect all statistically significant demographic associations between risk factors for depression and msp. although generalisability of the study is limited by participants being from community health clinics (rather than randomly selected), our findings are highly consistent with other studies in other geographic areas. a common concern of a selfreporting mental health survey is the possibility of overor under-reporting of mental disturbances, especially when the research objectives were known to the participants. while imprecision of estimation seems inevitable, this is unlikely to be differential according to the status of msp. more importantly, in a society where mental diseases are stigmatised or at least seen as undesirable, overreporting of mental health problems is unlikely.24,33 furthermore, we applied two screening tools for mental health in our survey, and both depression (measured by phq-9) and psychological distress (measured by srq-20) were strongly associated with msp. conclusion this study among women in rural india is highly supportive of the association between msp and depression and psychological distress, which is highly consistent with other studies. where msp is reported, depression is highly likely and should be evaluated by the treating practitioner. indian guidelines for managing msp should outline this association in order to limit unnecessary treatments or mismanagement of these women. references 1. gureje o, von korff m, kola l, demyttenaere k, he y, posada-villa j, et al. the relation between multiple pains and mental disorders: results from the world mental health surveys. pain®. 41 grills, singh & anderson june 2022. christian journal for global health 9(1) 2008;135(1-2):82-91. http://doi.org/10.1016/j.pain.2007.05.005 2. haukka e, kaila‐kangas l, ojajärvi a, saastamoinen p, holtermann a, jørgensen m, et al. multisite musculoskeletal pain predicts medically certified disability retirement among f inns. eur j pain. 2015;19(8):1119-28. http://doi.org/10.1002/ejp.635 3. vargas-prada s, coggon d. psychological and psychosocial determinants of 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boyanagari vk. determinants of chronic pain among adults in urban area of udupi, karnataka, india. clin epidemiol global health. 2019;7(2):141-4. http://doi.org/10.1016/j.cegh.2018.03.002 27. mahfoudh a, fennani k, akrout m, taoufik k. determinants of occupational multisite musculoskeletal disorders: a cross sectional study among 254 patients. reumatismo. 2018:92-9. 28. mishra m, srivastava ak, srivastava vk. prevalence and risk of musculoskeletal pain in rural homemakers of north india. med j of dr dy patil university. 2017;10(2):138. http://doi.org/10.4103/0975-2870.202092 29. balaji s, hoq m, velavan j, raji b, grace e, bhattacharji s, et al. a multicentric cross-sectional study to characterize the scale and impact of polypharmacy in rural indian communities, conducted as part of health workers training. j family med primary care. 2019;8(7):2234. http://doi.org/10.4103/jfmpc.jfmpc_410_19 30. grills n, velavan j, balaji s, grace e, arun s, raji b, et al. opportunistic research in rural areas through community health worker training: a costeffective method of researching medication misuse in rural india. indian j commun health. 2016;28(1):28-34. 31. porter g, grills n. medication misuse in india: a major public health issue in india. j public health. 2016;38(2). http://doi.org/10.1093/pubmed/fdv072 32. derogatis lr, melisaratos n. the brief symptom inventory: an introductory report. psych med. 1983;13(3):595-605. 33. chowdhury a, sanyal d, bhattacharya a, dutta s, de r, banerjee s, et al. prominence of symptoms and level of stigma among depressed patients in calcutta. j indian med asso. 2001;99(1):20-3. available from: http://imsear.searo.who.int/handle/123456789/1038 46 peer reviewed: submitted 30 may 2021, accepted 1 feb 2022, published 20 june 2022 competing interests: none declared. the authors did not receive support from any organization for the submitted work and have no relevant financial or non-financial interests to disclose. correspondence: nathan john grills, nossal institute of global health, university of melbourne. ngrills@unimelb.edu.au cite this article as: grills nj, singh p, anderson p. associations of multisite pain with mental ill health among women in north india. christian journal for global health. june 2022; 9(1):33-42. https://doi.org/10.15566/cjgh.v9i1.559 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://doi.org/10.5271/sjweh.3377 http://doi.org/10.2106/jbjs.h.01512 http://doi.org/10.1093/inthealth/ihs011 http://doi.org/10.1016/j.cegh.2018.03.002 http://doi.org/10.4103/0975-2870.202092 http://doi.org/10.4103/jfmpc.jfmpc_410_19 http://doi.org/10.1093/pubmed/fdv072 http://imsear.searo.who.int/handle/123456789/103846 http://imsear.searo.who.int/handle/123456789/103846 mailto:ngrills@unimelb.edu.au https://doi.org/10.15566/cjgh.v9i1.559 about:blank abstract key words: pain, mental health, women, india, widowhood, multisite musculoskeletal pain, depression, psychological distress disorder points of interest introduction methods results discussion conclusion references field reports nov 2014. christian journal for global health, 1(2):89-91. a healing dr. mitch a a md, (full name withheld for security purposes) almost every time i do my month long rotation of medical teaching at the jungle school of medicine (jsmk), i end up with a case that is way over my head. this time, it was already waiting for me before i even arrived. a stoic 5-year old karen boy lay quietly on the first floor space to the right; we don't have beds in our little hospital so patients lie directly on the hardwood floor. his concerned father sat next to him. the father said that about ten days ago, the boy had developed a fever and right, lower abdominal pain. he didn't want to eat anything, but he had no vomiting or diarrhea. then the boy's abdomen became hard. in fact, he did not want anyone to touch his belly. over the next few days, however, he seemed to slowly improve.the father ended up bringing his son to our out-patient clinic a few hours before i arrived. one of our senior staff members at jsmk checked him and felt a tender mass in the right, lower quadrant of his abdomen. although the boy had no fever and now described the pain as only coming and going, the medic decided to admit him for further evaluation. i arrived later that day after a muddy, rainy, exhausting walk over the mountain. still suffering from the last vestiges of jetlag, i had pictured a nice slow start to my teaching rotation . . . a little extra rest. maybe i'd have to see a few diarrhea cases, a simple malaria patient, perhaps someone with a mild pneumonia. these are all common problems in the jungle but well within our usual scope of practice. i also hoped to take some uninterrupted time to learn about the brand new ultrasound machine i had carried with me from the us. it had been given by a very generous donor and included three different kinds of transducers, giving us the capability to evaluate a wide range of problems. i like to learn about new things. unfortunately, an uncomfortable pattern in my life seems to be the recurring need to learn some of those new things on the fly, often with a touch of desperation. after examining the boy, i agreed that he needed further evaluation. we unpacked the new ultrasound machine and attached the linear transducer. although it took me a while as i fumbled around with the unfamiliar software, i could clearly see the abdominal mass on the new machine. actually, i was shocked at how clear it was. usually, our ultrasound images on the old machine's tiny deet fogged screen looked like some hazy ghost clouds in a snow storm. i was never really sure what i was seeing. this clearly showed a mass that contained fluid and lay just beneath the abdominal muscles. despite the visual clarity, i was still confused. from the patient's history, i was thinking he probably had an abscess from a ruptured appendix, and the ultrasound images seemed to confirm that. however, the boy now had no fever and, although sore, didn't seem to be in that much pain. freely admitting my lack of experience with this sort of thing, i sent the ultrasound picture out via e-mail (another new feature of the machine) to some very skilled colleagues and waited. as if the boy had deliberately waited to deteriorate until he could do so in our presence, overnight he developed a high fever and started 90 mitch nov 2014. christian journal for global health, 1(2):89-91. having much more pain. as perverse as it may sound, this was actually an answer to prayer: "lord, heal this boy or tell me what to do to help him." the fever and pain made it seem to me much more likely that it was indeed an intraabdominal abscess that would need to be surgically drained. getting the boy to a general surgeon where he belonged, however, would mean carrying him in a stretcher for 2 days, enduring a long boat trip that would finish with several hours in a bumpy car ride. that's a long ways of hard travel for someone with a ruptured appendix. i was torn. i really don't like to be in the position of having to do something to a patient that i have never done before. even if the technical aspects of the procedure are easy, i have a pretty good imagination and can picture all sorts of things going wrong. i could see myself accidentally getting into the bowel or hitting a major artery. i would give a large amount of money to get this kid to a more qualified doctor . . . to someone who would find this sort of thing boring. in medicine, boring is good. but considering all the circumstances, i thought it would logically be better if we could drain the abscess at jsmk. i sent out a request to a few colleagues to walk me through a draining procedure using the ultrasound, and we started iv antibiotics. soon, technical advice came trickling in via e-mail. i asked a few colleagues, who could sympathize with our situation to pray for both patient and doctor. slowly, hesitantly, like my little granddaughter's first attempts at walking, . . . i began to experience a confidence that the great physician, himself, was trying, admittedly with some difficulty, to help me help this boy. the next day, we set up the "operating room." armed with my active imagination, i pulled out every bit of technological back up we had, just in case. we would use a very safe general anesthesia, ketamine. i still started the generator and hooked up the oxygen machine in case he stopped breathing. we readied the suction machine in case he aspirated. a visiting trauma nurse, with a no nonsense calming effect on all around her, set up the ekg monitor, meds, and got the patient ready. mind you, although we were pulling out all of our stops, it was still nothing fancy. our "o.r." consisted of a rickety wooden table in a curtained off area of the hospital with petzel headlamps for lighting. ominously, one of the alarms on the monitor kept going off, sounding the "he's going to die” rustlings in my subconscious. the boy lay on the table quietly watching us make all these preparations. a few minutes after giving the ketamine, his "watching" became a blank stare, and i began. i made the incision over the mass and cauterized a few bleeders in the subcutaneous tissue by holding an old pair of forceps over an alcohol lamp from the lab. this was probably not necessary, but it made me feel better. i spread a pair of hemostats down through the muscle layers using the ultrasound images to guide me, and soon, just like that, we were looking at thick brown pus flowing from the wound. ahh — the joy of liberating the body of the burden of a festering abscess full of pus. it always seems so gratifying. after irrigating the wound, i loosely sewed in a drain, and we were done. the boy was pretty sore the next day, but the fever was gone, and the pain steadily improved. once, i had a flare of my imaginative doctor doom alter ego when i heard him crying. i was very relieved to find out he was crying because he was hungry; we were limiting his oral intake to liquids for a while. soon, he was playing. i caught him smiling at a movie i took of him. after several days, we switched him to oral antibiotics, and tomorrow, we are sending him home. for anyone in the surgical field, this is not a big deal at all, probably boring. but for me, it was well outside my comfort zone. although i waited until i was sending the boy home to write this (in case he crashed and burned and god was actually trying to tell me something else “. . . oh, ye of little faith” applies to me for sure), i honestly felt god was orchestrating the whole thing. from the timing of the boy coming to the clinic, to actually having the new ultrasound machine with us when we arrived, to having all the medicine that we 91 mitch nov 2014. christian journal for global health, 1(2):89-91. needed, and to the timely input of our prayerful consultants, god was there. and, this is my point: how many times do we miss god's provision for others just because it would call us out of our own comfort zone? competing interests: none declared. cite this article as: mitch. the healing. christian journal for global health (nov 2014), 1(2):89-91. http://dx.doi.org/10.15566/cjgh.v1i2.43 © mitch. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.15566/cjgh.v1i2.43 http://creativecommons.org/licenses/by/3.0/ editorial nov 2014. christian journal for global health, 1(2):4-6. family planning as a christian global health agenda w. henry mosley a a md, mph, professor emeritus, department of population, family and reproductive health, johns hopkins bloomberg school of public health the christian journal for global health is coming at an opportune time in terms of looking at issues of global health and development. in the next year, we will be coming to the end of the period of the millennium development goals (mdgs) for 2015, and will be looking forward to the challenges of the post-2015 development agenda. although this is a secular agenda, it is consistent with the christian values of global poverty alleviation and the improvement of the health and welfare of the disadvantaged peoples around the world. christian organizations and individuals will be active participants in contributing to these new goals as they have been with the mdgs. in this context, i would like to highlight one of the most cost-effective public health interventions available that should be an integral part of every christian health program. this is family planning as defined by christian connections for international health (ccih a network of over 170 christian organizations) to mean “…enabling couples to determine the number and timing of their pregnancies, including voluntary use of methods for preventing pregnancy, not including abortion, harmonious with their values and religious beliefs.” 1 why should christians in international health give special attention to family planning? first of course, it has well documented direct health benefits in saving the lives and improving the health of mothers and children. second, it promotes family, community and national wellbeing, both socially and economically. third, of special interest to christians, by preventing unintended pregnancies, family planning prevents abortions. 2 let’s look at the data, first globally and then in two countries – bangladesh and nigeria – where i have worked over the years. globally, there are an estimated 80 million unintended pregnancies annually, and 42 million of these end in abortion. at the same time it is estimated that there are 222 million women with an unmet need for contraception. if this unmet need could be met, an estimated 54 million unintended pregnancies and 26 million abortions could be prevented every year. 3 bangladesh and nigeria provide informative case studies as it relates to family planning and the achievement of the mdgs. both had comparably large populations in 1970– nigeria with 57 million and bangladesh with 67 million and each had fertility rates of over 6 births per woman. with a longer period of independence and oil production, nigeria has had considerable social and economic advantages over bangladesh, a new country gaining independence from pakistan in 1971. bangladesh initiated an effective family planning program in the 1970s with fertility rates declining over the ensuing years to the current level of 2.3 births per woman. by contrast, family planning has not taken hold in nigeria so that the current fertility rate is still 5.5 births per woman. 4,5 as a consequence of these divergent trends, between 1990 and 2013 the number of births annually in bangladesh declined by 10% from 4 million to 3.6 million, while in nigeria the number of annual births rose by 58% from 4.4 million to 6.8 million in the same period. these dramatically different fertility trends have had significant consequences in terms of achieving the mdgs. to cite a few, since 2000, female primary school attendance rates in bangla3 nov 2014. christian journal for global health, 1(2):2-4. desh have risen from 33% to 82%, while in nigeria these have virtually stagnated, only rising from 54% to 62%. 6,7 childhood immunization rates have now reached 86% in bangladesh, but only 25% in nigeria, under-5 mortality is 64/1000 in bangladesh compared to 144/1000 in nigeria and the maternal mortality ratio is 170/100,000 live births in bangladesh compared to 560/100,000 in nigeria. 4,5,8 induced abortions are hard to measure but a well-documented study in bangladesh showed that abortion rates dropped by 58% and 68% in the 1980s and 1990s respectively in an area where an intensive family planning program was implemented compared to an area without these services. 9 by contrast, in nigeria a 2006 study gave a conservative estimate of 760,000 induced abortions, the majority among women not using contraception. put another way, among sexually active women ages 15-49 years, 1 in 7 attempted an abortion, and 1 in 10 were completed. 10 it is estimated that half of all maternal deaths in the major city of lagos are due to abortions. 11 fortunately, the family planning picture in nigeria is not representative of all of sub-saharan africa. this is in no small measure because, beyond strong government support in many african countries, there are networks of christian health institutions that have made family planning integral to their operations. these national christian health associations in 21 countries have come together to form the africa christian health associations’ platform (achap). achap, among other activities, has advocated for family planning support to the unfpa, at international public health meetings, and with ccih to the us congress. 12 christian health professionals concerned about meeting the holistic health needs of their communities should have no hesitation in integrating family planning into their programs. there is no other single public health intervention that can meet not only their physical needs, but also promote their mental, social and spiritual wellbeing and the welfare of their families, communities and nations. references 1 . ccih. think you know where christians stand on family planning? think again. november, 2013. [cited 2014 oct 10]. available from: http://www.ccih.org/hill-fact-sheet-fp.pdf 2 . ccih. family planning reduces abortions and faith based groups can help. january, 2014. [cited 2014 oct 10]. available from: http://www.ccih.org/fp-reduces-abortions.pdf 3. singh s, darroch je. adding it up: costs and benefits of contraceptive services-estimates for 2012. guttmacher institute and united nations population fund (unfpa), 2012. [cited 2014 oct 10]. available from: http://www.guttmacher.org/pubs/aiu-2012estimates.pdf 4. bangladesh demographic and health survey, 2011. [cited 2014 oct 10]. available from: http://dhsprogram.com/pubs/pdf/fr265/fr265.p df 5. nigeria demographic and health survey, 2013. [cited 2014 oct 10]. available from: http://dhsprogram.com/pubs/pdf/fr293/fr293.p df 6. primary school gross and net attendance rates, bangladesh. [cited 2014 oct 10]. available from: http://www.epdc.org/sites/default/files/document s/bangladesh_coreusaid.pdf 7. primary school gross and net attendance rates, nigeria. [cited 2014 oct 10]. available from: http://www.epdc.org/sites/default/files/document s/nigeria_coreusaid.pdf 8. trends in maternal mortality: 1990 – 2013. who, unicef, unfpa and the world bank estimates. who, 2012. [cited 2014 oct 10]. available from: http://apps.who.int/iris/bitstream/10665/112682 /2/9789241507226_eng.pdf 9. rahman m, davanzo j, razzaque a. do better family planning services reduce abortion in bangladesh? lancet 2001; 358: 1051-56. http://dx.doi.org/10.1016/s0140-6736(01)061827 10. bankole a, et al. unwanted pregnancy and induced abortion in nigeria: causes and consequences. guttmacher institute, 2006. [cited 2014 oct 10]. http://www.ccih.org/hill-fact-sheet-fp.pdf http://www.ccih.org/fp-reduces-abortions.pdf http://www.guttmacher.org/pubs/aiu-2012-estimates.pdf http://www.guttmacher.org/pubs/aiu-2012-estimates.pdf http://dhsprogram.com/pubs/pdf/fr265/fr265.pdf http://dhsprogram.com/pubs/pdf/fr265/fr265.pdf http://dhsprogram.com/pubs/pdf/fr293/fr293.pdf http://dhsprogram.com/pubs/pdf/fr293/fr293.pdf http://www.epdc.org/sites/default/files/documents/bangladesh_coreusaid.pdf http://www.epdc.org/sites/default/files/documents/bangladesh_coreusaid.pdf http://www.epdc.org/sites/default/files/documents/nigeria_coreusaid.pdf http://www.epdc.org/sites/default/files/documents/nigeria_coreusaid.pdf http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf http://dx.doi.org/10.1016/s0140-6736(01)06182-7 http://dx.doi.org/10.1016/s0140-6736(01)06182-7 4 nov 2014. christian journal for global health, 1(2):2-4. available from: http://www.guttmacher.org/pubs/2006/08/08/ni geria-up-ia.pdf 11. gaestel a. how do you get an abortion in lagos? the pulitzer center on crisis reporting, september 25, 2013. [cited 2014 oct 12]. available from: http://pulitzercenter.org/reporting/africa-nigeriaabortion-methods-maternal-health-fertilitypregnancy 12. mwenda s. achap-ccih partnership takes advocacy to us congress. [cited 2014 oct 5]. available from: http://www.africachap.org/x5/index.php?option=c om_content&task=view&id=35&itemid=62 _____________________________________________________________________________ competing interests: none declared. dr. mosley is a member of the international advisory board of cjgh. correspondence: w. henry mosley, johns hopkins bloomberg school of public health, baltimore, md, usa. hmosley@jhsph.edu cite this article as: mosley, w henry. family planning as a christian global health agenda. christian journal for global health (nov 2014), 1(2):2-4. http://dx.doi.org/10.15566/cjgh.v1i2.47 © mosley wh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ _____________________________________________________________________________ www.cjgh.org http://www.guttmacher.org/pubs/2006/08/08/nigeria-up-ia.pdf http://www.guttmacher.org/pubs/2006/08/08/nigeria-up-ia.pdf http://pulitzercenter.org/reporting/africa-nigeria-abortion-methods-maternal-health-fertility-pregnancy http://pulitzercenter.org/reporting/africa-nigeria-abortion-methods-maternal-health-fertility-pregnancy http://pulitzercenter.org/reporting/africa-nigeria-abortion-methods-maternal-health-fertility-pregnancy http://www.africachap.org/x5/index.php?option=com_content&task=view&id=35&itemid=62 http://www.africachap.org/x5/index.php?option=com_content&task=view&id=35&itemid=62 http://dx.doi.org/10.15566/cjgh.v1i2.47 http://creativecommons.org/licenses/by/3.0/ short communication scripture matters for sustainable whole-person nursing diane mccroskeya a msn rn ccrn, instructor of nursing, lincoln memorial university, harrogate, tn, usa abstract nursing is truly an ever-evolving profession. it is one of the most versatile occupations within the health care arena. it is not the same profession today as it was years ago. nurses need direction to create order out of chaos in today’s complex multifaceted healthcare environment. my survival plan entails a personal relationship with christ which is strengthened by consistent time spent in the holy scriptures. reading the bible daily and studying scripture is a necessity. scripture passages can inspire nurses particularly in going forward, in endlessly caring for other individuals and in sharing our passion to serve others as we venture forth. key words: nursing, survival, strength, healthcare, scripture, service nursing is truly an ever-evolving profession. it is one of the most versatile occupations within the health care arena. it is not the same profession today as it was 40 years ago when i became a registered nurse. new tech development in addition to the swift rate of change in patient populations mean that nursing is more dynamic than ever before. in today's fast-paced world, transformation is happening in every aspect of nursing. according to hader, change is unavoidable and the only constant is change.1 nurses often experience significant stress at work that is associated with increased workloads, understaffing, higher acuity patients, and emotional demands.2 as an icu nurse, i dealt with many of these stressors daily. others would frequently ask “how do you continue to show up and push forward with a smile shift after shift?” for twenty-five-years, my answer was always the same: my survival plan entails a personal relationship with christ which is strengthened by consistent time spent in the holy scriptures. i have learned that surviving in the day-to-day nursing world requires a foundation that is built on the solid rock of jesus christ. the apostle paul wrote, “i can do all things through christ which strengthened me” (philippians 4:13, kjv). because of the firm foundation we have in christ, we can build our lives in such a way that no matter what comes, we able to be sustained (matthew 7:24-27, kjv). each day we need to live our lives seeking to learn more about him and becoming more and more like him. studying the scriptures is spending quality time with god. studying the scriptures is crucial because of the direction we need in our lives. “thy word is a lamp unto my feet, and a light unto my path” (psalm 119:105, kjv). scripture lights the way ahead so we can see plainly which way to go. in every season of life, we can be confident that god is always leading through his word. nurses need direction to create order out of chaos in today’s complex multifaceted healthcare environment. scripture also strengthens us in our faith. “so then faith cometh by hearing, and hearing by the 123 mccroskey june 2022. christian journal for global health 9(1) word of god” (romans 10:17, kjv). because nurses are charged with providing emotional, spiritual, and physical care, nurses must live out their faith on a day-to-day basis. exposure to god’s word will spur on faith in a person. time spent in scripture will help one to know what to believe and upon what to base their faith. when a person spends time with him in scripture, god promises that he or she can gain wisdom and understanding. “all scripture is given by inspiration of god, and is profitable for doctrine, for reproof, for correction, for instruction in righteousness” (2 timothy 3:16, kjv). wisdom and understanding provide the capability to make correct decisions or choices. “for the lord giveth wisdom: out of his mouth cometh knowledge and understanding” (proverbs 2:6). now more than ever, nurses need to draw upon their discernment abilities to aid with a patient’s spiritual needs as much as physical needs. when nurses study the scriptures, god’s knowledge and understanding accumulates in their mind and heart. scripture will permeate their life with god’s encouragement and truth. it tends to splash onto and infuse into the people around you as you live for god. the more you receive god’s holy word in you, the more his love and power will flow through you to patients, family members, and coworkers. “let the word of christ dwell in you richly in all wisdom; teaching and admonishing one another in psalms and hymns and spiritual songs, singing with grace in your hearts to the lord” (colossians 3:16, kjv). those who tuck away scripture in their hearts, who ponder it, who allow themselves to be guided by it, can inspire others to do the same. nurses on the front lines of patient care often influence and inspire those around them. others are constantly watching, listening, and often mimicking what they see and hear. in my role as a nurse educator, i found this particularly true in the clinical setting with students. recently, students followed me into a room of a patient who had just expired. i realized death is a difficult thing, perhaps the most difficult part of life. those few moments immediately after a patient dies have been the hardest thing for me, ever since the beginning of my career. because of my faith in christ and reliance on scripture, coping with these losses has become much easier for me. a scripture that i have drawn strength from time and time again is found in 2 corinthians 5:8, kjv: “we are confident, i say, and willing rather to be absent from the body, and to be present with the lord.” this verse sweeps across my soul, and i often recite it aloud while at the bedside of the deceased. i hold on to my faith and know that there is something greater after this mortal life. scriptures are god's personal communication to us and can bring comfort and encouragement as well as hope even in the face of our mortality. students listen and pay attention to everything. hopefully, what they see in me fosters hope, encouragement, and a desire to serve christ as a nurse. as nurses, we strive to provide holistic care for our patients. this means being mindful of their mental, emotional, physical, and spiritual needs. having a caring heart and loving our neighbors shows that we are desiring to be like jesus. scripture passages can inspire us particularly to press on in endlessly caring for other individuals, and in sharing our passion to serve others as we venture forth. “and we know that all things work together for good to them that love god, to them who are the called according to his purpose” (romans 8:28, kjv). keeping one’s spiritual faith strong and firm is essential as we take care of patients and families shift after shift. though we may feel pressed for time, reading the bible daily and meditating upon scripture is a necessity. it will help us not only to become better nurses, but better people as well. although nursing is one of the most challenging professions, it is also one of the most personally fulfilling. every time i step into the nursing arena, i am afforded the amazing opportunity to make a real difference in the lives of others while consciously serving god. scripture is the essential element to keep a nurse’s life firmly on the rock of jesus christ in the midst of the storms life and death in healthcare. i am eternally grateful for his word. mccroskey 124 references 1. hader r. the only constant is change. nursing manage. 2013:44(5):6. http://doi.org/10.1097/01.numa.0000429006.47269 .22 2. mudallal rh, othman wm, al hassan nf. nurses' burnout: the influence of leader empowering behaviors, work conditions, and demographic traits. inquiry j med care org provis finan. 2017:54, 46958017724944. https://doi.org/10.1177/0046958017724944 submitted 25 may 2021, accepted 14 jun 2022, published 20 jun 2022 competing interests: none declared. correspondence: diane mccroskey, lmu, harrogate, tn, usa tad51@bellsouth.net cite this article as: mccroskey d. scripture matters for whole-person nursing. christ j global health. june 2022; 9(1):122-124. https://doi.org/10.15566/cjgh.v9i1.665 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://doi.org/10.1097/01.numa.0000429006.47269.22 http://doi.org/10.1097/01.numa.0000429006.47269.22 https://doi.org/10.1177/0046958017724944 mailto:tad51@bellsouth.net https://doi.org/10.15566/cjgh.v9i1.665 about:blank abstract references original article nov 2020. christian journal for global health 7(4) the experience of mission hospitals in southern ethiopia in identifying and responding to infectious disease outbreaks bernt lindtjørna, thor henrik henriksenb a md, phd, professor, centre for international health, university of bergen, norway and hawassa university, southern ethiopia b phd, department of microbiology, vestfold hospital trust, tönsberg, norway abstract epidemics are often seen at mission health institutions. such christian institutions seek to practice holistic medicine, and the core priorities include dedicated clinical care combined with community responsibility. this paper describes some unusual, and some more common, epidemics that occurred at three mission hospitals in southern ethiopia during the last 60 to 70 years. the hospitals covered vast areas and large populations, mostly from poor subsistence farming communities. with great topographical and climatic variations, the catchment areas include multiple climate zones that cause substantial variations in ecology and vegetation, and thus, also in disease patterns. our review is based on personal notes, hospital records, and previous scientific publications. we observed epidemics such as cholera and other diarrheal diseases, relapsing fever, meningitis, gonococcal conjunctivitis, the emerging of hiv and helicobacter infections, and parasitic infections, such as malaria and visceral leishmaniasis. hospitals, ideally, should have collaborated with local and national health authorities to combat such events. unfortunately, that was not always possible because of wars, political unrest, or lack of capacity. sometimes these hospitals did not have sufficient laboratory infrastructure to diagnose infections such as arboviral diseases. more emphasis should have been placed on enabling hospitals to both diagnose and control epidemics. key words: mission hospitals, epidemics, ethiopia introduction although ethiopia remains among the 20 poorest countries in the world and is the second most populous country in africa, it has, in recent years, experienced improvements in living standards and health. ethiopia includes 75% of all highlands above 2000 m in africa and also contains the lowest points in the world. thus, given these great topographical variations, the country includes multiple climate zones that cause large variations in ecology and vegetation, and thus, also in disease patterns. in recent years, many researchers have published manuscripts describing ways to control infectious diseases. although it is also theoretically possible to eradicate diseases, only smallpox has been eliminated. recent statistics on malaria in africa, along with the history of malaria 4 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) eradication, reveal that although reducing the occurrence of the infection is possible, some even doubt if it is feasible to completely eradicate it.1 in the 1960s, the united states attempted to eradicate measles, but in recent years, it has returned with large numbers of cases both in the usa and in europe.2 hence, are there any roles for mission hospitals to contribute towards an outbreak response? since about 1950, the norwegian lutheran mission (nlm) has been running several hospitals in southern ethiopia. their work methods were to some extent influenced by the organization’s previous work in china, as well as the experience of british missionary doctors such as dr. stanley g. brown, who practiced hospital work, research, and community engagement in order to alleviate disease burden.3 this work focused on practicing holistic medicine.4 the core priorities included, what have become, important elements in the development of health care in the uk and in scandinavia: confidence, confidentiality, competence, contract, community responsibility, and commitment.5 the authors of this study worked in ethiopia while smallpox was being eradicated and when ebola was first described in the congo. based on earlier publications, we regarded southern ethiopia as a potential area for emerging infections, and we recorded unusual events. in addition, the epidemiology of commonly occurring infections had previously been poorly described. this manuscript presents a narrative concerning the mission’s response to previous epidemics, and the ways in which this was documented and operationalized in order to control the infectious disease outbreaks. to our knowledge, many of the records from southern ethiopia are not publicly available. we, therefore, believe that this presentation is valuable for other mission hospitals and for future researchers attempting to learn about epidemics and potential epidemics and to intensify measures for meeting such challenges in the future. mission hospitals in southern ethiopia the norwegian lutheran mission began health care work in southern ethiopia in 1950.4 in general, these hospitals—located in yirga alem, arba minch, and gidole—could perform basic and essential functions in surgery, gynecology and obstetrics, pediatrics, and internal medicine.6 basic laboratory tests were available, including bacteriology, and in the 1980s we became aware of the highly prevalent resistance to commonly used antibiotics.7,8 5 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) figure 1. map of ethiopia showing the catchment areas of the hospitals included in this study since these hospitals were among the few functional health institutions in southern ethiopia, patients from almost all of the southern part of the country came for treatment. the main catchment areas, however, were the sub-provinces depicted as the colored areas in figure 1. a study done in 1985 revealed that the primary catchment area of a given hospital comprised the population living within a 50-km radius of the institution.9 the population in the catchment areas was, in the 1980s, about 2.5 million people. methods for this study, we utilized three information sources. the background information concerning the development of the health care system in ethiopia is described by schaller and kuls, as well as by berhane et al.10,11 when referring to previously published work on epidemics, we use the original publications as references. in addition, both of the authors have, from 1978 to 2020, been working at different hospitals and universities in southern ethiopia. during the course of our work, we registered outbreaks of epidemics in our notebooks. these records have not been published before, and we believe that such data could provide some historical information concerning the situation in the area. we also reviewed the archives of the hospitals, particularly from gidole hospital and yirga alem hospital, to record the epidemics that may have occurred in the catchment areas of the hospitals. results and discussion hiv the earliest countries affected by the hiv pandemic included uganda and nations in central and southern africa. the epidemic was first registered in ethiopia in 1984. since yirga alem hospital is located along the main transportation route from kenya to addis ababa, and the hiv epidemic in ethiopia originally spread via truck drivers along the main transportation roads, we feared that yirga alem hospital would be affected 6 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) early on by this disease.12 therefore, in 1985, we performed an anonymized survey of all admitted patients to yirga alem hospital. we obtained one of the earliest versions of the elisa kit from norway and analyzed the sera from 185 patients admitted to the hospital on one day. we did not have an elisa reader since it was possible to observe color changes on the elisa plates suggesting infection. at that time, only one patient had a slight color change, and we concluded that the prevalence of hiv infection was low among our patients. during the years 1986 to 1990, however, the prevalence of the disease increased dramatically, and a large proportion of the hospital admissions were for this disease.12 as soon as antiretroviral drugs were available and the first studies had been completed in uganda in 1994,13 we initiated work to start treatment as we had not observed any reduction in the occurrence of the infection based on preventive measures carried out by local churches and communities. unfortunately, neither the mission organization nor the norwegian agency for development cooperation (norad) was willing to fund such treatments. this changed, however, when less expensive and generic antiretroviral drugs became available from india in 2002. our hiv treatment work was based on experiences from haiti, where they had initiated treatment without any advanced laboratory setup.19 we confirmed that it is possible to perform both testing as well as treatment without sophisticated laboratories. our treatment protocol was based on hiv testing, clinical staging, and total lymphocyte counts. our results were encouraging and similar to the good outcomes of early studies carried out in europe; details about the studies are described elsewhere.14-16 as such, they became a model for the later nationwide efforts to scale up antiretroviral treatment in ethiopia. malaria before the 1930s, the epidemiology of malaria was not well known in ethiopia. italian researchers performed surveys between 1936 and 1941; however, that provided information on vectors and the prevalence of infection.10 in 1958, a severe malaria epidemic occurred in the central ethiopian provinces, with over 3.5 million cases and approximately 150,000 deaths, leading to the establishment of the malaria eradication program.10 unfortunately, due to a lack of sustainability and the emergence of resistance to the insecticide ddt, this program ended. the civil war between 1974 and 1991 altered ethiopia’s political landscape and further complicated eradication efforts. social and economic development halted, and the health system suffered.17 thus, even though malaria was an ancient disease in ethiopia, its epidemiology changed after the 1980s. in the autumn of 1980, a severe malaria epidemic was noted in gidole. during october and november, about 80% of the hospital beds were occupied by severely ill malaria patients, often with multiple organ involvement and some with cerebral malaria. the patients received standard treatment with chloroquine in addition to supportive care. diagnosis was based on microscopy of thin and thick blood slides. most of the admissions, during this period, were patients coming from the lowlands. both young children and adults were affected, suggesting that the population may not have obtained any prior immunity. the lowland villages were inhabited by people from the gidole highlands who had been forcefully relocated to the malarious lowlands.18 this was the so-called “villagization program” and was a part of the communist regime’s efforts to politically control the population and settle them in villages, something similar to the collectivization that happened in the former soviet union.19 thus, efforts to discuss this with the authorities were difficult for two reasons: people were not allowed to move back to their home areas, where there was a lower prevalence of malaria, and the government did not have resources to instigate preventive measures; indoor residual spraying was the tool used at that time. concurrently, the local administration in gidole was persecuting christians, and the hospital had limited freedom of movement. in 1992, health authorities at shakiso south of yirga alem asked one of the authors (thh) to investigate a possible outbreak of yellow fever. 7 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) many patients had died, and many were icteric. microscopy of their blood revealed heavy loads of the parasite plasmodium falciparum. since they had been treated with chloroquine, this was one of the first indications of chloroquine resistance in southern ethiopia, a phenomenon that was later confirmed by others.24 following this event, we increasingly used quinine to treat pl. falciparum infections. visceral leishmaniasis visceral leishmaniasis is a zoonotic infection that affects people living in areas where the disease occurs among a reservoir (animal, mainly rodents) population. during our work in yirga alem and gidole, we recorded patients coming from the segen-woito, genale, dawa, and galana lowland river basins.20,21 many years later, these areas were confirmed to be endemic areas of this deadly infection, affecting a large proportion of the rural population.22 this demonstrates the importance of noting even rare events at outpatient departments as they could signify major public health problems farther away. patients with this disorder came to the hospitals because they were gravely sick, were severely wasted, and had huge spleens. the diagnosis was done by spleen or lymph-node punctures through microscopic identification of intracellular parasites (amastigotes) in stained slides. sometimes, we also cultured the parasite using the novy-macneal-nicolle (nnn) medium. by publishing such reports and actively seeking collaboration with national research institutions, control programs to improve the community diagnosis through rapid tests, such as the direct agglutination test (dat), and decentralized treatment, were established.23 measles measles is a well-known disease in ethiopia. mothers know how to diagnose it, and the disease has many local names. it is probably the most important vaccine-preventable disease. the expanded program on immunization (epi) started in ethiopia in 1980. by 2002, however, nationwide coverage had only reached 40%, and a survey taken in southern ethiopia in 2017 revealed that only 60% of children under the age of five were fully vaccinated.24 before starting the epi program at gidole hospital in 1980, we performed a serological survey of schoolchildren in the area for one week. of 35 children aged 9–36 months examined for measles antibodies (elisa method, central laboratory and research institute, addis ababa), 25 (71.4%) had low antibody values, and 6 (17.1%) had post-infection values. while conducting the survey, over 400 children with measles were admitted to the hospital and to konso clinic. these children were severely ill, and many were as old as 10 years of age, suggesting that they had not contracted the disease before. in a previous publication, we showed that a survey covering the preceding four months, carried out in 19 villages with 45,884 inhabitants and 14,452 children younger than 10 years of age, identified 1,536 deaths due to measles (a case fatality rate of 10.6%).25 we attempted to carry out a large-scale vaccination campaign covering two districts with about 200,000 people, but it partially failed because we started too late and also because the population refused to be vaccinated. the community beliefs or attitudes can be summarized as follows: • the “umbay” fruit (solanum incanum) is placed above the entrance of each hut in which there is a child with measles. • a vessel filled with water is placed at the hut’s entrance. this was thought to cool the fever of the child. • the hut, especially the floor, is thoroughly cleaned, and the child is placed in a dark, shallow place inside the hut. • crushed grains (“kolo”) are spread on the floor near the place where the child sleeps. • the sick child should not receive water. • a child with measles should not eat meat, nor should any members of the family. any food containing blood was thought to aggravate bloody diarrhea, which was regarded as a very serious sign. in shillalle village, the local religious leaders put a ban on meat consumption after the village was 8 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) affected by measles. anyone disobeying this order was fined and punished. • a bleeding wound was regarded as a bad sign; hence, jiggers (sand fleas found that burrow into the skin and lay eggs that cause swelling, itching, and infection) were not allowed to be removed as long as the child had measles. • if the rash disappeared quickly, measles was thought to enter the body, which could result in diarrhea and death. • the clothes of a sick child should not be washed. • the sick child should not receive injections. • in some places (gawada), dried bread was placed in trees near the hut, and goats were sacrificed. • measles is a disease resembling smallpox and must be hidden. diarrheal diseases, including cholera outbreaks of typhoid fever and of bacterial dysentery (shigellosis) were often observed. the diagnosis was based on the clinical features, often in combination with laboratory tests such as the widal test. during the 1980s, we had established a microbiological laboratory and analyzed stool cultures. in addition, there are multiple historical records of cholera epidemics afflicting ethiopia. in the amharic language, the affliction is known as “november disease”, and routes of communication, markets, pilgrimages, and troop movements have always played a role in the spread of the disease. in 1971, 47 patients with “ricewater” diarrhea were observed at the konso clinic, affiliated with gidole hospital. two of those patients died. this was a part of a much larger cholera outbreak that affected southern ethiopia, and the norwegian lutheran mission, in collaboration with the ministry of health, vaccinated 28,722 people in the same area. similar vaccination campaigns were carried out around the yirga alem area, where there was an even larger outbreak of cholera. this demonstrates the close collaboration between the public health authorities. during the communist period (1974–1991), there were several outbreaks of cholera. the largest occurred in the mid-1980s after the great famine that affected large parts of southern ethiopia.26 at that time, it was strictly forbidden to use the word cholera. the international organization médecins sans frontières (msf) published the occurrence of cholera and was expelled from the country.27 at the time, the government preferred the euphemism “sudden severe dehydration diarrheal diseases” (s2d3). they actively supported the treatment of these patients by mission hospitals although it was strictly forbidden to announce the occurrence of the disease. in 1985, at yirga alem hospital, approximately 320 patients were clinically diagnosed to have the disease over a period of six weeks, 9 (3%) of whom died. at the time, we had established a basic microbiological laboratory, and stool cultures from approximately 50 specimens revealed vibrio cholera biotype eltor, the dominant strain in the seventh global cholera pandemic.28 this microbiological lab was a part of the routine work at the hospital, and we trained national staff to do the daily work. however, we were not able to use this laboratory on a large-scale because of scarcity of reagents and difficulties in importing them. relapsing fevers relapsing fevers belong to a group of acute infections caused by arthropod-borne spirochetes. the louse-borne relapsing fever caused by borrelia recurrentis is endemic in ethiopia. over the years, there have been many small outbreaks, especially among the prison populations, and the hospitals received permission to visit prisons in order to prevent such infections through de-lousing campaigns, improving access to washing facilities, and treating sick persons. following the civil war, 1990–1991, however, a relapsing fever epidemic affected large parts of ethiopia. the root cause was thought to be approximately 500,000 soldiers returning from the war in eritrea to their homes in all parts of ethiopia, thus, spreading the disease to many parts of the country.29 9 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) from 1987 to 1995, we ran two small health and demographic surveillance sites in southern ethiopia, from which we monitored demographic, nutritional, and infectious disease trends.30,31 every second week, we visited approximately 500 households with 2,500 inhabitants in two areas (arsi and borana). in 1992, we observed a huge increase in the crude death rate, most of which was due to relapsing fevers (figure 2; not previously published), although some was due to malaria. the high crude death rate in 1988 was caused by a malaria epidemic (figure 2). figure 2. crude birth and death rates in elka (arsi) showing an increase in the death rate during the relapsing fever epidemic in 1992 the relapsing fever outbreak of 1992 represents an unusual way for an endemic disease to become a national epidemic. even if southern ethiopia had not experienced a major war, the unstable political situation, in combination with the lawlessness during that period and a weakening of the public health structure, meant that only those patients able to reach institutions such as mission hospitals received proper treatment. smallpox ethiopia was one of the last countries in which smallpox existed. the most severe epidemic was in the mid-1950s. until it was eradicated in 1976, there were multiple outbreaks of smallpox.10 in the early 1950s, the government of ethiopia made smallpox vaccination compulsory. the nlm-supported hospitals actively participated in vaccination campaigns and also in treating patients with smallpox. in the years after the last case of smallpox was observed, there was increased surveillance for possible smallpox cases in southern ethiopia. we reported several potential cases at yirga alem hospital that were investigated by the ministry of health and, fortunately, not confirmed as smallpox. helicobacter pylori until 1980, the understanding was that peptic ulcer disease were rare in africa, and, when helicobacter pylori was established as its cause, it was declared that this did not concern africa.32, 33 however, peptic ulcer disease was commonly seen at the hospitals, and many patients were operated upon for complications of this disorder. therefore, and because of a collaboration with the university hospital in bergen in norway, endoscopy of the upper gastrointestinal tract was introduced at the hospitals in the 1980s. based on 10 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) a simple and cheap staining of the mucus obtained during gastroscopy, it was possible to identify comma shaped helicobacter pylori bacteria using methylene blue staining.34 thus, within a few minutes, our patients received eradicative treatment for h. pylori nearly two decades before this infection was accepted as an etiological agent in africa.35 community-wide outbreak of gonorrheal conjunctivitis in 1987, an unusual outbreak of acute conjunctivitis with profuse exudation was observed among 9,075 young children in konso.36 similar outbreaks of acute keratoconjunctivitis due to neisseria gonorrhoeae were seen in the nile delta in egypt, the last time in 1948.37 microscopy revealed gram-negative intracellular diplococci, and growth of penicillin-susceptible n. gonorrhoeae was confirmed at arba minch hospital. treatment was successful, using ampicillin plus probenecid as an oral single dose treatment. the epidemic stopped when the rains started in june 1988. on one occasion, neisseria gonorrhoeae subspecies kochii was identified, and our observation was the first known major outbreak in 40 years outside egypt.37 meningitis the northwestern section of ethiopia is part of the meningitis belt of africa. before 1979, there had been no systematic studies on the distribution of meningococcal meningitis epidemics in other parts of the country.38 although southern ethiopia lies outside the meningitis belt of the sahel, records from mission hospitals show outbreaks of meningitis. in 1962, a meningitis epidemic was recorded in gidole, with another occurring in 1979. lumbar punctures revealed purulent spinal fluid, high cell counts, and low sugar. in 1981, additional cases were recorded from the mashille villages south of gidole, and gram staining of the patients’ spinal fluid showed intracellular gram-negative diplococci. in 1988, 1996, and 1997, numerous cases were reported from konso and also at yirga alem hospital. the largest outbreak observed at yirga alem coincided with the nationwide outbreak that occurred between 2000–2001.39 arboviral diseases a large epidemic of yellow fever occurred in southwest ethiopia from 1960 to 1962.40 a norwegian missionary doctor, responsible for the public health services in gamo-gofa province during the same period, participated in the vaccination campaigns. since then, there have been repeated outbreaks of yellow fever in the same area. in recent years, these epidemics were also investigated by arba minch university, which, through the support of former nlm missionary doctors, had established a molecular entomological laboratory.41 this laboratory was primarily established to do molecular studies of the malaria and leishmania parasites and the disease transmitting mosquitoes. when the yellow fever epidemic occurred, we also used the laboratory for such diagnosis. the laboratory is a part of arba minch university’s routine work and is run within a national and sustainable context. we were well aware of reports of other hemorrhagic fevers that had occurred in ethiopia. dengue fevers had been reported by italian researchers in 1940, and based on serological evidence, researchers from the naval medical research unit (namru 3) had reported the occurrence of west nile fever, zika, chikungunya, and marburg-like viruses in southern and western ethiopia.40,42 we clinically suspected chikungunya infection in patients presenting with high fever, headache, and joint and muscle pain. this group of patients came from bilate, just north of lake abaya, and at the hospital, the diagnosis of these patients was referred to as “bilate disease.” over the years, we attempted to obtain permission to take serum samples to the arbovirus reference laboratory in the united kingdom but were not permitted to export the blood samples by the ethiopian authorities. in retrospect, we should have established immunological tests earlier at our hospitals in order to confirm such outbreaks. 11 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) general discussion and conclusions over the years, the mission hospitals in southern ethiopia have observed multiple epidemics. some of these events, such as shigella and typhoid fever epidemics, were expected, while at other times, the epidemics occurred in different forms and in unexpected scales. given the large size of some of the outbreaks, it was often beyond the capacity of the mission hospitals to control these adverse events. the relapsing fever epidemic of 1991–1992 was such an occurrence. in hindsight, we should have invested more in laboratory efforts to diagnose such infectious diseases, especially in patients with unexplained fevers. several of the outbreaks we have described in this study have not been previously published. the reasons could be that the topic was too sensitive (e.g., cholera), while at other times, it was because there was limited time at a busy hospital to report and perform more in-depth investigations. the local ministries of health, however, were always informed about local outbreaks, since that was part of the standard routine. another limitation of our multiple case reports is that many of them were not populationbased, although cases coming to the hospital often reflect what is going on in communities. david morley, who worked as a pediatrician in nigeria, stressed that physicians working at institutions should serve their communities.43 during busy work schedules at rural hospitals, this may be difficult. it remains the physician’s community responsibility, however, not only to treat patients, but also to understand the patient’s background and the environment in which they live.3 often, community-based preventive interventions will save more lives than treating patients at hospitals. at times, it was possible to collaborate with the national authorities to control disease outbreaks. at other times, this was beyond the capacity of the mission organization, and occasionally, the government opposed any involvement from a foreign organization. by maintaining a low profile and limiting strategies that could humiliate the government, however, it is usually possible to collaborate and develop practical solutions. gill walt has proposed that by focusing on small-scale politics, including micropolicies that are the responsibility of the local and regional ministry of health, it is usually possible to bring about policy changes.44 for every epidemic outbreak, early warning and early action are essential. however, mission hospitals have limited resources, and mission organizations usually do not budget for unforeseen events such as epidemics. it may be appropriate to suggest that mission organizations set aside some of their budget for such unforeseen events. mission hospitals are well-placed to identify outbreaks. furthermore, given their close collaboration with local, regional, and national governments, it is often possible to coordinate efforts, thereby limiting epidemic outbreaks. references 1. ghebreyesus ta. the malaria eradication challenge. lancet. 2019;394(10203):990-1. http://doi.org/10.1016/s0140-6736(19)31951-8 2. hinman a, orenstein w, papania m. evolution of measles elimination strategies in the united states. j infect dis. 2004;189(supplement_1):s17-s22. http://doi.org/10.1086/377694 3. gibbs m. stanley browne and cross-cultural missional motivation. baptist quarterly. 2011;44(3):151-70. 4. lindtjørn b. the role of a mission organization in building a sustainable government hospital in southern ethiopia. christ j global health. 2020;7(2):133-46. available from: https://journal.cjgh.org/index.php/cjgh/article/view/ 351/749. 5. smith r. medicine's core values. bmj. 1994 nov 12;309(6964):1247-8. [eng. epub 1994/11/12]. pmid 7888834. http://doi.org/10.1136/bmj.309.6964.1247 6. lende s, lindtjørn b. sykehus i utviklingsland. erfaringer fra sidamo regional hospital i søretiopia [vitenskapelig artikkel]. tidsskrift for den norske legeforening. 1990;111:1118-22. norsk, bokmål. 7. lemma e, niemi m, lindtjørn b, getaneh d. bacteriological studies of tuberculosis in sidamo regional hospital. ethiop med j. 1989;27:147-9. pmid 681. about:blank about:blank about:blank about:blank about:blank 12 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) 8. lindtjørn b, degife s, niemi m. sensitivity patterns of bacteria isolated from patients at sidamo regional hospital. ethiop med j. 1989;27:27-31. pmid 680. 9. møgedal s, godal t, lende s, lindtjørn b, sanna s, sæterøy r. report on norad supported health services through norwegian lutheran mission in ethiopia. oslo: mission nl; 1985. [report. norwegian lutheran mission]. 10. schaller kf, kuls w. ethiopia. geomedical monograph no 3. berlin: springer; 1972. 11. berhane y, mariam dh, kloos h. epidemiology and ecology of health and disease in ethiopia. addis ababa: shama books; 2006. isbn: 9994400002. 12. kloos h, mariam dh, lindtjørn b. the aids epidemic in a low-income country: ethiopia. human eco rev. 2007 january 1. pmid 4625446224185915317related:tfdfknx imeaj. 13. connor em, sperling rs, gelber r, kiselev p, scott g, o'sullivan mj, et al. reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. new eng j med. 1994;331(18):1173-80. pmid 7935654 http:/doi.org/10.1056/nejm199411033311801 14. jerene d, naess a, lindtjørn b. antiretroviral therapy at a district hospital in ethiopia prevents death and tuberculosis in a cohort of hiv patients. aids res ther. 2006 jan 1;3:10. pmid 14871636226385867917related:jxspxlqqys4j. http://doi.org/10.1186/1742-6405-3-10 15. mulissa z, jerene d, lindtjorn b. patients present earlier and survival has improved, but pre-art attrition is high in a six-year hiv cohort data from ethiopia [research support, non-u.s. gov't]. plos one. 2010;5(10):e13268. [eng. epub 2010/10/16]. pmid 20949010. http://doi.org/10.1371/journal.pone.0013268 16. jerene d, endale a, hailu y, lindtjorn b. predictors of early death in a cohort of ethiopian patients treated with haart. bmc infect dis. 2006 sep 1;6:1471-2334. pmid wos:000240735200001 http://doi.org/10.1186/1471-2334-6-136 17. gish o. malaria eradication and the selective approach to health care: some lessons from ethiopia. int j health serv. 1992;22(1):179-92. pmid 1735625. 18. kloos h, abate t, hailu a, ayele t. social and ecological aspects of resettlement and villagization among the konso of southwestern ethiopia. disasters. 1990;14(4):309-21. pmid 1050. 19. markakis j. ethiopia: the last two frontiers. boydell & brewer ltd; 2011. [isbn: 1847010334] 20. lindtjørn b. kala-azar in sidamo, south ethiopia. ethiopian med j. 1980;18:99-100. pmid 48. 21. lindtjørn b, olafsson j. kala-azar in the seggen and woyto valleys, southwest ethiopia. ethiop med j. 1983;21:35-41. pmid 26. 22. gadisa e, tsegaw t, abera a, elnaiem de, den boer m, aseffa a, et al.eco-epidemiology of visceral leishmaniasis in ethiopia. parasite vector. 2015 jul 19;8:381. [eng. epub 2015/07/19]. pmid 26187584. http://doi.org/10.1186/s13071-0150987-y 23. kimutai r, musa am, njoroge s, omollo r, alves f, hailu a, et al. safety and effectiveness of sodium stibogluconate and paromomycin combination for the treatment of visceral leishmaniasis in eastern africa: results from a pharmacovigilance programme. clin drug investig. 2017 mar;37(3):259-72. [epub 2017/01/10]. pmid 28066878. http://doi.org/10.1007/s40261-0160481-0 24. hailu s, astatkie a, johansson ka, lindtjorn b. low immunization coverage in wonago district, southern ethiopia: a community-based crosssectional study. plos one. 2019;14(7):e0220144. [epub 2019/07/25]. pmid 31339939. http://doi.org/10.1371/journal.pone.0220144 25. lindtjorn b. severe measles in the gardulla area of southwest ethiopia. j trop pediatr. 1986 october;32(5):234-9. pmid 3795332. 26. kloos h, lindtjorn b. malnutrition and mortality during recent famines in ethiopia: implications for food aid and rehabilitation. disasters. 1994 june;18(2):130-9. pmid 8076157. 27. binet l. famine and forced relocations in ethiopia 1984-1986. crash [a publication of médecins sans frontières]; 2013. available from: https://www.msfcrash.org/en/publications/humanitarian-actors-andpractice/famine-and-forced-relocations-ethiopia1984-1986 28. who. recent advances in cholera research: memorandum from a who meeting. bull world health organ. 1985;63(5):841-9. [eng. epub 1985/01/01]. pmid 3879198. 29. almaviva m, hailu b, borgnolo g, chiabrera f, tolesse g, gebre b. louse-borne relapsing fever epidemic in arssi region, ethiopia: a six months about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 13 lindtjørn & henriksen nov 2020. christian journal for global health 7(4) survey. t roy soc trop med h. 1993;87(2):153. http://doi.org/10.1016/0035-9203(93)90466-4 30. lindtjørn b, alemu t, bjorvatn b. population growth, fertility, mortality and migration in drought prone areas in ethiopia. t roy soc trop med h. 1993;87:24-8. pmid 887. http://doi.org/10.1016/0035-9203(93)90407-h 31. lindtjørn b, alemu t, bjorvatn b. nutritional status and risk of infection among ethiopian children. j trop pediatrics. 1993;39:76-82. pmid 910. http://doi.org/10.1093/tropej/39.2.76 32. holcombe c. helicobacter pylori: the african enigma. gut. 1992 apr;33(4):429-31. pmid 1582581. http://doi.org/10.1136/gut.33.4.429 33. henriksen th. peptic ulcer disease is strongly associated with helicobacter pylori in east, west, central and south africa. scand j gastroenterol. 2001 jun;36(6):561-4. pmid 11424312. available from: https://pubmed.ncbi.nlm.nih.gov/11424312/ 34. tedla z. helicobacter pylori infection in patients with upper gastrointestinal symptoms in arba minch hospital: southwestern ethiopia. ethiop med j. 1992 jan;30(1):43-9. pmid 1563364. available from: https://pubmed.ncbi.nlm.nih.gov/1563364/ 35. henriksen th, nysaeter g, madebo t, setegn d, brorson o, kebede t, berstad a. peptic ulcer disease in south ethiopia is strongly associated with helicobacter pylori. trans r soc trop med hyg. 1999;93(2):171-173. pubmed; pmid 1623. http://doi.org/10.1016/s0035-9203(99)90297-3 36. mikru fs, molla t, ersumo m, henriksen th, klungseyr p, hudson pj, kindan tt. communitywide outbreak of neisseria gonorrhoeae conjunctivitis in konso district, north omo administrative region. ethiop med j. 1991 jan;29(1):27-35. [eng. epub 1991/01/01]. pmid 1900468. 37. maxwell-lyons fac. the epidemiology and prevention of the acute ophtalmia in egypt. b ophtalmol soc egypt. 1949;42:116-34. 38. habte-gabr e, tekle s, mamo m. meningococcal meningitis in ethiopia 1974-1983 and strategies of control. ethiop j hlth dev. 1984;1:47-63. pmid 678. 39. berhane y, worku s. meningococcal meningitis. in: berhane y h-md, kloos h, eds. epidemiology and ecology of health and disease in ethiopia. addis ababa: shama books; 2006. p. 508-18. 40. serie c, andral l, lindrec a, neri p. epidémie de fièvre jaune en ethiopie (1960-1962). observations préliminaires. b world health organ. 1964;30(3):299-319. epid'emie de fi'evre jaune en ethiopie (1960-1962). [observations pr'eliminaires. fre. epub 1964/01/01]. pmid 14163955. 41. mulchandani r, massebo f, bocho f, jeffries cl, walker t, messenger la. a community-level investigation following a yellow fever virus outbreak in south omo zone, south-west ethiopia. peer j. 2019;7. http://doi.org/10.7717/peerj.6466. 42. mekonnen m, kloos h. yellow fever and other arboviral diseases. in: berhane y, haile. mariam d, kloos h, eds. epidemiology and ecology of health and disease in ethiopia. addis ababa: shama books; 2006. [chapter 37] p. 635 45. 43. morley d. paediatric priorities in the developing world. kent: butterworths; 1973. 44. walt g. health policy: an introduction to process and power. johannesburg: witwaterstrand university press; 1994. p. 226. peer reviewed: submitted 10 aug 2020, accepted 19 oct 2020, published 9 nov 2020 competing interests: none declared. correspondence: bernt lindtjørn, university of bergen, norway. bernt.lindtjorn@uib.no cite this article as: lindtjorn b, henriksen th. the experience of mission hospitals in southern ethiopia in identifying and responding to infectious disease outbreaks. christian journal for global health. november 2020; 7(4):3-13 https://doi.org/10.15566/cjgh.v7i4.433 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v7i4.433 https://doi.org/10.15566/cjgh.v7i4.433 about:blank introduction methods results and discussion general discussion and conclusions references book review nov 2020. christian journal for global health 7(4) god and the pandemic: a christian reflection on the coronavirus and its aftermath by n.t. wright. zondervan, 2020 daniel w. o'neilla a md, mth, assistant clinical professor of family medicine at the university of connecticut school of medicine. managing editor, christian journal for global health introduction in keeping with the historical tradition of both theological reflection and active engagement in the face of disasters, calamity, or disease, the covid19 pandemic has elicited an awakening of both deep spiritual questions and innovative effective responses throughout the world. during times of vulnerability, all religions seek to draw from their ancient texts and traditions some profound insight, solace, and inspiration.1 aspects of global human responsibility, the meaning or cause of disease and suffering, and the need for god’s comfort and rescue are highlighted amid these challenging times. this year’s responses from within the christian community have varied. some have emphasized the sovereignty of god even in his “bitter providence” and the necessity of repentance.2 some offer comfort or fresh apologetics for the veracity of the christian faith in pluralistic or academic contexts.3 some have been reminded of the historic and normative christian response to epidemics as a christian distinction.4 some also highlight the need to protect the vulnerable and marginalized in line with new and old testament teaching, to pray, and to retain social but not relational distancing.5,6 others are calling christians not to forget their moral obligation to follow public health measures for the sake of others.5 theologians and church leaders raising conscientiousness regarding disease and human health, as well as responsibilities for community and global health are very welcome responses. in god and the pandemic, n.t. wright presents a brief and concise treatment of some of the contemporary issues the pandemic raises. his purpose in this very readable small (75 page) book is to avoid knee-jerk responses and presuppositions and to keep reactions within a biblical framework. (xi) summary wright begins with a critique of some common western responses such as stoic passive resignation, epicurean pleasure seeking and self-preservation, or platonic spiritual detachment. he takes aim at christians who assume this is a sign of the end times, or those who foster escapism. he eschews the “blame game”, especially when it involves ascribing it to the sin of victims (5,10). he even critiques those who receive the pandemic as a newfound opportunity for evangelism, or who ascribe it to “ancient pagan theories” of retributive destructive acts of an angry deity (6). as a corrective to what he would describe as misunderstandings or misapplications, he begins in chapter 2 to trace the deuteronomic biblical story of israel and god’s “healing, rescue, restoration, and new creation following after a time not only of judgment but of despair.” (14) this is manifest in the example of the babylonian captivity followed by the regathering. in his brief old testament interpretive framework, wright recognizes the deeper story of the good creation and the “dark power that has from the start tried to destroy god’s good handiwork,” (14) but remains agnostic toward that unknowable dark power. his main thesis is that the response to a pandemic like covid-19 is mainly to lament, complain, state the case, and leave the results with god. (14) 64 o’neill nov 2020. christian journal for global health 7(4) in chapter 3, he addresses jesus and the gospels as this “healing after judgment” story line is now (in a new way) carried through into the central biblical story of jesus’ healing and redeeming work, culminating in his resurrection. he contrasts the signs of the kingdom of god as signs of new creation, forward-looking signs, instead of looking back at hypothetical causes and calling for retributive destruction (16-17). instead, following jesus’ kingdom-oriented approach is to start with tears and groans of lament, then to look forward to see what god is going to do about it. the authority of jesus’ reign was given in power at the resurrection/ascension and salvation continues to spread, with the central sign for all nations being the resurrection, appropriated through the suffering servant’s crucifixion. in the gospels, a new notion of power is presented, and a new way of taking dominion through weeping, suffering, prayer and trust. he calls for providence and atonement to be kept together. (28) in chapter 4 wright gives a further perspective on reading the new testament which is “all about restoring creation the way it was meant to be. god always wanted to work in this world through loyal human beings.” (32) he identifies a call to repentance not because of any subsequent events such as famines or plagues but because of jesus himself. (37) in an exposition of romans 8, he emphasizes the christians’ responsibility to groan with all of creation, lamenting and weeping with the suffering, “at the point where the world is in pain” (45), then praying for renewal, healing and reconciliation. he then calls for courageously and sacrificially joining with god (synergeo rom 8:28) in bringing it about in the here and now, which god does creatively through human agency, “creating a context for the multiple works of healing and hope . . tears and toil, lament and labor.” (51) finally, in chapter 5 wright presents a direct application of the thesis of the book to the present pandemic. he wants to keep central the narrative of renewal after devastation, of the singular sign of christ’s resurrection, and the starting point of humble lament. understanding evil as an intrusion into god’s creation, he warns that it’s like putting “wind in a bottle” to spend time analyzing what evil is, why it’s allowed or what god does with it – other than that he overcomes it through jesus’ atoning death. (57) he calls for practical responsibility as stewards of creation for “proper investigation and accountability” for whatever caused the virus to leak out and spread. (58) signs of new life erupt in the presence of faithful people, with indiscriminate and fearless care for those in communities, including hospitals and hospices, the mark of the early church and throughout her history. (62) “out of lament must come fresh action,” as “sign-producers for god’s kingdom.” (64) this includes holding world leaders to account and for the church to not abrogate her responsibility for medical work, which is part of its long track record. (66) wright’s answer to “where is god in the pandemic?” is this: “out there on the front line, suffering and dying to bring healing and hope.” (68) this is the healing presence of jesus himself. he finishes the book likening the lockdowns and pandemic precautions as a time of exile like in babylon where the people of god are never quite satisfied but nevertheless seek the welfare of the city, longing for a return to jerusalem. (71) our political leaders’ “acrimonious dialogue of the deaf” (72) emerges when death and economic down turn are seen as the worst possible outcomes. he calls for psalm 72 to consider the disproportionate effect the pandemic has on the poor, hoping for new creation to come to birth. with “vision and realism,” seeing “new signs of genuine new possibilities, new ways of working which will regenerate old systems and invent new and better ones, which we could then recognize as forward-looking hints of new creation.” (75) review n.t. wright has once again, in a memorable and persuasive fashion and in short order generated a theological reflection to a contemporary issue weighing heavily on people’s minds. his critiques 65 o’neill nov 2020. christian journal for global health 7(4) against the extremes of perspectives or responses are well founded, but may not be as generous as would be fitting a unified global christian community, whose diversity might capture the greater grandeur of god, contextualized for deep localized meaning. he recognizes the reality of resident evil, not denying its existence as some higher criticism theologians and materialists often do. yet he takes an agnostic approach instead of an interventionist approach to evil, which pentecostal streams might find evasive. his main thesis starts as more pastoral (lament, weep, comfort, pray and hope) than what might drive a scientist, clinician, or activist to engage with solving problems in the physical or social or political realms. however, he does get to the latter eventually, which ends up appealing as much to the nurse, researcher or public health specialist as it does to the pastor. wright captures the oft-forgotten sign of suffering as an identification with the “one-off death of the messiah” (38) and creatively balances that with the glory to be revealed in the eschaton pictured in revelation 21, as a “final move in a longer sequence.” (40) that longer sequence is manifest in the ongoing work of transformational development and global health promotion many of us engage in among the suffering, which wright says grows out of lament (50) and is a sign of god’s coming with new life and health as part of this glorious continuum. the insightful and non-technical framework shared in this book encourages readers from all disciplines to follow christ’s example, acknowledge his presence, embrace suffering if needed, pray fervently for restoration, engage in meaningful redemptive work, and look with hope to the renewal of all things. god and the pandemic contributes significantly to filling the literature gap between theology and heath, and creating a very accessible and much-need convergence to tackle the devastating effects of this disease with meaning, purpose and tear-streaked hope.. references 1. xiong j, isgandarova n, panton a. covid-19 demands theological reflection: buddhist, muslim, and christian perspectives on the present pandemic. international journal of practical theology 24(1), july 2020. 5-28. https://doi.org/10.1515/ijpt-2020-0039 2. lennox jc. where is god in a coronavirus world? epsom, surrey, england: the goodbook company, 2020. 3. piper, john. coronavirus and christ. wheaton: crossway, 2020. 4. just b. historic plagues and christian responses: lessons for the church today? christian journal for global health. april 2020;7(1):7-12 https://doi.org/10.15566/cjgh.v7i1.373 5. stetzer e. removing the coronavirus mask: may this crisis reveal us as christians. usa today, 19 march 2020. [internet] available from: https://www.usatoday.com/story/opinion/2020/03/19 /during-pandemic-cornoavirus-christians-act-asjesus-taught-column/5055427002 6. sims, s. care and compassion during covid-19. matthiasmedia. [internet] available from: https://matthiasmedia.com.au/blogs/news/care-andcompassion-during-covid-19 7. gabriele m. christian groups that resist public-health guidelines are forgetting a key part of the religion’s history. time. 20 april, 2020. [internetr] available from: https://time.com/5824128/early-christiancaritas-coronavirus/ submitted 30 oct 2020, accepted 3 nov 2020, published 9 nov2020 competing interests: none declared. correspondence: dr. daniel o'neill, connecticut, usa. dwoneill@cjgh.org cite this article as: o’neill dw. god and the pandemic: a christian reflection on the coronavirus and its aftermath by n.t. wright. zondervan, 2020. christ j for global health. nov 2020; 7(4):63-65. https://doi.org/10.15566/cjgh.v7i4.473 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to vie a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1515/ijpt-2020-0039 https://doi.org/10.15566/cjgh.v7i1.373 https://www.usatoday.com/story/opinion/2020/03/19/during-pandemic-cornoavirus-christians-act-as-jesus-taught-column/5055427002 https://www.usatoday.com/story/opinion/2020/03/19/during-pandemic-cornoavirus-christians-act-as-jesus-taught-column/5055427002 https://www.usatoday.com/story/opinion/2020/03/19/during-pandemic-cornoavirus-christians-act-as-jesus-taught-column/5055427002 https://matthiasmedia.com.au/blogs/news/care-and-compassion-during-covid-19 https://matthiasmedia.com.au/blogs/news/care-and-compassion-during-covid-19 https://time.com/5824128/early-christian-caritas-coronavirus/ https://time.com/5824128/early-christian-caritas-coronavirus/ mailto:dwoneill@cjgh.org https://doi.org/10.15566/cjgh.v7i4.473 http://creativecommons.org/licenses/by/4.0/ references editorial nov 2014. christian journal for global health, 1(2):1. christian impact in global health the editors are pleased to publish issue two of the christian journal for global health. this second issue features three original articles, a case study, two reviews on the relationship between christians and secular public health, two commentaries on theology and health, two conference reports, a book review, an invited editorial by johns hopkins emeritus professor henry mosley, and a new feature described in more detail in a separate editorial. we are pleased about the flow of articles being submitted for publication in the journal and hope that the two new calls for papers, one on health care in conflict circumstances and the second on disability and rehabilitation, will stimulate additional contributions in these fields. original articles examine the relationship between knowledge of diabetes and action to control it in jamaica, the potential of a christian mindset to influence community health workers in providing cost-effective maternal health services in rural kenya, and the effectiveness of mobile surgical services both in providing surgical care and in enabling the entry of christian gospel witness in rural areas of india. we publish a case study describing the use of “clustering” to amplify and synchronize community health development in kenya. there are two reviews which address the intersection of the christian church with secular public health agencies on the one hand and the united states government on the other. clydette powell reviews the history of engagement between the united states agency for international development and faith-based organizations. professor matthew bersagel braley takes somewhat wider aim, examining whether the engagement between the church and public health authorities serves only the agenda of the secular authority or whether the church might itself speak authoritatively and effectively to those authorities concerning a deeper definition of the whole person and a broader meaning for health. this issue contains two commentaries on the role of christians in global health, one theological piece on what it means to fully care for the afflicted person and the other offering a framework for scholarship, research and innovation by christians. we commend the accompanying editorial on the reports from the field feature, with its invitation to reflect on the challenges, conflicts and conundrums arising from the everyday work of a medical missionary. one of the reports offers a window on the west african ebola outbreak from the standpoint of a nigerian physician who contracted the virus and her struggle to survive. a book review by huw morgan critiques a book that scrutinized religious perceptions of organizations which are involved in development. finally, there are reports from two major conferences involving christians in global health, one the annual conference of christian connections for international health held in virginia in june and the other, the 2014 world congress of the international christian medical and dental associations held in the netherlands. the editors are willing regularly to publish news and accounts of such events as contributing to effective understanding and communication between christians in global health. in our view this issue continues to affirm the viability and the need for a distinctly christian perspective on global health. there is an historical precedent in the vast legacy of christian responses to disease and poverty, and there is rational justification to address the existing hollowness of empirical approaches lacking a theological foundation. so, gentle reader, we invite you to read on and engage in the conversation. www.cjgh.org http://journal.cjgh.org/cjgh/index.php/cjgh/announcement editorial december 2021. christian journal for global health 8(2) vaccines, the faith community, and the common good this is the ninth volume for the christian journal for global health and we are experiencing an increasing number of submissions from lowand middle-income settings. the journal wants to be a venue for work from these sources, but accompanying this development are challenges regarding scientific rigor and english language usage. our reviewers provide excellent advice and help regarding the former and the editors assist extensively with the latter. one objective of the journal is to be a stimulus for original thinking and research in the majority world. this issue has two articles which highlight the unique role of faith-based people and organizations in global health. sara melillo and her colleagues from usaid’s momentum country and global leadership program and staff from christian connections for international health have reviewed the literature on the role faith actors can have in understanding and overcoming vaccine hesitancy in lmics. danielle ellis and tamara fitzgerald offer a commentary on what faithbased organizations and non-faith-based organization have in common, both ideologically and historically. these commonalities are a basis for partnerships in fostering the common good. a christian understanding of the human person is an antidote for the tendency of contemporary culture to disregard the unity of mind, body, spirit, and soul essential to true humanity. thus, two articles offer examples of holistic mission. paltzer, taylor & patel have studied how community health evangelism can be a model of integral mission. braganza & oliveira describe how a martial arts program in canada includes a spiritual component to the bio-psycho-social framework that enables it to be truly holistic. two articles deal with the continuing potential for expatriates working in lmics. wendler, lindberg, and sund surveyed mission sending organizations on the role healthcare research occupied in their mission strategy. ritchie and woods analyzed medsend exit interviews to see why cross-cultural healthcare workers had left their work earlier than expected. both propose solutions on how these efforts can be more effective. even in highincome countries like the usa, there are significant disparities in health measures and healthcare access, especially in urban areas across cultures. amanda martinez records an interview with the leader of a faithbased clinic in north philadelphia, suggesting the ways in which this effort has had the effectiveness it has had. the journal editors believe clinical articles based on experience in lmics can inform practice more broadly and offer creative solutions for circumstances in which the practice guidelines in common use in western countries are inappropriate or inadequate. a study by grills, singh, and anderson correlates mental illness and marital status with multisite pain in patients in north india which has not been previously evaluated. mathew, mathew, cherian & david present results of a clinical trial of pain control with epidural ketamine in total knee arthroplasty in a faith-based hospital setting in india. a clinical case report by marpaung, aryati, and soehita describes rare suppurative thyroiditis managed with limited resources in indonesia. finally, a study from iran by aziznejadroshan, et.al. shows how resilience can aid clinical competence among nurses. two papers offer an encouragement to faith in healthcare contexts. emily garmon offers a reflection and a prayer for those with pain. diane mccroskey writes on the role scripture has played in helping her meet the challenges of a sustainable nursing career toward caring for the whole person, body and spirit. finally, we want to acknowledge that some articles in this issue relate to areas that are contested amongst christians. as a journal we do not shy away from areas of controversy, but we have always actively encouraged respectful academic discussion and christian discernment on such issues. articles are assessed on their academic merit and alignment with the journal’s objectives. if the article is rigorous and relevant, and receives positive peer review, then we will publish it to promote mutual learning and growth. https://journal.cjgh.org/index.php/cjgh/article/view/587 https://journal.cjgh.org/index.php/cjgh/article/view/585 https://journal.cjgh.org/index.php/cjgh/article/view/585 https://journal.cjgh.org/index.php/cjgh/article/view/643 https://journal.cjgh.org/index.php/cjgh/article/view/593 https://journal.cjgh.org/index.php/cjgh/article/view/647 https://journal.cjgh.org/index.php/cjgh/article/view/647 https://journal.cjgh.org/index.php/cjgh/article/view/603 https://journal.cjgh.org/index.php/cjgh/article/view/633 https://journal.cjgh.org/index.php/cjgh/article/view/633 https://journal.cjgh.org/index.php/cjgh/article/view/559 https://journal.cjgh.org/index.php/cjgh/article/view/641 https://journal.cjgh.org/index.php/cjgh/article/view/641 https://journal.cjgh.org/index.php/cjgh/article/view/583 https://journal.cjgh.org/index.php/cjgh/article/view/583 https://journal.cjgh.org/index.php/cjgh/article/view/547 https://journal.cjgh.org/index.php/cjgh/article/view/655 https://journal.cjgh.org/index.php/cjgh/article/view/665 https://journal.cjgh.org/index.php/cjgh/article/view/665 book review faithful is successful: notes to the driven pilgrim. grills. n, lewis. de, and swamidass. sj, eds. usa: outskirts 2014 nicollette maunganidzea abs, ma, founder and president of global-i, atlanta, ga, usa faithful is successful (grills et al, 2014) is a collection of memoirs authored by individuals who fall under the umbrella of “successful christian professionals.”it explores the topic of success from the christian worldview, drawing on insights from years of explaining how success in vocation can and should be achieved. subthemes include the essential definition of success, how it is to be measured, and how each person of faith is expected to exemplify success. success, the authors suggest, is a result that every person can only authentically assess after the fact. the refreshing honesty of each author’s disclosure, including contributions from a u.s army serviceman turned hedge-fund co-founder in africa and a respected artist working in los angeles, makes the book a page-turner. some of the contributors are medical professionals: authors, denholm and grills, and editors, swamidass and grills. their life experiences coincide with the theme of this volume: “caring in conflict.” whether at work or at home, in new or old environments, some of the authors, and at times their families, have had to navigate life through seasons of interpersonal conflict. this collection meets my life journey with providential timing. it expounds how the mystery of calling, success, and ambition and, ultimately, god’s presence in these aspects workto his honour. focusing on one of these themes, each author chronicles their journey of integrating the sacred, their faith and the secular, their vocation, or, in other words, their struggle to infuse the secular with the sacred — if such is humanly possible. vishanoff evaluates compartmentalizing —such as sacred vs secular — as the result of man’s uniformed and egocentric attempt to understand the world. the collection is filled with liberating discoveries, demonstrating that such distinction cannot exist. . . all is sacred! success in vocation is, therefore, achieved by the very same process that success in one’s faith journey and relationship with god is achieved: exploring and enduring the subject his way. “his way,” a ubiquitous principle, appears, with continued reading, to be a masterful guide for responding to the questions at the root of this work:“what is success? how should the “souled out” christian achieve it, and measure it?” the answers, we learn, lay in each inquirer’s humbled and intentional return to the creator of truth, his truth, and his standards, despite the abounding and unrelenting temptations of, “worldly norms and pressures.” the authors find that this rediscovery of and submission to god’s standards for success requires accepting dispossession of our plans and acceptance of a plan that serves the existing needs within our communities and world. readers might want to be aware that one or two of the chapters contain dense and discipline-specific rigor. also, the multiple authorship can result in the repetition of some thoughts and concepts. take care to not judge these repetitions redundant. although each author is unique, their journeys, insights, and purposes may take common pathways. nevertheless, because every vocation has distinct standards and challenges, each of the authors can offer relevant wisdom. each thought and concept, albeit elsewhere echoed, is valuable in its context. the fundamental revelation of this collection is that there is no clear cut path to success. because the principles governing the discussion all originate from one book, the bible, the insights are applicable to every christian despite age, gender, and nationality. the restricted authorship does, however, render the content most accessible to the working christian man, woman, and home-maker. accessibility, as well as the power of the overall message, might have been improved by including accounts from authors from other parts of the world and from other age-groups. upon reaching the end of this collection and strengthened in the understanding that your identity is rooted in nothing less than christ, you may choose to adopt one of the life-standards advocated: “waiting.” abandoning the busy and numbing seat of “unmessy” curricula vitae and crisp 10-year forecasts, you may instead choose the involved wait: seeking, fasting, and praying. god, whom alone it is that you are seeking to please, will periodically modify your conscious wait, progressing you from one season to the next. what a blessed life if you should be that seeker who abides with the creator as well as in his truth, as he wills and does in and through you. this seeker is successful in the call, serving god not self, faithfully. competing interests: none declared. correspondence:nicollette maunganidze, nicollettemaunganidze@gmail.com cite this article as: : maunganidze n. faithful is successful: notes to the driven pilgrim. grills. n, lewis. de, and swamidass. sj, eds. usa: outskirts 2014. christian journal for global health (may 2015), 2(1): 73-74 ©maunganidze, n. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ . editorial dec 2020. christian journal for global health 7(5) more than the pandemic it is fitting for this issue of the christian journal for global health to come to you just before christmas. we remember the birth of the christ child, god with us. god with us not just in the ordinariness of human life, but in the calamities, defeats, and suffering entailed in that ordinariness. the coronavirus pandemic, as well as myriad of other human afflictions, is a reminder of those aspects of life. surely the greatest spiritual lesson of the pandemic is that we are not the masters of our own destiny. the pandemic is a rebuke to the hubris of our age – that human knowledge is the remedy for all ills. responses to the pandemic have exposed the fissures in our societies as well. while the healthcare community has responded heroically to the challenges, churches have served as a much-needed solace and source of health information, as well as, at times, sources of spread. some who consider faith non-essential and are antagonistic to it have proposed severe restrictions to much-needed fellowship. in the providence of god, we are able to rejoice at the arrival of effective vaccines to prevent sars cov-2 infection, the world-wide calamity that has dogged us for nearly an entire year. the vaccines come out-of-time, as it were, having been developed, produced, and tested with a speed that is astonishing. hopefully, they will enable this devastating infectious disease to be put behind us. if that proves to be possible, it is salutary to ponder what is able to be anticipated and to appreciate the perspicacity of someone like dr. jono quick, whose book, the end of epidemics, foresaw in 2018 what came to pass in 2020. for additional insights, we are pleased to feature in this issue a guest editorial by dr. quick which surveys some of the challenges that the release, use, and equitable global distribution of the vaccines hold for us, as well as the christian responsibility to follow the data for both individualized whole-person care and community care as acts of love for our global neighbor. the covid-19 pandemic has highlighted systemic vulnerabilities, health inequities, and the ongoing diseases and conditions that continue to threaten individuals and populations. the response to the pandemic has affected the global economy and exacerbated hunger and extreme poverty. progress in global health to control the remaining poliovirus, hiv, malaria and tuberculosis has also been tragically impaired due to the pandemic.1 two original articles describe efforts to evaluate health needs for chronically impoverished villages and then to train christian health workers in the ways to most effectively service those needs. claudia bale reports that the results of surveying guatemalan villages for health needs and barriers to health produced a variety of themes that provided guidance for the organizations seeking to meet these needs. sneha kirubakaran and colleagues evaluated a short course in global health from australia that sought to prepare christian health workers for international service. this issue features three reviews. samuel adu-gyamfi and his colleagues from ghana completed an extensive systematic review of the role of missions in sub-saharan africa, finding that although the scope of work changed over time, the aim of sharing the gospel motivated work in a broad scope of activities in development, education, and healthcare which continues to be relevant. omololu fagunwa from nigeria provides a history lesson based on original source documents on how the 1918 influenza pandemic affected the growth of pentecostalism in africa. alexander miles, matthew reeve, and nathan grills from university of melbourne completed a systematic literature review showing evidence of the significant effectiveness of community health workers in dealing with non-communicable diseases in india. https://journal.cjgh.org/index.php/cjgh/article/view/495 https://journal.cjgh.org/index.php/cjgh/article/view/391 https://journal.cjgh.org/index.php/cjgh/article/view/415 https://journal.cjgh.org/index.php/cjgh/article/view/417 https://journal.cjgh.org/index.php/cjgh/article/view/417 https://journal.cjgh.org/index.php/cjgh/article/view/455 https://journal.cjgh.org/index.php/cjgh/article/view/455 https://journal.cjgh.org/index.php/cjgh/article/view/439 https://journal.cjgh.org/index.php/cjgh/article/view/439 2 editors dec 2020. christian journal for global health 7(5) two commentaries offer fresh approaches to persisting healthcare issues. richard thomas and niels french describe the population health model and explain how it is particularly suited to a role in the future for mission hospitals and to address a variety of global health concerns. melody oereke, kenneth david, and ezeofor onyedikachukwu from nigeria offer their thoughts on how christian pharmacists can employ a model for prayer, faith, and action in their professional calling. the coronavirus pandemic has required healthcare and aid organizations to come up with creative solutions to completely novel circumstances if they were to be able to continue their ministries. daryn joy go and her colleagues from international care ministries describe their employment of social networking technologies in the philippines to continue their work in extreme poverty alleviation as well as spiritual nourishment despite lockdown conditions and severe limitations on travel and communication. finally, pieter nijssen reviews creating shared resilience: the role of the church in a hopeful future, by david boan and josh ayers. in our world of short-term gain and short attention spans, resilience is a commodity in tragically short supply. pastor nijssen’s discussion helpfully expands on an ongoing discussion of how faith and justice must be integrated in any faithful gospel ministry and how this, itself, promotes resilience in the face of crises. we call our readers’ attentions to our current call for papers, environmental concern and global health. our stewardship of the earth and its resources was part of god’s first command to adam and eve and an important aspect of human flourishing throughout the bible. that stewardship has implications for global health that deserve study and explanation. click on the link to the call for a list of the subjects we hope to see in submissions on this topic and many others within the unique and broad scope of the journal. during this season of both widespread challenge and enduring hope, we pray for peace on earth, and good will to all people. references 1. mandavilli a. ‘biggest monster’ rebounds. science times. the new york times. 2020 aug 4. [updated sept. 23, 2020]. d1, d5. available from: https://www.nytimes.com/2020/08/03/health/cor onavirus-tuberculosis-aids-malaria.html from bailey d. coronavirus: how soon can we expect a working vaccine? bbc news. 2020 nov 9. https://www.bbc.com/news/health-54027269 https://journal.cjgh.org/index.php/cjgh/article/view/363 https://journal.cjgh.org/index.php/cjgh/article/view/363 https://journal.cjgh.org/index.php/cjgh/article/view/447 https://journal.cjgh.org/index.php/cjgh/article/view/447 https://journal.cjgh.org/index.php/cjgh/article/view/479 https://journal.cjgh.org/index.php/cjgh/article/view/489 https://journal.cjgh.org/index.php/cjgh/cfp/environment https://journal.cjgh.org/index.php/cjgh/cfp/environment https://www.nytimes.com/2020/08/03/health/coronavirus-tuberculosis-aids-malaria.html https://www.nytimes.com/2020/08/03/health/coronavirus-tuberculosis-aids-malaria.html references original article the makunda model: an observational study of high quality, accessible healthcare in low-resource settings caleb flinta, vijay anand ismavelb, and ann miriamc a jd, mba, wharton school of business, the university of pennsylvania, philadelphia, pa, usa b mbbs, ms(general surgery), mch(pediatric surgery), senior administrative officer, makunda christian leprosy and general hospital, bazaricherra, assam, india c mbbs, md, consultant anesthesiologist, makunda christian leprosy and general hospital, bazaricherra, assam, india abstract background: mission hospitals in low-resource regions of the world face significant challenges in providing high-quality, accessible care to patients. external funding is limited and can fluctuate significantly from year to year. additionally, attracting and retaining well-qualified healthcare professionals for more than short stints can seem almost impossible. located in a remote region in northeast india, the makunda christian leprosy & general hospital has developed a model over the past 25 years that has enabled it to sustainably expand access to high-quality care for the region’s poor, which we evaluate in this paper. methods: we combine an external assessment by a research team at the wharton school of business with internal insights from two leaders at makunda hospital to evaluate the makunda model. the external assessment included 31 in-depth, on-site interviews of patients, employees, and competitor hospital administrators; physical observation of makunda’s facilities and operational practices; and an analysis of years of financial documents and hospital statistics. results: we studied the impact of the makunda model on volumes, efficiency, quality, and community impact. in 2018-19, makunda hospital provided 109,549 outpatient visits, 14,731 hospital admissions, 6,588 surgeries (2550 major), and 5,871 baby deliveries in a 162-bed facility with a bed occupancy rate of 88%. the hospital operates with an annual budget of $2.7m ($1 = inr 75.70) and receives only 2.5% of its operating revenue from external sources. the hospital has developed a strong reputation in the community and beyond for providing excellent maternal care and catering to the poor. discussion: the hospital’s business model revolves around two key business strategies: (a) poor-centric strategies and (b) thoughtful cost management. innovative poorcentric strategies include “ability-to-pay”-based pricing, equal services for all (in contrast to a freemium model), hyper-tailored charity (using the “shared meals” and “vital assets” tests), and community engagement. thoughtful cost management is accomplished by “revised gold standard” treatment protocols and recruitment and retention of an efficient workforce. 38 flint, ismavel, miriam june 2020. christian journal for global health 7(2) conclusion: we conclude that makunda hospital’s unique combination of poor-centric strategies and thoughtful cost management have enabled it to achieve the volumes necessary to sustainably improve access to care for the poor in northeast india. key words: poor-centric strategies, equal services, charity, christian mission hospitals, makunda model introduction the makunda christian leprosy & general hospital,1 founded in 1950 by baptist mid-mission usa, is located in a remote region in northeast india at the border of three neighboring states: assam, tripura, and mizoram (see figure 1). originally a leprosy colony on 1,000 acres of land, the hospital became a general hospital from the late 1950s until the early 1980s, when the expatriate staff running it were asked to leave india. consequently, the hospital fell into a state of disuse until 1992 when it became a member of the emmanuel health association (eha), an association of 20 independent hospitals in india.2 figure 1 in october 1992, two of the authors, drs vijay anand ismavel and ann miriam from the south indian state of tamil nadu, visited the hospital and were impressed by the area’s needs. they were motivated by a search for a location that provided the highest potential for transformational impact, as determined by the population that they could serve divided by the number of other similar care providers. makunda was situated in a place that was moderately populated with no other comparable hospital within 100 km. it also had a large campus that could be used to provide other services in the future. since eha felt that it could not safely assume responsibility for a hospital in such a remote location, the founding doctors gave a career-long commitment to serve there for 30 years. the early days were difficult, but they persevered in spite of the challenges.3 to cover the full time period they planned to stay at makunda hospital, drs vijay and ann developed a 30-year strategic plan with three key phases. phase i was aimed at stability: resolving tensions with local community members and generating enough revenue to cover costs. phase ii focused on local expansion, including building a secondary school, nursing school, and branch hospital to serve the community. finally, phase iii centered on distant impact, including developing and sharing best practices with organizations in other low-resource settings. this period also included a new community college, a nature club, and a larger emphasis on agriculture. today, 25 years into its strategic plan, makunda hospital has completed two phases and is well into its third. in the 2018-2019 fiscal year, the hospital provided care for 109,509 outpatients, had 14,731 inpatient admissions, performed 6,588 surgeries (2,550 major), and conducted 5,871 deliveries. it also opened another branch in tripura, 39 flint, ismavel, miriam june 2020. christian journal for global health 7(2) a neighboring state, that served 7,838 of these patients in 2018-19. makunda hospital provides its services at very low prices and provides 15% of its income as charity to poor patients. furthermore, makunda hospital has created various educational and agricultural businesses. it runs a k-12 school system with over 1,000 students, a nursing college with 61 students, and a nurse assistant training program with 43 students. most of the nursing college and nurse assistant program students stay in dormitories provided by makunda hospital. on the agricultural side, makunda owns a farm that generates food for its school hostels for most of the year, and it owns several fisheries and a piggery. finally, makunda hospital recently designated a wildlife area within its boundaries and created the “makunda nature club” to document and publish biodiversity records.4 all of these activities are performed to further makunda hospital’s mission to provide christian service to the people of northeast india regardless of their background (see appendix i for the hospital’s mission statement). the goal of our observational study was to assess the impact of the makunda model on access to quality healthcare within northeast india and to identify the underlying drivers for the hospital’s financial sustainability and success. a team of students from the wharton school of business conducted the external research assisted by a faculty member and generated an initial report about the model.5 the team focused its research on how makunda hospital utilizes poor-centric strategies and thoughtful cost management to provide highquality care to the poor. methods our observational study is primarily descriptive and relies on a mixed methods research design. we relied on three approaches to gather and triangulate the necessary data: (1) in-depth interviews, (2) facility observations, and (3) document analysis. the interviews provided qualitative insight about the impact of makunda hospital and the drivers of its impact, verified through facility observations and by reviewing and analyzing hospital statistical and financial documents. makunda hospital's management committee and research committee provided permission for the study and provided access to the hospital's financial and statistical information. statistical data for other eha hospitals were taken from publicly available reports. irb approval was not deemed necessary for the study. 1. in-depth interviews a total of 31 in-depth interviews were conducted by the wharton research team of (a) makunda hospital employees, (b) hospital patients and community members, and (c) competitor hospital administrators and staff, as summarized in table 1. table i. number of interviews by interviewee type type of interview # of in-depth interviews makunda hospital employees 16 hospital patients and community members 7 competitor hospital administrators and staff 8 total interviews 31 first, confidential interviews were conducted by a wharton research team member with 16 makunda hospital employees in a broad range of roles, including managerial, clinical, teaching, and technical positions (see appendix ii for details). at the beginning of each interview, interviewees were informed of the purpose of the study and that any information they disclosed may be shared in an anonymized format with hospital management or in a published report, but that no statements would be personally attributed to any specific individuals without their permission. interviews focused on the strengths, weaknesses, changes, differentiators, and impact of makunda hospital (see appendix iii for the full list of survey questions used). after the unique drivers behind the makunda model were 40 flint, ismavel, miriam june 2020. christian journal for global health 7(2) identified (i.e., poor-centric strategies and thoughtful cost management), additional questions were used to probe deeper. interview notes were coded by these drivers and reviewed by the other members of the wharton research team. in addition, a wharton research team member visited five local communities representing a broad cross-section of the hospital’s patients to understand how patients and their families view makunda hospital. a total of 7 in-depth interviews were conducted, most with the assistance of a translator. the five communities included the following groups: (1) tea garden laborers, among the poorest people in indian society and who usually live in crowded primitive huts and earn around inr 100 ($1.42 usd) per day; (2) members of the brahmin community, who tend to occupy leadership positions and live in larger homes with electricity; (3) members of the vaishya community, which include skilled laborers who live in humble homes on their own land; (4) members of the tribal community, who cultivate rice for work and live in more isolated communities; and (5) muslim families, who make up about a third of makunda hospital’s patients. finally, hospital administrators and staff from three competitive hospitals in northeast india, including two government hospitals and another mission hospital (also a member of eha), were interviewed. questions focused on the services and value proposition of those hospitals versus makunda hospital. the following individuals were interviewed in-depth, with additional physicians and staff providing comments throughout the tour of the facilities: 1. the chief medical officer and medical supervisor of dharmanagar civil hospital. this is the nearest district hospital in tripura, about 30 km from makunda. 2. the medical superintendent and an administrative officer of karimganj civil hospital. this is the nearest district hospital in assam, about 54 km from makunda. 3. senior administrative officer (ceo), nursing school superintendent, nursing staff supervisor, and general surgeon of burrows memorial christian hospital. this is the nearest mission hospital, about 123km from makunda. 2. facility observations to understand makunda hospital’s model, an extensive tour of the facilities was conducted, and the outpatient experience was followed from checkin to the waiting area to the physician consultation to the pharmacy. significant time was spent observing patients and operational practices in each of these areas. then the lab testing rooms, operating rooms, and inpatient facilities — which include 162 beds across the female ward, male ward, maternal ward, pediatric ward, postnatal ward, high dependency unit, and nicu — were toured. finally, other facilities surrounding makunda hospital, including the makunda primary and secondary schools, nursing and nursing assistant schools, grain farms and fisheries, physician and staff dormitories, and wildlife preservation area were visited. for purposes of comparison, the facilities of both government hospitals and the other mission hospital were also toured. 3. document analysis makunda hospital provided financial and statistical documents for review. this included over 10 years of historical revenue and cost data and detailed patient volume statistics. makunda hospital’s annual report and emmanuel hospital association’s annual reports (obtained from their website) were reviewed and various financial analyses were conducted to understand makunda’s model and how it compares to other hospitals both in the united states and india. finally, the patient complaint log and statistical data on hospital complications and mortalities were reviewed. based on these in-depth interviews, facility observations, and detailed document analysis, the makunda model and its impact on the local community were evaluated. 41 flint, ismavel, miriam june 2020. christian journal for global health 7(2) results the impact assessment of makunda hospital’s volume, efficiency, quality, and overall community impact are presented below: 1. volume in the 2018-2019 fiscal year, makunda hospital completed 109,549 outpatient visits (a 7.7% compounded annual growth rate (cagr) from 2014-19); 14,731 inpatient admissions (6.0% cagr); 6,588 surgeries (10.2% cagr); and 5,871 deliveries (5.1% cagr). figure 2 shows makunda hospital’s growth in deliveries and surgeries for the period from 2007 to 2019. figure 2. makunda hospital’s growth in deliveries and surgeries, 2007-2019 to put these numbers in context, we looked at the emmanuel hospital association6 (the largest christian non-profit healthcare provider in india with 20 hospitals and 40+ community-based projects), where the average hospital had 45,825 outpatient visits; 5,034 inpatient admissions; 1,542 major surgeries; and 1,245 deliveries. of the 19 eha hospitals reported, makunda hospital was the largest by number of outpatients, deliveries, and surgeries, and second largest by number of inpatients and beds. furthermore, many of the other eha hospitals are facing declining patient volume, as opposed to makunda, which has seen consistent cagr growth over the past several years.7 although there are many external factors which affect statistics among different eha hospitals (such as competition from nearby hospitals or lower population densities), it is notable that makunda has grown to become one of the highest-volume eha hospitals despite starting off as a completely closeddown hospital 25 years ago. for an additional point of comparison, the average hospital in the u.s. has 7,745 discharges per year, with urban hospitals hitting 11,295 discharges per year on average, and rural hospitals reaching 2,467 discharges per year on average.8 furthermore, u.s. hospitals tend to see about twice as many outpatients as inpatients per year, far below makunda hospital’s numbers.9 overall, makunda hospital has achieved very high patient volume, especially considering its location in a remote area 0 1000 2000 3000 4000 5000 6000 deliveries surgeries 42 flint, ismavel, miriam june 2020. christian journal for global health 7(2) of india, as seen in figure 3, by expanding access to quality healthcare services. figure 3. comparison of average hospital inpatient volumes 2. efficiency in achieving these volumes, makunda hospital operates on a total budget of $2.7m usd (for 201819), which includes the total costs for the hospital, educational, and agricultural portions of its operations. the income from the hospital alone is $2.2m and accounts for 83.9% of income. the nonhospital activities run at a loss and are subsidized by hospital income. furthermore, makunda hospital has run efficiently enough to reinvest nearly 6.5% of its annual revenue in new buildings and equipment (in 2018-19) and to write off 15% of its bills to charity. for the fiscal year 2018-19, the average outpatient cost was only $11.56 usd (inr 875), and the average inpatient cost was only $68.03 usd (inr 5150), figures that were substantiated by examining detailed accounting and financial documents. these numbers represent very efficient costs per patient treated, particularly given that less than 2.5% of operating revenue comes from external sources.10 3. quality makunda hospital is well-known for its highquality services, particularly in maternal care. to make our assessment of quality, we examined the hospital’s certification, key performance metrics, and qualitative interview responses. first, makunda hospital has achieved entrylevel certification for safety and quality from the national accreditation board for hospitals and healthcare providers (nabh).11 such a certification requires passing an extensive audit process, creating a detailed quality assurance process that includes continuous tracking of certain metrics, and meeting stringent standards for the treatment and disposal of medical waste products. second, makunda hospital tracks favorably on key metrics for hospital quality, including overall inpatient mortality and maternal mortality rates. in 2018, the overall mortality rate in the hospital was 2.0%, down from 2.4% in 2016. the proportion of maternal deaths among mothers who delivered in makunda similarly declined from 0.5% in 2016 to 0.1% in 2018. considering that many community members come to makunda hospital only for their most complicated births (as noted by those we interviewed), this is particularly indicative of its standards of quality. the hospital has been part of a private-public partnership with national health mission assam for maternal and child health services since 2008 and is recognized as a referral center for high-risk obstetrics patients in the district. makunda’s impact on local measures of health is also noticeable. for example, as shown below in table 2, the mmr and imr rates for the region dropped significantly in the district of karimganj during the years (2009 to 2013) in which makunda hospital sharply increased its number of deliveries (as captured above in figure 2).12 table 2. mmr & imr statistics for karimganj district year 2009-10 2010-11 2012-13 mmr per 100,000 live births 474 342 281 imr per 1,000 live births 87 69 69 14,731 5,034 7,745 0 5,000 10,000 15,000 volume makunda eha average hospital us hospitals 43 flint, ismavel, miriam june 2020. christian journal for global health 7(2) during interviews, we found near-universal respect for makunda hospital among both competitive hospital administrators and community members. one government hospital administrator indicated his hospital loses “many, many patients” to makunda hospital despite the fact that makunda hospital charges for its services (as opposed to government hospitals, which are essentially free) and despite the fact that it is located hours away. though he had not visited makunda hospital himself, he said, “we hear from patients that the services are much better there; people tell us that it is well-managed, patient satisfaction is high, and it has good cleanliness.” another government administrator said that makunda hospital was well respected by their staff of doctors, and many of this hospital’s patients know it for its strong maternal services and travel hours to go there instead for baby deliveries. one hospital staff member at the burrows memorial christian hospital stated that makunda is “probably the best-run mission hospital in india” and added that many healthcare professionals like to start their careers there because of the great training it provides. when local community members were visited, one previous patient asserted that makunda hospital is the “best hospital in assam” and “we know that they will take care of us.” similar confirmations of the community’s trust in makunda hospital were made in each of the five communities who were visited. in the tea garden community, one mother said that she brought her dying son to makunda hospital at the urging of friends despite believing it was too late. her positive experience with her son’s recovery led her to bring back her three other children over the years and to strongly recommend the hospital to any of her friends who need services. 4. community impact makunda hospital is unique from many private hospitals in india in that it was founded specifically with the intent to help the poor, and its management team has proactively worked to ensure that all hospital policies and decisions are carefully designed to benefit them. in 2018-2019, 15% of its patients received charity for the services it provides; in many cases, these patients would otherwise not have received treatment at all and would have died or lived with great pain. over time, makunda has built a reputation for low baseline prices and charity for those who cannot afford even these prices, and more generally for taking care of anyone who comes to its doors. while makunda hospital has had a substantial impact on healthcare in the local community, interviews revealed that its impact extends far beyond that to the community at large, including a k-12 program started in 2004 that educates more than 1000 students each year. in addition to its k-12 education program, makunda operates a nursing assistant program started in 2015 and a nursing school program started in 2006 to train local community members in preparation for working at makunda hospital and other locations. both of these training programs are subsidized by the hospital so that poor communities can access these services. in addition to education, makunda provides direct employment to hundreds of people, with cascading benefits on the local economy. some people we interviewed described the transformation they have seen in the local marketplace over the past few decades as more people with more income have stayed in the area because of the employment and educational opportunities. the government has also recognized the value of makunda as a service provider for the local community, bestowing it with the chief ministers certificate of commendation in 2015, and has invested money in local infrastructure and provided support for new hospital construction projects. discussion analyzing data from interviews, documents, and facility observations to understand how makunda hospital achieves such levels of impact, we found that makunda hospital’s business model 44 flint, ismavel, miriam june 2020. christian journal for global health 7(2) revolves around two key business practices: (1) poor-centric strategies, and (2) thoughtful cost management. these business practices enable makunda hospital to operate a business model of generating higher total earnings by providing very high volumes of very low-margin services. this approach permits makunda to achieve economies of scale and lower prices, drawing in more pricesensitive patients, which in turn creates more scale and enables them to further lower prices — creating a virtuous cycle. makunda hospital has also been able to attract talented young professionals seeking good training opportunities at a high-volume facility. these business practices — poor-centric strategies and focused cost management — are the keys to this virtuous high-volume, low-margin, strategic advantage. 1. poor-centric strategies makunda hospital employs a range of innovative poor-centric strategies that have enabled it to drive high patient volume in a low-resource setting which drive demand. these include (a) an ability-to-pay based pricing approach, (b) equal services for all, (c) hyper-tailored charity, and (d) addressing cultural barriers to usage through community engagement. (a) ability-to-pay based pricing approach. traditionally, hospitals decide on a set of services to offer and adopt “costing” methods to fix prices. instead, makunda asked the question, “what can the poor afford to pay?” and then figured out how to provide services that fit within that price point. this was based on community engagement in the early years; for example, the cost of an outpatient consultation was fixed as the cost of having a village haircut. this decision — to start with consumer’s ability to pay — drove all the other decisions regarding costs. many hospital patients are already hard pressed to pay for a car ride to the hospital, which often costs more than the actual hospital services. the decision to make the hospital’s price points more accessible was the difference between touching only a wealthier subset of the population and reaching nearly the full local population — with important implications for a high-volume, low-margin strategy. costly services such as treatment in an intensive care unit (icu), which can quickly impoverish a poor family, are substantially lowered at makunda hospital through internal cross-subsidies from other departments, where costs are easily affordable and large volumes generate greater departmental profits. to illustrate, icu care at makunda (including ventilation and all procedures but excluding drugs) is charged at inr 650 ($8.60 usd) per day. this is cross-subsidized by income from other departments such as ultrasound, which performed 16,854 higher-margin ultrasound scans in 2018-19. (b) equal services for all. another key decision made early on was to provide equal services to all patients regardless of wealth. many mission-driven hospitals utilize what amounts to a freemium-like model, in which wealthy individuals pay much more for much better services in order to subsidize services to the poor.13 in these models, the wealthy are placed in a separate, shorter queue; receive private rooms; and have a private consultation with a physician of their choice. in contrast, the poor are placed in the longer queue and in general inpatient wards. the problem with the freemium-like model is that the wealthy expect better services because they know they are paying more and, thus, demand more attention from physicians and staff. in addition, to keep their business, hospital administrators must cater to the needs of wealthier patients by providing what they want, when they want it. over time, the organization and processes of the hospital become increasingly oriented towards providing services for the wealthy at the expense of the poor — often unintentionally. as this occurs, the poor feel more and more out of place in the hospital and come to see themselves as second-class citizens, so they come less and less often and refer their family and friends less and less often. at the end of the day, 45 flint, ismavel, miriam june 2020. christian journal for global health 7(2) this reduces volumes, which reduces scale and increases costs, which requires higher pricing to compensate — creating a vicious cycle. in contrast, makunda hospital has held to its philosophy of providing equal services to all patients, regardless of wealth. the hospital is unique in that it has no private wards, only general wards with reasonable privacy. according to makunda administrators and employees, this practice is probably the most obvious evidence of equal treatment for the poor when they come to the hospital. this has served to bolster makunda hospital’s brand as a place for the poor to go, which drives volumes and revenue up while simultaneously upholding the ideals that led the founding doctors to reopen the hospital in the first place. (c) hyper-tailored charity. in fulfilling its mandate to help the poor, makunda hospital — like many other mission hospitals — frequently provides services to poor patients for free. doing so exposes mission hospitals to both type i and type ii errors; that is, they may fail to provide aid to those who truly need it, or they may provide aid to those who do not actually need it and lose the corresponding revenue they could have earned to support their hospital. what makes makunda hospital unique is the hyper-tailored methods it uses to both identify those who truly need charity and to provide it to them in the most effective manner. historically, makunda hospital has identified the poor primarily through a set of behavioral observations, and more recently, it has experimented with more formalized diagnostic tools. two notable examples of behavioral observations — the “shared meals test” and “vital assets test” — merit specific mention. these observational criteria to diagnose financial vulnerability and the risk of destitution are currently being studied and validated by the hospital. first, in the shared meals test, physicians and nurses (who spend the most time with patients) are instructed to pay attention to the meal habits of family members and friends who accompany a patient at the hospital. if family members and friends frequently skip meals or share a single meal among multiple people, they are identified for charity. this is based on the fact that poor people are willing to go through suffering to get treatment, a behavior that is difficult for wealthy patients to fake. second, in the vital assets test, makunda employees pay attention to how patients act with regards to their medical bills. the poorest of patients will frequently ask how much an additional service will cost and may try to limit their stay in the hospital when they feel they have exhausted their budget even when a doctor recommends that they stay longer. interestingly, the founding doctors found that the poorest patients are actually much less likely to ask for charity than the moderately well-off patients, who are more likely to try to negotiate on hospital bills to get them reduced even though they can afford to pay. in contrast, the poor typically go to great lengths to pay a bill, including selling so-called “vital assets” that they need for basic living (such as their home) or to maintain their livelihood (such as a work animal or farming equipment). one technique makunda employees use is to ask how a patient will pay for a planned or billed medical expense. if the patient says they have the money, will be able to borrow the money, or will sell some non-essential items, they are allowed to do so. however, if they mention sale of a “vital asset” that is specially mentioned on a list created by makunda, they receive charity. furthermore, if makunda hospital finds out after the fact that a patient has sold a “vital asset” (often a distress sale at low value), it goes out into the community and repurchases the asset on behalf of the patient. if a patient says that they will need to sell a vital asset in order to pay for services, they are asked how much they could pay if they do not sell the vital asset. they are then asked to pay that amount, and the rest is written off as charity. many poor people 46 flint, ismavel, miriam june 2020. christian journal for global health 7(2) have a strong sense of dignity and often ask for the pending amount to be kept as “due” rather than ask for charity. one practice makunda engages in is to write off all “due” amounts at the end of the financial year. another way makunda hospital provides charity in a targeted way is to write off large medical expenses related to unexpected complications. since complications happen so infrequently, writing them off is a relatively small cost for the hospital to incur when spread across many procedures, while not doing so would impose a huge financial burden on a single individual. in effect, makunda hospital is providing a form of informal insurance to make healthcare more accessible to the poor. from a business perspective, makunda hospital’s unique focus on identifying and providing tailored charity enables it to retain revenues from those who can afford to pay — essentially operating as a form of efficient price discrimination — and drives patient volume by reinforcing makunda hospital’s brand as a hospital for the poor, by retaining patients, and by encouraging referrals. (d) removing cultural barriers through community engagement. during the early years of makunda hospital, it sought to expand its labor and delivery services but initially faced slow growth. at the time in northeast india, most villages had an informally designated woman to help with childbirth within that village. this midwife also helped with household work like cooking and taking care of the children when the mother had her delivery, thus, ensuring the least disruption to the family. this practice was so convenient that villagers were willing to forget about the occasional maternal death, saying that it was inevitable. based on local infant and maternal mortality rates, the founding doctors knew that many mothers and babies were dying during childbirth, but when they asked the de facto village midwife in each of the villages if they had seen any deaths, each of them indicated that they had not. however, by digging deeper, the doctors realized that the village midwives were witnessing significant infant and maternal mortality but were afraid to admit it and were secretly terrified of complicated deliveries — such as malpresentation, hemorrhage, and eclampsia — but did not know what to do about them because their communities looked to them as the experts. in response, makunda hospital began to encourage village midwives to send only their most complicated cases to the hospital. when a village midwife brought such a complicated patient to the hospital, doctors at the hospital explained to the family that the mother’s life had been saved because of the timely referral by the midwife. when referred patients found that they had a good experience at the hospital, they referred friends and relatives for their deliveries too. the midwives became trusted community members in the eyes of both the villagers and the hospital. by seeking to understand the barriers to usage and building community partnerships, makunda saw large growth in the number of deliveries performed, helping it to achieve its strong reputation within maternal care as a hospital for everyone, especially the poor. in summary, each of these four poor-centric strategies — an ability-to-pay-based pricing approach, equal services for all, hyper-tailored charity, and addressing cultural barriers to use through community engagement — play into the success of makunda’s high-volume, low-margin approach. 2. thoughtful cost management given its commitment to providing care to the poor, makunda hospital has by necessity always been intensely focused on cost management — the “supply side” of their operating model. to succeed in providing low-price services, it has primarily reduced costs to its patients through two innovative methods: (a) implementing a “revised gold standard” of care that reduces unnecessary testing 47 flint, ismavel, miriam june 2020. christian journal for global health 7(2) and procedures for patients, and (b) recruiting and retaining individuals who are willing to accept lower salaries and heavier work obligations because of the training opportunities it provides or their commitment to makunda hospital’s mission. these themes emerged through triangulating comments from makunda employees with financial data on workforce and procedure costs. (a) “revised gold standard.” medical students are often taught the “gold standard” approach to medicine: a broad set of tests and procedures that should be done to maximize diagnostic accuracy and patient health in an ideal world. unfortunately, physicians in low-resource settings typically do not have the luxury of running all of the tests and procedures outlined under the “gold standard” of care for two reasons: first, their facility may lack the necessary medical equipment; and second, the patients they treat may simply not be able to afford such full-scale services. to deal with these realities, makunda hospital has developed a set of “revised gold standards” to provide services that are affordable to its patients. these standards serve to impact both how physicians make clinical assessments and what lab tests, procedures, and drugs they recommend to patients. doctors at makunda think about the cost versus benefit of a test before asking for it. the same process is used for prescription of medicine — a patient is more likely to comply long-term with a set of drugs that the patient can afford. as another example, makunda performs choledochoduodenostomies as an alternative to endoscopic retrograde cholangiopancreatography (ercp) in patients with calculi in the common bile duct. drs vijay and ann have published several articles on interventions that are as safe and effective or nearly as safe and effective as much more expensive alternatives commonly used today during their postgraduate studies.14,15,16 makunda hospital’s “revised gold standard” approach has enabled it to lower the cost of providing health care services so it can in turn lower prices, which drives greater volume. (b) recruitment and retention of efficient labor. in addition to practicing its “revised gold standard” practices, makunda hospital has lowered costs for patients by recruiting and retaining individuals who are willing to accept lower salaries and heavier work obligations because of the training opportunities it provides and their commitment to makunda hospital’s christian mission. government hospitals tend to pay physicians and nurses nearly twice as much as makunda hospital, and many government physicians work in their own private practice in the evening after leaving the government hospital, further boosting their salaries.17 employees at makunda hospital noted that the hospital also gets much more leverage from employees by asking them to multitask throughout the day and work longer hours to meet the high patient load. a typical nurse at makunda hospital works eight hours a day, six days a week, but may also voluntarily work overtime during a particularly busy shift transition. because salaries make up the largest expense category for most hospitals, being able to reduce that cost translates to significant savings for patients and contributes to the hospital’s low-price approach. despite the heavy obligations and lower salary, many employees choose to work at makunda hospital either because of the training it provides or their commitment to the mission of makunda hospital. because makunda has a nursing school on site, skilled physicians, and high patient volume, many aspiring nurses come to makunda hospital to get large-volume, high-quality experience before moving on to other hospitals. even more striking, however, is the strong commitment to makunda’s mission that starts with the founding doctors and extends to employees in both the hospital and the school system. most of the people who were interviewed cited their commitment to christian 48 flint, ismavel, miriam june 2020. christian journal for global health 7(2) service and makunda’s focus on the poor as the driving force in their decision to work at makunda hospital. furthermore, despite the heavy obligations, these employees tend to find great satisfaction in their work; or in the words of one supervisor, they leave their shift “tired, but happy and content,” knowing their work is full of purpose. makunda hospital leaders constantly reinforce the culture of commitment by challenging the predominantly christian staff — all makunda’s professional staff are christians — to live by biblical principles of service (such as “walking the second mile”). the hospital’s efforts to develop the school system have also helped to retain young professionals with families who might have left sooner but now have viable local educational opportunities available for their children. transferability of the makunda model there are some factors that may limit the transferability of this model to other hospitals in low-resource settings: 1. makunda hospital’s ability to use scale to reduce costs is possible because of its high volume of patients. the hospital is located in a remote area which is moderately populated with little competition for the services offered by the hospital. hospitals facing intense competition or situated in less-populated areas may not be able to achieve the same advantages of volume. 2. hyper-tailored charity only works if a mix of incomes exists in the region so that the wealthier subset of patients who pay their bills fully can subsidize those who cannot. hospitals located in places where everyone is poor may not be able to use this internal crosssubsidy model. despite these potential limitations, we believe that mission hospitals can successfully adopt elements of the model — including some of the poor-centric strategies and thoughtful cost management techniques — to expand access to much-needed healthcare services throughout the world. conclusion many of the principles identified above can be used by mission-focused healthcare providers in low-resources settings around the world. for example, hospitals can drive volume by utilizing poor-centric strategies such as setting prices according to ability to pay, creating equal services for all patients, tailoring charity according to observable indicators of true need, and engaging with the community to overcome cultural barriers to usage. they can also reduce costs (thus enhancing their ability to lower prices and virtuously drive up volumes even further) by creating customized “revised gold standards” and decrease labor costs by providing a work environment conducive to training and a strong commitment to service. factors such as low population density and the presence of closely situated competition may limit the transferability of this model. the absence of a variation in income levels of patients will also not permit internal cross-subsidy. additional research and study are needed to understand how much these factors play a role in makunda hospital’s success and how well the model can be transferred to other settings. nonetheless, we believe that this study illuminates several extremely promising and innovative approaches to providing high-quality, accessible care in low-resource settings that can be applied elsewhere. we invite others to engage in additional research and study to substantiate and refine the claims made in this paper. indeed, some of the general principles warrant further evaluation in the context of discussions about healthcare costs around the world. in conclusion, we believe that the “makunda model” developed by drs vijay and ann offers encouragement for those seeking to provide high-quality, accessible healthcare in lowresource settings across the world. 49 flint, ismavel, miriam june 2020. christian journal for global health 7(2) references 1. makunda christian leprosy and general hospital [internet]. available from: http://www.makunda.in/ 2. emmanuel hospital association. hospital location map. makunda christian hospital [internet]. available 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inpatient stays in rural hospitals, 2007. statistical brief #85 healthcare cost and utilization project [internet]. agency for healthcare research and quality. 2010 january. available from: https://www.hcupus.ahrq.gov/reports/statbriefs/sb85.pdf 9. us census bureau. analysis of american hospital association annual survey data, 2014, for community hospitals. us census bureau: national and state population estimates [internet]. 2014 july 1. available from: http://www.census.gov/popest/data/national/asrh/2 014/index.html. 10. ellison a. average hospital expenses per inpatient day across 50 states. becker’s hospital cfo report [internet]. 2019 january 4. available from: https://www.beckershospitalreview.com/finance/a verage-hospital-expenses-per-inpatient-day-across50-states.html . 11. national accreditation board for hospitals & healthcare providers [internet]. available from: https://www.nabh.co/. 12. based on annual health survey fact sheets and kolkata missions — november 2016.pptx. other hospitals in the area may have contributed to this improvement, including karimganj civil hospital, which had 2,333 deliveries in 2016; and silchar medical college, which had 10,236 deliveries in 2016 (see www.smcassam.gov.in for more recent statistics). but makunda certainly played a role given its relatively high and rapidly increasing patient volumes [note]. 13. narayan r. robbing peter to pay paul. christ med j india. 1993 jan-mar;8(1): 8-9. 14. ismavel va. pneumonostomy in the surgical management of bilateral hydatid cysts of the lung. ped surgery intl.2001 feb;17(1):29-31. https://doi.org/10.1007/s003830000439 15. anand v, thomas g, zachariah n, sen s, chacko j. use of plastic material from a urine drainage bag in the staged closure of gastroschisis. j indian assoc paed surg. 1999 jan.4(1):31-3. 16. miriam a, korula g. a simple glucose insulin regimen for perioperative blood glucose control: the vellore regimen. anesth analg. 2004 sept;99(2):598-602. https://doi.org/10.1213/01.ane.0000122824.2106 5.ca 17. magotra r. public hospital and private practice. ind j med ethics. 1998;6(4). peer reviewed: submitted 29 april 2019, accepted 16 june 2020, published 29 june 2020 competing interests: none declared. acknowledgements: we acknowledge the help provided by the staff of the makunda christian leprosy and general hospital, especially dr. roshine mary koshy (medical superintendent) for all logistics and support about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 50 flint, ismavel, miriam june 2020. christian journal for global health 7(2) provided during the site visit. we thank staff of other institutions who provided time for interviews and site inspections as well as community members for their time. we also acknowledge the assistance provided to this project by alomi parikh, kerianne fernandez, and shannon ridge, all mba students at the wharton school of business who were part of this study and based in the usa. we also thank dr. stephen sammut, faculty member at the wharton school of business, for his insight and comments on the final report. correspondence: dr ann miriam, assam, india. dr.annanand@gmail.com cite this article as: flint c, ismavel va, miriam a. the makunda model: an observational study of high quality, accessible healthcare in low-resource settings. christ j global health. june 2020; 7(2):37-51. https://doi.org/10.15566/cjgh.v7i2.389 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ appendix i: makunda hospital mission statement makunda christian leprosy & general hospital aims to provide high quality medical care at costs that are affordable to the people of north-east india through development of appropriate health care models the hospital also aims to provide comprehensive services to all, irrespective of caste, religion, race or sex, with the assets at its disposal and through collaboration with other like-minded agencies to improve the social, economic and spiritual lives of our target people. the hospital further aims to create and sustain a pool of trained manpower and inculcate in them the values of christian service as exemplified by the life of our lord jesus christ. appendix ii: interview list of makunda hospital staff serial number designation 1 ceo / pediatric surgeon 2 anesthesiologist, correspondent (training programs) 3 medical superintendent, physician 4 deputy medical superintendent, pediatrician 5 psychiatrist 6 resident – md (global health) from netherlands 7 vice-principal – nursing school 8 principal – community college 9 nursing superintendent 10 nursing school tutor about:blank about:blank about:blank 51 flint, ismavel, miriam june 2020. christian journal for global health 7(2) 11 principal – higher secondary school 12 school teacher 13 school teacher 14 civil engineer 15 biodiversity project staff (ex-student of school) 16 hospital manager appendix iii: sample survey questions initial list 1. what is your role at makunda hospital? 2. what are some of makunda hospital’s strengths? 3. what are some of makunda hospital’s weaknesses? 4. what are some of the challenges you have seen at makunda hospital? 5. what are some of the major changes you have seen in the hospital and in the community during your time here? 6. what is unique about the makunda model versus other hospitals? 7. do you see any challenges with transferring the makunda model to other hospitals? additional probing questions 1. what are some ways that you have seen makunda hospital cater to poor patients? a. how do makunda hospital employees identify those who need financial help? 2. how does makunda hospital keep costs down for patients? a. what are some examples of the “revised gold standard” practices you have seen at makunda hospital? b. how does makunda hospital attract and retain quality employees? original article nov 2014. christian journal for global health, 1(2):42-47. surgical work in medical missions: a study in remote areas of india jesudian gnanaraj a and michael rhodes b a mbbs, ms, mch (urology), fics, fiages, farsi (rural surgery), director of medical services, surgical services initiative, association of rural surgeons of india, seesha and karunya university b ma(cantab),bmbch(oxon),md,frcs, associate professor in surgery, university of east anglia, uea and chairman, surgical services initiative abstract the ministry of the lord jesus christ consisted of preaching, teaching, and healing the sick. medical work has been part of christian missions for over a century. in india, it has varied from simple nurse run clinics to state-of-the-art medical colleges like the christian medical college, vellore. most medical work in remote rural areas has been limited to primary care. we look at the surgical work in remote mission fields to find out how it has affected mission work over the last three decades as compared to pure medical work in mission fields. in theory, surgical work on the mission field should contribute to the development of the mission and the local church. the surgical services initiative (ssi) helps a team of national and international surgeons provide cost–effective surgical care to the poor and the marginalized and an excellent opportunity to teach and to train local surgeons and doctors. the initiative has partnered with many missions like friends missionary prayer band (fmpb), operation mobilization (om), gospel for asia (gfa), and many local churches and organizations. ssi has helped to gain access to various villages where christian missions were previously not allowed entry thus facilitating their missionary work. introduction in the early eighties, when the first author was a medical student at the christian medical college in vellore, almost all missionaries who came to the hospital expressed concern about the medical needs in remote areas of the country where they were working. a survey carried out by a team of medical students and missionaries in the dangs district of gujarat showed an infant mortality rate of over 300 per 1000 [n= 200]. as many as eight villages or hamlets had the entire population die of diarrhoeal disease in the year 1980. 1 on that 1 st mission in 1980, a patient came to the clinic critically ill with a perforated duodenal ulcer. his perforation sealed spontaneously which was an answer to prayer as there were no facilities for major surgery or intensive care in the camp. he remained alive and well for many years. the patient had been very antichristian, but through his recovery at the hands of christian missionaries, several churches were planted and grew along the direct route to baenskatri in dangs district, an area previously closed to christians. 43 gnanaraj & rhodes nov 2014. christian journal for global health, 1(2):42-47. the first author joined the fmpb at that time, when medical interventions like immunization and oral rehydration therapy were considered a high priority along with health education. implementation was made much easier when the local population realized that the author could also perform surgical procedures. in 1980, the fmpb was spending about 22% of their entire income for medical work. 2 this was enough to support 40 full time missionaries, and it was in this context that the ssi was started in the year 2000. having observed the impact of adding surgical work to medical missions in the 1980s in gujarat, it has been our long term aim to expand the provision of surgical services. this led to the introduction of the ssi diagnostic camp in 2000, followed by surgical camps in 2002. our hypothesis was that increasing surgical provision might help reach more remote populations and increase the impact of parallel missionary endeavour. methods the aim of the ssi was to make modern surgical treatment modalities available at an affordable cost and to use the diagnostic and surgical camps as an entry point for evangelical work. the mission or the evangelistic team chose and organized the places for diagnostic camps. often, these were places where entry to evangelists had become possible because of the medical work. the ssi team was from the mission hospital and often had volunteers who were interested in the work of missions. mission organizations like fmpb and operation mobilization were part of the ssi team. local churches organized innovative plans like the “pig for surgery plan.” in this scheme, the church donated a piglet to the family. when it matured, the family sold the pig and paid for their surgery. diagnostic camps the concept of medical camps organized by the missionaries of fmpb helped them enter new areas in gujarat and maharastra. subsequent to the camps, 14 new churches were planted in the area (see table 1 and map 1). a survey conducted at nine churches near the chinchpada christian hospital in maharashtra on the gujarat border showed that 7 of 9 founder elders of the church heard the gospel at the hospital for the first time. 3 this survey was carried out by fmpb as part of their expansion program. the survey indicated that hearing the gospel message from the nurses was the most effective means of evangelism. fifty-three of 78 elders (from the 9 churches) who were interviewed became christians and church elders after hearing the gospel from one of the senior nurses at the hospitals. at chinchpada, the medical camps were followed by surgical camps that undertook surgical procedures at remote villages, sometimes using sunlight for surgical illumination. figure 1: diagnostic camp at a tripura village in 2000, the local churches in mizoram, tripura, nagaland, and meghalaya helped organize diagnostic camps in these ne indian states. a diagnostic camp takes all of the diagnostic facilities usually available at hospitals to remote areas. 4 this includes an entire laboratory with as many investigations as possible, including the pharmacy and gastroscopy, cystoscopy, and ultrasound examinations. local churches, social service organizations, or the villages themselves organize these diagnostic camps. in addition, organizations like the young mizo’s and operation mobilization (om) have accompanied the hospital teams to these camps. figure 1 shows a diagnostic camp at tripura. http://cdn.mdcurrent.in/wp-content/uploads/2014/01/diagnostic-camp.png 44 gnanaraj & rhodes nov 2014. christian journal for global health, 1(2):42-47. the advantages of this model are: 1. it is a cost-effective model that has worked since 2000. seventy-five percent of patients requiring surgical intervention were diagnosed for the first time during these camps. 2. it aids missionaries in generating new contacts in the isolated community. 3. volunteers were able to participate in the work. volunteers helped to organize and advertise the diagnostic camps, identify those who qualified for concessional treatment, and provide transport to where camps were being held. surgical camps the surgical camps, started in 2002, were located at nearby hospitals or health care facilities. advanced surgical procedures, endoscopic surgical procedures, and laparoscopic surgical procedures were possible with the set of mobile equipment. qualified and trained personnel were available at these hospitals. a study showed that more than half of the patients who required surgical intervention for prostate disease received the necessary treatment with this model. 5 this model also proved financially viable, and funding from external sources was necessary only for capital items. patients on an average paid only about $100 to 200 for a major surgical procedure. advantages of this model are that it is the most cost-effective way of treating many surgical conditions with donations only necessary for capital items. during the last decade, over 3500 patients were able to get modern laparoscopic and over 5000 patients endoscopic surgical treatment at nominal cost. table 2 gives the cases undertaken at surgical camps to date. in addition to providing low cost surgical care, the visiting team helped to train local doctors and upgrade facilities available at the local hospital. many rural surgeons from india and from african countries have also benefitted from training during the surgical camps. 6 research work in rural areas surgical work in rural areas is challenging. there are problems of availability, accessibility, and affordability. several research projects have been carried out to investigate these problems and their findings are also reported in this paper. results in the 1980s, fmpb organized several medical camps in the dangs district of gujarat. this helped access to new areas for evangelism. villages and headmen who were opposed to evangelistic work gave access to medical work because it was perceived as a good thing for the community. table 1 lists the places where churches were founded following the medical work. prior to the medical (surgical) work, these places were vehemently opposed to christian evangelism. table 1. places where missionaries were able to get entry only through the medical camps year place [no. of initial camps] outcome 1983 hanuvatchond [3] a church and bible translation work started 1983 jhavda [5] a new church 1983 piturpada [3] a new church 1983 halmoodi [8] church and bible translation 1983 ahwa [4] two churches 1984 unai [3] two churches 1984 songad [4] church and children’s home 1984 piplaidevi [2] a new church 1984 pipri [2] a new church 1985 waghai [4] a church and mission field 45 gnanaraj & rhodes nov 2014. christian journal for global health, 1(2):42-47. 1985 vyara church and mission field 1983-85 pipalwada [several] church, hospital and development project the success of medical and surgical work as a precursor to evangelism in the 1980s led to the formation of ssi in 2000, with surgical camps started in 2002. table 2 lists the operations undertaken to date as part of this initiative. the impact on the local churches and christian missions is documented in table 3. table 2. laparoscopic surgery at burrows memorial christian hospital and ssi camps 2002-2014 remarks type of surgery no. of surgeries performed surgical site infection cholecystectomy 855 20 cholecystostomy 78 7 cbd exploration 2 1 duodenal perforation closure 58 7 ileal perforation closure 13 1 appendectomy 248 9 drainage of appendicular abscess 23 4 adhesionolysis 160 2 diagnostic laparoscopy 382 7 hernioplasty with mesh 14 0 tubectomy 96 0 tubal recanalization 27 0 myomectomy 46 3 ovarian cystectomy 344 11 lap assisted vaginal hysterectomy 685 27 palamo procedure 66 1 ureterolithotomy 12 0 pyelolithotomy 7 1 lap assisted gj vagotomy 27 0 lap assisted anterior gj 72 2 lap assisted hemicolectomy 23 2 lap assisted nephrectomy 18 3 omental harvesting for vvf repair 4 0 lap assisted anterior resection 2 0 lap assisted ape 17 2 capd catheter placement 47 0 after 2011 sills diagnostic laparoscopy 8 0 sills appendectomy 104 0 sills cholecystectomy 2 0 lift laparoscopic cholecystectomy 4 0 sills & lift inguinal hernia repair 4 0 sills burch colposuspension 1 0 sills ovarian cystectomy 39 3 sills myomectomy 9 0 sills lavh 20 1 sills infertility package 106 5 total laparoscopic surgeries performed 3628 105 note. sills = single incision lift laparoscopic surgeries 46 gnanaraj & rhodes nov 2014. christian journal for global health, 1(2):42-47. table 3. links between ssi surgical camps and local missionary work 2002-2014 state places of surgical camps diagnostic camps organizers impact mizoram aizawl, kolasib, champhai, lunglei, lawngtlai, saiha, kawnpuii, mamit, seiling, darlawn, serchip, vairengte, bairabi, young mizos’ association [ktp], churches, mission hospitals, the church helped many poor to get elective surgeries. the contributions of the church increased by 20% nagaland bethel hospital kohima mokokchung and villages near burma border bethel hospital many volunteers joined the churches. one new church in burma was formed. tripura agartala ambassa, balicherra, bishamganj, chakmaghat, dharamnagar, dhalai, gandhacherra, jampuii hills, kamalasagar, teliamura, gospel for asia, private churches, catholic churches, mizo churches 83 new churches in the gfa area where patients came for diagnostic camps and 22 new churches where om team camped after diagnostic camps, 40% increase in membership of catholic churches from 2002 to 2009 manipur sielmat and leshiphung hospital ukhrul churachandpur the local hospital and bfw contacts in 3 new villages research surveys of the rural population showed that 92% of the patients came for surgical procedures after hearing from other patients. 7 most of them would not be willing to travel more than 5 kilometers for outpatient clinics while they were willing to travel any distance for elective surgical procedures. most could afford to pay about 5000 to 10000 rupees for surgical procedures ($100 to $200). minimally invasive surgery is more relevant to the rural population as many of the patients are the breadwinners for the family and absence from work needs to be kept to a minimum. research on gasless or lift laparoscopic surgery helped us to make laparoscopic surgery available to the rural patients at a fraction of the cost of regular laparoscopic surgery. 8,9 low cost monitoring systems developed by the staff and students of karunya university have made these affordable to many rural hospitals and helped properly monitor postoperative patients. 10 discussion surveys of medical missions all over the world have shown that most missions are in remote areas. many missionary organizations in india have primary medical care as part of their mission. our observation was that the involvement of surgical staff made both primary medical care and missionary work easier. it was more cost-effective for mission hospitals to conduct medical and diagnostic camps than for a missionary organization to do it on their own. during the study period (2002 to 2014), missions like fmpb and iem had doctors working in the mission fields, and their work contributed to development of many new churches in both gujarat and the states of ne india. modern surgical methods, like laparoscopic surgery, attracted patients from villages and helped the entry of the missionaries to villages that were otherwise not willing to let them in. the surgical services initiative, in addition to helping poor and marginalized patients, helped to train junior doctors and facilitated specialists in offering their services and teaching skills. high quality surgical work in remote areas is a financially viable solution. between 2002 and 2014, no specific funding has been available for such work; however, donations were obtained for capital items for the mission hospital, but all other expenses for the camps were met from income arising from the camps. 47 gnanaraj & rhodes nov 2014. christian journal for global health, 1(2):42-47. references 1. gnanaraj j. report of the mission field visit and proposal for starting medical mission fmpb. fmpb executive committee presentation. april 1981. 2. araikooval. the magazine of friends missionary prayer band. 1980. 3. annual report of chinchpada christian hospital, 1992. 4. gnanaraj j, jason lxx, khiangte h. high quality surgical care at low cost: the diagnostic camp model of burrows memorial christian hospital. indian j surg. 2007dec;69(6):243-7. http://dx.doi.org/10.1007/s12262-007-0034-0 5. gnanaraj j, gnanaraj l. transurethral electrovaporisation of prostate. a boon to the rural surgeon. anz j surg. 2007 aug;77(8):708. 6. gnanaraj j. laparoscopic surgeries in rural areas: challenges and adaptations: an experience of over 1300 laparoscopic surgeries. anz j surg. 2007; 77(9): 799-800. 7. gnanaraj j. what do rural surgical patients say? analysis of 1000 patient satisfaction surveys. rural surgery. 2006 jan;2(1):4-5. 8. gnanaraj j. gasless lift laparoscopic surgeries. rural surgery. 2013 jan;8(4):17-9. 9. sailo l, gnanaraj j. single incision gasless laparoscopic surgeries and other low cost minimally invasive techniques for evaluation of infertility in rural areas. int j infert fetal med. jan-apr 2014;5(1):413-4. 10. sheela i, rajasekaran k, gnanaraj j. wearable vital signs monitoring system. rural surgery. june 2011;7(3):22-3. peer reviewed competing interests: none declared. correspondence: jesudian gnanaraj. seesha karunya community hospital, karunyanagar, coimbatore, india 641114 jgnanaraj@gmail.com cite this article as: gnanaraj j and m. rhodes. surgical work in medical missions: study in remote areas of india. christian journal for global health (november 2014), 1(2):42-47. http://dx.doi.org/10.15566/cjgh.v1i2.33 © gnanaraj j and m rhodes. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.1007/s12262-007-0034-0 mailto:jgnanaraj@gmail.com http://dx.doi.org/10.15566/cjgh.v1i2.33 http://creativecommons.org/licenses/by/3.0/ review article june 2020. christian journal for global health 7(2) health systems strengthening through the faith-based sector: critical analysis of facilitators and inhibitors of nationalization of mission hospitals in india perry jansena a md, mph, dtmh, vice president-teaching hospital network, african mission healthcare abstract introduction: the extensive network of christian mission hospitals in india faced an abrupt loss of financing and supply of medical missionaries during and after independence in 1947. many of the remaining went on to become indigenously owned christian hospitals and prestigious medical colleges that maintained the heart for the poor and for spiritual care that was inspired by their founders. the aim of this critical analysis is to explore the literature to understand what helped these hospitals survive when others failed and lessons that can be learned to help direct future investment and programs for health systems strengthening. methods: a literature review was conducted utilizing pubmed and google scholar and combinations of keywords (mission, hospital, india, independence, indigenization, sustainability, history, health system). the initial list of 785 articles was filtered down to 28 that specifically address the research questions. excerpts from these articles were annotated, coded, and evaluated for core themes. results: the following core themes arose as factors that contributed to their success: 1) shared mission, vision, and core values, 2) early emphasis on medical education, especially for women, 3) local champions, patrons, and governance, 4) strong community linkages, 5) strategic collaborations, and 6) healthy systems and infrastructure. recommendations: most international investment in health systems strengthening has focused on shortand medium-term health outcome goals. while these have certainly saved the lives of millions, we must also consider what will be required to foster healthy healthcare systems. long-term investment in building committed healthcare leaders and healthy institutions is challenging, but necessary, to meet longterm health goals. faith-based hospitals are key allies in this endeavor. key words: india, mission hospital, indigenization, nationalization, sustainability, christian. 105 jansen june 2020. christian journal for global health 7(2) introduction since the time of christ and the nascent christian church, healing has been at the core of the christian faith. since the early church, christians have repeatedly led the way, responding to the needs of the sick during the great plagues that ravaged the globe, often sacrificing their lives in the process.1,2 most early hospitals and medical schools in the west were started by christian churches, both catholic and protestant, with the earliest arising from within catholic monasteries.3 early missionary efforts to foreign lands did not consider formal medical work to be critical to their mission, as medicine prior to the mid-19th century had very little to offer.4 “medical missions” as a strategic approach to evangelism was likely first represented by the medical missionary society in china in 1838. its most famous representative, dr. peter parker (1804-1888), led the movement of christianity into inland china, capitalizing on his ability to use medicine to bring healing.5 in india, the east india company (eic) was a british joint-stock company founded in the 1600s to strengthen and control trade in the indian ocean region. in the early 1800s, eic controlled most of the trade in the indian subcontinent. eic’s exploitation of basic commodity markets for silk, cotton, indigo, spices, and even opium became critical to the growth of the british empire.6 merchants were wary of including religious propagation in their agenda, fearing reprisals that would impact their trade activities. it wasn’t until the early 1800s that the british parliament enacted laws that would support missionary activities in india. the years that followed marked the beginning of what has been termed the great century of missions as christian churches and organizations in europe and the united states increased their evangelistic efforts among the “heathen” tribes being encountered in expanding empires. colonial india was central to british missionary strategy, and, by the middle of the 19th century, one quarter of all protestant missionaries were in india.7 the explosion of scientific and medical knowledge and public health in the mid-19th century impacted the birth of what we call “modern medicine” and added an effective “instrument” to the expansion of the christian missionary movement of that era.8 during this period, the growing number of mission hospitals in india provided a significant proportion of health services and were generally located in rural communities serving the poor. by 1905, there were 280 medical missionaries in india, many being women.6 because of muslim and hindu prohibitions of physical contact between male physicians and female patients, female doctors and nurses were able to have greater impact than their male counterparts. early work training physicians and nurses further increased the impact of mission hospitals within communities as they generated additional health providers. as a result, by the time of independence, a number of healthcare leaders, including the minister of health and the governor of west bengal province, were female physicians trained at mission hospitals.9 through much of india, nursing was considered a lowly profession suited only for untouchables. christian nursing education promoted the status of nurses to an honorable profession. until just before wwii, 90% of nurses in india were christian, and 80% were trained in christian nursing schools.10 core to medical missionary motivation was service to the poor and outcast. because of india’s pervasive “caste system,” missionary efforts were therefore also directed at lower caste indians. it was this group that most enthusiastically embraced not only the message of christianity, but also western cultural values and philosophies. under british imperial rule, this christianization (most evident in the south) represented a degree of liberation from the restrictions of the caste system that was more appealing for lower caste indians than higher caste communities. by the end of the nineteenth century, 106 jansen june 2020. christian journal for global health 7(2) 95% of christians in southern india came from the lowly nadar caste.11 the admixture of christian mission and colonialization left a mixed legacy.12 in many settings, western missionaries emulated the prevailing colonial models and had full control of indian churches and hospitals. the most effective missionaries were those who mastered the local language and culture and lived humbly among the common people.13 many committed themselves to developing local leaders and supported aspirations of decolonization. indeed, indian christians also played key roles in supporting independence leaders and movements.6,10 in the decade following indian independence from great britain (1947), the indian government became less and less tolerant of western christian missionaries, considering them to be guilty of cultural aggression.14 a committee of the government declared that “evangelization in india appears to be part of a uniform world policy to revive christendom, to re-establish western supremacy and is not prompted by spiritual motives”. this led to greater restrictions on western missionaries and relationships between indian churches and their western counterparts. because of inadequate investment by western mission agencies in developing local buy-in and building local leadership, many of the hospitals that missionaries planted failed when support from the u.s. or britain failed, and western missionaries were expelled following independence.15,16 although precise numbers are not well documented, a number of these mission hospitals survived, and some have grown to become influential medical centers and training centers while maintaining their spiritual roots and commitment to serving the healthcare needs of the poor.17 in areas where mission hospitals were planted, but later closed, improved health outcomes, when compared to similar areas without western missionary involvement, can be documented even decades later.18 the years that followed independence saw rapid expansion of private indian hospitals that have increasingly improved the quality of their services. many of these hospitals provide world-class services at a fraction of the cost in western countries.23 as a result, india has become a destination for “medical tourism” as patients come to india for advanced medical services that would not be affordable in their home countries. these private hospital systems were designed to meet the needs of the growing indian middle class, leaving the public sector to care for the needs of the poor. this process of privatization has undermined resources that would have been available for the public sector which has therefore further restricted access to quality healthcare for the poor.24 developing high quality health services has taken significant investment in infrastructure, and the pressure to have a return on this investment has resulted in “profit-oriented,” rather than “mission oriented,” strategies.19 specific aims the aim of this critical analysis project is to assess the factors that facilitated the emergence of these nationally led christian hospitals at a time when most others failed. this analysis was guided by the following questions: 1. what are themes that emerged from the literature? 2. in what ways did “organizational culture” or “foundational principles” contribute to maintaining a commitment to spiritual care and service of the poor? 3. what other historical, cultural, or strategic factors may have contributed to the longevity of these hospitals? 4. from this body of work, what recommendations can be made regarding strengthening faith-based health care systems? . 107 jansen june 2020. christian journal for global health 7(2) methods an initial literature search was conducted using pubmed, google scholar, and scopus. search terms included india, mission, hospital, indigenization, nationalization, and sustainability. the search produced 785 articles that were reviewed for relevance. the world council of churches, the christian medical association of india, and the emmanuel hospital association were consulted for relevant articles, some of which were cited above, but not available online. as each article was reviewed, additional publications were identified through citations and added to the list for review. the list was narrowed to those contributing to the research questions. two lengthy publications were used for historical background only, and 28 were included for in-depth analysis. some of the publications referred broadly to medical missions, but emphasized those that were focused specifically on india. only four of these publications could be described as “studies” that applied systematic evaluations. there were three academic papers that covered history, as well as pertinent organizational principles. the majority of the papers were historical in nature, but also contained useful information about key characteristics of some of the major medical institutions as they were founded and during the transition to indian independence. case studies and biographies of early missionaries also shed light in these areas. the remainder could best be described as opinion pieces about what is needed in medical mission. a database matrix was developed to capture key quotations and summaries that addressed the research questions extracted from the articles. review of each publication included annotations that addressed the research questions. after review of these annotations, an initial list of topical areas from the research questions was expanded as recurring themes emerged. each excerpt was then coded from this list. the coded excerpts were recorded in excel where they could be grouped and sorted. many excerpts addressed multiple areas and were included in each code area. each topical area was viewed as a group to determine specific overall themes emerging from the stories (see table 1). table 1. themes 1 creation and transmission of shared mission, vision, and core values 2 business models that maintained emphasis on serving the poor 3 early emphasis on formal medical education, especially for women 4 fostering local ownership — champions and governance 5 mentoring local leaders 6 strong relationship with and sensitivity to the community 7 strategic collaborations 8 healthy systems and infrastructure results: themes creation and transmission of shared mission, vision, and core values evaluations of failing mission hospitals in india clearly demonstrated a linkage with poorly defined goals and objectives, and a lack of planning, organization, and coordination.16 by contrast, at successful hospitals, staff at every level were more likely to know the history and mission of the hospital and took seriously the spiritual nature of each person (made in the image of god) and their responsibility to show christ’s love in action.20 most of these hospitals had their mission statements clearly visible to staff and visitors and could state them when asked. it was observed that “persons with such a high level of awareness of their institutional mission showed greater tendency to work toward the accomplishment of that mission.”21 108 jansen june 2020. christian journal for global health 7(2) an important distinctive of effective mission hospitals was a strong linkage to biblical mandates for justice and service of vulnerable groups (the poor, widows, orphans, homeless). hospitals with pervasive awareness of the institution’s mission were also characterized by interdepartmental coordination, symmetric and systematic growth, and highly strategic use of limited resources. it is clear from biographies of the missionary founders of these successful hospitals that these values were evident from the inception of the ministry and were passed on not just through formal documents and administrative systems, but through modeling of sacrificial service to the poor, accompanied by great “thrift” and an entrepreneurial spirit that became, as it were, part of the dna of the institution.22 many missionaries were influenced by, and significantly contributed to the shifts of, the thinking that preceded and eventually led to india’s independence.10 following independence, missionaries used their relationships and influence to hold accountable rich landowners who had exploited the poor.14 there were cases when missionaries paid from their own resources the debts that poor people owed to oppressive landowners, further prompting conversions to christianity.6 business models that improved sustainability but maintained service to the poor as the financial support and volunteer missionary workforce decreased around the time of, and just after independence, mission hospitals had to find new ways to make their work sustainable. many mission hospitals started “private wards,” offering a higher level of privacy and service as a mechanism for generating resources to fund service to the poor. the added benefit was that women of higher caste could finally access services (often from women providers) that met their need for healthcare.error! bookmark not defined. as modern secular hospitals with high quality services expanded, their focus was generally on offering high quality care through a fee-for-service model. indeed, many of india’s hospitals could be ranked with the best hospitals in the world, with quality care at a fraction of the cost of equivalent care in the west.23 however, the business model of private hospitals focused their services on wealthy indians and the growing middle class, leaving the poor to continue to rely on under-resourced public hospitals and mission hospitals. some mission hospitals followed suit by increasing their focus on fee-for-service care to improve hospital sustainability. james mcgilvray, the first director of the christian medical commission (1968), observed that, “hospital staff who, conscious that their christian vocation directed them to serve the poor, were now forced to cater to the rich in order to do so and even that on a decreasing scale.”16 while privatization of healthcare throughout india widened the disparity between the rich and the poor, mission hospitals that had a strong and shared commitment to serving the poor were able to find a better balance between equity and sustainability, though not without tension.24 in his piece on the future of christian health services, dr. steffen flessa concluded that: . . . reliable health care services, where the dignity of human beings is respected under all conditions, are not a luxury, but a resource of unconditional reliability. christian healthcare services have the unique calling to make this respect and love perceivable, irrespective of their clients’ success or failure in life, or their ability to pay.5 early emphasis on formal medical education, especially for women traditional social constructs in india during the early colonial period deepened the disparity and access to health services for women because they were not permitted to see male providers. early female missionaries, like ida scudder, were 109 jansen june 2020. christian journal for global health 7(2) compelled to improve the plight of indian women and were able to overcome these barriers as women providers. many of the first medical schools, and essentially all of the nursing schools, were womenonly. the female graduates from these early medical schools rapidly proved themselves to be some of the best doctors in the country.26 not only were they offering excellent education and patient care, but because of their history and value system, they maintained a commitment to serving the poor.25 these new institutions dedicated to educating and serving women were a new entity for maledominated, foreign missionary agencies. as a result, they were able to operate with greater autonomy than other missionary endeavors.22 likewise, because the target beneficiaries of these hospitals were poor women, the colonial state powers did not consider them to be competition, further allowing freedom for growth.22 the formation of medical colleges became one of the most salient contributions of medical missions. not only did it improve access to medical services for indian women (by female providers), it also produced some of the most influential early indian leaders for healthcare, many of them women. this women empowerment was evident as india gained independence in 1947; a woman was appointed minister of health and another governor of west bengal province.11 fostering local ownership-champions, patrons, governance missionary women recognized the importance of establishing good relationships with local elites. these settings had complicated issues of gender, caste, and religion that missionaries had to navigate. the initial task was to develop credibility within the community, as well as established leadership structures. because they removed some of the gender barriers to receiving care (i.e., prohibitions about seeing a male physician), women missionaries had close relationships with influential families. many of these became local patrons and champions who not only supported hospitals financially but advocated for these institutions during the push for independence. influential, reform-minded indian men became generous philanthropists, enabling the founding of many schools and hospitals. in 1927, mahatma gandhi himself visited one of the more prominent of these hospitals, cmc vellore (see case study) and encouraged the leaders of the hospital to continue their faithful service to the poor.11 compared to africa, india was more successful at replacing foreign missionaries with nationals in hospital care and leadership.27 reviews of missionary endeavors in india do include many settings where missionaries and mission agencies were the ones to make all important decisions. it was not that there were no qualified indian leaders available, but there was a reticence to relinquish control.6 most of the important leadership decisions in these early hospitals were made by home mission offices, by leadership that was almost exclusively male and exclusively western. the hospitals that valued local input and empowered national leaders as they emerged were more successful when the forced transition took place during the process of independence. as it became more difficult to send medical missionaries and it became more expensive to support growing mission hospitals, western missionary agencies began handing over mission hospitals to local church leadership. this was often couched in the prevailing rhetoric of “selfgoverning, self-supporting, and self-propagating churches” or “partnership in mission.”16 the end result was a handover to national leadership that rarely had individuals with the training and experience required to run a hospital and were not able to attract the growing number of qualified indian health professionals, and many of these institutions deteriorated and eventually closed.19 by contrast, some of the enduring mission hospitals were able to maintain western missionary engagement because of their strong relationships with local leadership and their balanced approach to empowering national ownership. some institutions, 110 jansen june 2020. christian journal for global health 7(2) like christian medical college-vellore, transitioned to national leadership with years of mentorship and empowerment from the founder.12 institutions that were successful at transitioning from foreign-led mission hospitals to successful christian hospitals were those that prioritized the development of indigenous leadership from the time of their founding. intentional investment by medical missionaries in building technical skills was accompanied by modeling integrity and sacrificial service to the poor. the indian leaders that emerged from these hospitals were the very ones who led them after independence and helped to form some of the key national organizations that guide christian healthcare today. the emmanuel hospital association (eha) is a collaboration of 20 community hospitals, many of which were founded as mission hospitals, and is one of the largest non-profit providers of health services in north india.28 the christian medical association of india, the catholic medical association of india, and the seventh day adventist health system of india collectively play a very significant role in provision of care, as well as national healthcare leadership. a study commissioned jointly by the world council of churches and the christian medical commission in the late 1990s described the importance of a qualified and empowered local governance body to the long-term sustainability of church hospitals.20 a healthy board was one where its members were selected through a transparent and inclusive consultative process based upon their qualifications. it was also a board that had a healthy interface with the executive leadership and demonstrated an understanding of distinction between governance and management roles. these institutions also demonstrated a strong understanding of the distinction between leader (ceo) and manager (coo). developing strong relationships with and sensitivity to the community the earliest mission hospitals in india were initially birthed out of programs to meet the urgent needs of the communities identified for evangelical witness. most early missionaries lived many years within the very communities they served. they experienced first-hand the struggles that the local population had in every aspect of life. they had to develop practical alternatives to western medical techniques that were best suited to the local context and to limited resources.22 these programs were initiated in the context of very little existing information in terms of what we now refer to as “best-practices.” they developed organically and were customized to the unique needs, and often very limited resources, of the community. during the 1950s to the 1970s, churches and mission agencies were re-evaluating the role that mission hospitals played in their overall strategy. many concluded that the season of, and need for, mission hospitals had passed.29 in may of 1964, leaders of protestant mission societies called a meeting in tübingen, germany to discuss the role of healthcare ministry in the overall work of the church and missions.30 this meeting, now called tübingen i, was followed by a second meeting, tübingen ii, and a document called “the healing church.” these meetings and this document played a vital role in shaping the world health organization’s move toward primary healthcare and the alma ata declaration of 1978.31 two physicians who had served as medical missionaries in india, dr. james mcgilvray (christian medical college vellore and first director of christian medical commission) and dr. carl taylor (christian medical college ludhiana and unicef), made significant contributions toward drafting this landmark declaration.32,33 111 jansen june 2020. christian journal for global health 7(2) creating strategic collaborations in 1902, as missionary efforts were opening up in india, the conference of missionaries met in madras, india and drafted a resolution intended to avoid conflict and duplication. this resolution stated that mission communities were “prohibited from engaging in gospel works outside of their prescribed territories.”6 after wwii and indian independence, foreign missionary staff and funding diminished significantly. these “lean times” had a positive impact as it fostered increased interdenominational collaboration and a “teamwork” approach to foreign mission.22 it also set the stage for the formation of indigenous networks of health facilities. the largest of these networks are the catholic health association of india, the christian medical association of india, the emmanuel hospital association, and the seventh day adventist hospitals.34 in addition to mission hospitals, protestant missionary social activism became a foundation for indian civil society organizations. a number of “mission-spurred” organizations became critical players in shaping non-governmental organizations.14 as an indirect outgrowth of earlier work, ngos became increasingly important players in governmental programs for health and development. some health programs and public health service outlets are fully managed now by ngos.29,17 these organizational collaborations predated most current international and regional organizations and were also very organic and related to the context and relationships that existed at the time. developing healthy systems and infrastructure early missionaries generally started out their healthcare work with only the resources that they had shipped with them. they offered healthcare services in people’s homes or in small shacks that served as clinics. many did regular mobile outreach work, often with just a donkey cart.12 they utilized connections with churches and individual philanthropists in their home country to raise considerable resources to, bit by bit, grow these small clinics into hospitals and then medical and nursing schools. on limited resources, they had to establish water, power, wards, operating theaters, sterilization facilities, and housing. many of these hospitals became like small cities as they attracted staff who lived nearby and other residents who valued living close to such resources.22 the wcc/cmc study mentioned earlier identified a well-designed and well-equipped facility with limited or no debt contributing significantly to the sustainability of hospitals as they underwent nationalization.20 the development of strong financial and management systems also helped hospitals thrive. christian medical college of vellore has not only trained some of the country’s best doctors; it has also developed strong, locallyrelevant, management strategies, and even taken over the management of struggling mission hospitals and turned them around.35 hospitals with highly functioning boards and executive leadership also tended to be more strategic in their decisions and had business strategies that protected them against dependence on donor support.20 an illustrative example: ida scudder and the christian medical college, vellore dr. ida scudder was born into a family of missionaries in india. her father was a doctor and pastor and her grandfather, john scudder, was one of the first medical missionaries to india. despite her heritage, ida had not planned on being a missionary or a doctor when she grew up. her desire was to live in her home country, the united states, and enjoy all of the things that she’d missed out on while growing up in rural india. that was, until the “three knocks in the night.” she had been at home studying by lantern when she had three separate visits from men 112 jansen june 2020. christian journal for global health 7(2) in her village asking her to help their wives who were having complications with labor in their homes. she was just a girl and not medically trained so refused their requests, saying that she would get her father to help. each time that offer was refused because it was unspeakable in their culture to allow a man to attend a delivery. each of these women eventually died in labor. this event so impacted her that she was determined to become a physician and return to this community to serve the women who had been neglected. she did return to this rural village after her training and attracted other women health providers to be a part of her team. she started with a small, rustic clinic building and used a donkey cart to do her outreach clinics into surrounding communities. recognizing the plight of women at that time in indian history, and the lack of female providers to provide culturally-appropriate care, she set out to start the first all-women’s medical college. with no money, no buildings, and no staff, she was able to mobilize resources to make this dream a reality. christian medical college of vellore grew in numbers and in reputation. in 1922, her first graduating class of fourteen received the highest scores in the country and the madras presidency prize, competing against men from six other medical schools. mahatma gandhi made a special visit to vellore in 1927 to honor them for the work they had been doing for the poor. the hospital trained women who would go on to hold very influential positions in government and academia. cmc-vellore opened up to male students as the government increased their requirements for numbers of staff, students, and patient beds for teaching hospitals. as india gained its independence in 1947, dr. hilda lazarus took over the leadership of the hospital and the medical schools. dr. ida scudder’s early commitment to raising the standards of education and health care for women set an example that many others would follow. her heart of compassion for the poor and for her community is still felt in the continued commitment to serving the poor at vellore today. perhaps as much as any other founder missionary, dr. scudder successfully passed along her vision, mission, and values through her unswerving and humble leadership. her early commitment to developing strong leaders, especially women, significantly contributed to her success and to the growth of vellore. medical education was central to her strategy and many others followed. her entrepreneurial spirit and boldness in taking on seemingly impossible tasks allowed her to build an infrastructure that others could build upon. it also helped her respond to changing times and work collaboratively with others. discussion while the paucity of rigorous research in the area of nationalization of mission hospitals makes the conclusions from this analysis less generalizable, it points to the importance of documentation of all experiences in frontier areas, like sustainable healthcare for the poor. learning from past failures is even more challenging when there is no one left to tell the story, or when we don’t really want the story to be told. this study only scratches the surface in understanding the contributions of individuals, especially early national leaders, whose lives were dedicated to serving the healthcare needs of india. it is a cursory view of the complex historical, cultural, and social factors that impacted india’s journey to where it is today. it will hopefully serve as a call for the global health and medical mission community to tell stories, document failures as well as successes, and remain committed to a culture of learning and growing. the transition from the millennium development goals to the sustainable development goals signals a growing understanding that population health is intricately connected to factors outside the health system. poverty, gender inequality, poor stewardship of water and land, and unequal access to education and markets all 113 jansen june 2020. christian journal for global health 7(2) contribute to population health. an integrated, multi-sectoral, systems-based approach to health systems strengthening helps us identify tools that could possibly be employed to address the deep health disparities that our globe faces today. yet, it is not enough. we must also reflect on the past and recognize the role that compassion, ingenuity, courage, and faith have played in the development of our current knowledge and practices. faith-based hospitals and health programs still provide a significant proportion of healthcare to the poor, and they will continue to play a vital role in meeting the remaining gaps in development and health. quality, equity, and sustainability are all important features in a “healthy” healthcare system. however, in developing countries, it is difficult to impact one of these positively without negatively impacting one or both others. for example, generous external funding for programs addressing specific health outcomes (like hiv mortality) can enable significant improvements in the quality of services offered (free antiretroviral therapy), even to the poor. however, these programs would rapidly collapse if the funding waned because they are not locally sustainable. india has world-class hospitals that can compete with any hospital in the “developed world” and even turn a profit (high quality and sustainability), but these services are not accessible to the poor (low sustainability). what we often see in public sector hospitals in low-income countries is “poor quality care for all.” in many countries, the healthcare system is so fractured that even the wealthy cannot find quality care. the wealthiest are medically evacuated to nearby countries for advanced care, and they take their healthcare dollars with them. while this is arguably “sustainable,” it is hard to argue that it is “equitable” and impossible to argue that it represents “quality.” it is clear from this analysis that investment in missionary mentoring of national leadership had a significant impact on the long-term sustainability of mission hospitals in india. it is also clear that the prioritization of building leaders was really an expression of the values of some early missionaries who resisted the colonial model of top-down authoritative leadership. instead, they adopted a servant leadership that went beyond the mere transmission of knowledge and skills to naturally emphasize modeling and discipleship. this attitude also impacted their willingness to relinquish leadership and decision-making authority to those in whom they had invested. much of the credit for the successful transitions in leadership must go to the capable and committed indian nationals who stepped into these leadership roles. their individual stories were not emphasized in this analysis, but often included backgrounds of tremendous hardship that was met with opportunities for education and social advancement. the true leaders were those who then translated that opportunity into grateful service for others. this represented a true reflection of their mentors, as well as their new-found faith. a commitment to developing leaders must be a core component of organizational culture if it is to be realized. a colonial mindset results in an organizational culture that does not foster local ownership or accountability. because of the cultural background of western missionary physicians and the methods that were being refined in allopathic medicine significantly shaped the nature of medical education. a critical value within medical education is free sharing of knowledge and skills from teacher to student. indian medical ethics also adopted this principle that dates back at least to the time of hippocrates. to some degree, this may have been because this principle is consistent with the teachings of hinduism.36,37 a strong emphasis on formal medical education by early medical missionaries was not only important in the sustainability of the institutions they birthed, but also had a significant impact on the progress that the country would later make in education (especially of women) and medicine. early missionaries came from protestant cultures that emphasized thrift and reason. they 114 jansen june 2020. christian journal for global health 7(2) adapted the standards of their home country to the needs and resources of their new community. they also held up standards of infrastructure, financial accountability, and organizational structure. the sustainable hospitals with sound institutional management and high standards for their hospitals, including esthetics, were able to continue operating by these standards after their expatriate founders left or died. a common sub-theme in several of the themes listed above is the role of gender. prevailing cultural prohibitions of physical contact between male providers and women patients had a very negative impact on healthcare access for women. missionary women were able to provide healthcare to all ages and genders and recognized their important role in the care of women, especially related to pregnancy. access to prenatal care and good intrapartum care improved health outcomes in women and strengthened local support for missionary work. in addition to care for women, early mission hospitals also provided advanced medical education for women. early missionary nursing schools helped break down the negative stigma associated with the nursing profession and opened up advanced education to women. early medical schools clearly demonstrated that women could compete with men in higher education, and this impacted not only the health sector but also power dynamics in general. advancement of women played an important role in assuring local support and leadership for mission hospitals. recommendations a key strategy for medical missions is to respond to historical gaps in services that exist in settings in which it works. through much of medical mission history, provision of health services to the poor was recognized as a very effective strategy for building credibility in indian communities and breaking down barriers for the growth of christianity. while the majority of india remains resistant to christianity, seeing it as an extension of western domination, poor lower caste indians saw it differently. for them, christianity represented freedom from the entrenched caste hierarchy and placed them on more equal footing with their fellow indians. they resisted “indigenization” of christianity and were eager to adopt western practices and values. in this way, missionary efforts responded to a gap in services, as well as an equity gap for lower caste indians, the poor. the growth of private medical services in india has not closed the gaps of unequal access to healthcare for the poor; if anything, it has widened the gap. in most lowand middle-income countries, health outcomes are worse for rural citizens than for urban and are worse for lower income citizens than higher. there is still a role for church hospitals, most of which are located in rural areas where the majority of the poor live, filling the gap in service of the rural poor. train healthcare leaders existing data shows that there is a direct correlation between poor health outcomes and the ratio of health providers to population. high maternal mortality (pregnancy-related deaths) in much of the world is a reflection of inequities in access to healthcare.38 the who projected that there will be a shortage of at least 12.9 million healthcare workers by 2035, and this number may be as high as 18 million by 2030.39,40 mission hospitals have always served as major training centers for nurses and physicians, and most have the capacity to increase their numbers with additional support. the past two decades have seen an increase in the number of post-graduate training programs in mission hospitals with the aim of increasing national healthcare leaders.41,42 a 20-year follow up of the pan-african academy of christian surgeons (paacs) program documented that 100% of their 67 graduate surgeons are still serving in 20 african countries with another 74 currently in training programs.43 115 jansen june 2020. christian journal for global health 7(2) in sub-saharan africa, christian hospitals may provide as much as 40% of health services. these hospitals in lowand middle-income countries represent a rich resource for expanding and improving training of physicians and other healthcare providers. training in rural, non-profit hospitals not only provides the unique set of skills required to provide cost-effective, compassionate medical care, it often comes with role models (instructors) who can model compassionate, whole person care. investing in healthcare leaders of all cadres is an important long-term component of eventually having healthy, autonomous healthcare systems. balance short-, medium-, and long-term goals for global health global investment in health programs targeted at the most pressing health problems in lowand middle-income countries (lmics) has already paid unprecedented returns. between the years 1990 and 2015, global maternal mortality dropped by 44%, and the chance of dying before the age of 5 has decreased by more than half.44,45 the global commitment to ending the hiv/aids epidemic has led to dramatic increases in the affordability of, and access to, antiretroviral therapy. a record 21.7 million people are receiving; hiv treatment and hiv-related mortality in sub-saharan africa decreased by 42%, and globally by 34%.46 despite these achievements and others, healthcare systems in many lmics remain very weak and these “vertical” programs are fully dependent upon continuous financial and technical support from abroad. there has been a movement in the who and donor community to support what has been termed a “sector-wide approach” (swap) to health systems investment. the swap directs funding to the broad priorities set by the local ministries of health and helps to balance the often “siloed” funding that focuses on a narrow set of health objectives.47 this trend has improved funding streams for broad health sector investments, as well as resources to more fully engage faith-based hospitals and coordinating bodies.48 what is still needed is intentional investment in developing the internal capacity and competent leadership of the ministry of health and leadership throughout the health sector. some have found that investing in advanced training of national professionals abroad led to difficulty in getting them to return to generally low-paying and difficult jobs in their home country. providing advanced training in-country does decrease this likelihood but some of the brightest and best are “poached” by the ngo or international sector. building cadres of well-trained healthcare leaders will require a coordinated effort and interagency cooperation. the key to retaining these staff is not “bonding” but inspiring them and supporting them in their roles in government and institutions. invest in institutional strengthening training healthcare leaders also requires significant investment in strengthening training institutions. training in a dysfunctional institution that offers poor quality care guarantees that these patterns will continue to exist. most district hospitals in lmics are run by physicians who have not even had specialty training, much less training in management or leadership. investment in disease focused, or even health systems focused, intervention should be accompanied by investment in strengthening healthcare institutions of all types. improving governance and leadership, strengthening financial and supply chain systems, improving health systems planning and public health, developing contextualized information systems and improving physical infrastructure are all long-term investments that must be made before we will truly see “healthy healthcare systems.” healthcare leaders that can transform broken healthcare systems need more than competence; they need character and commitment. the experience and modeling that takes place in rural christian hospitals provides the environment that can create competent and committed healthcare leaders. 116 jansen june 2020. christian journal for global health 7(2) capture the power of local solutions every country and every community have within them tremendous power for innovation. the poor are often the most resourceful because their very lives depend upon it. while guidance from who and other players in global health can be extremely useful in focusing resources and informing decisions, we must always create room for local solutions that capture local markets, meet local needs, and develop local livelihoods. fostering innovation through creating awards and grants for entrepreneurs, coming alongside local champions and inspiring local genius, will likely spark solutions that, as outsiders, we could never have dreamed. a new paradigm of cross-cultural, international partnerships history teaches us that an authoritarian, colonial approach to building health systems does not inspire local ownership and leadership. while it is easy to criticize the self-serving and racially biased practices of the colonial era, many practices of bilateral donors and multi-lateral agencies still practice very top-down styles of leadership. some give lip service to concepts like community empowerment, cultural humility, and mutual accountability but, when it comes to setting priorities and budgets, the “golden rule” still applies, “whoever has the gold, makes the rules.” vastly different values and worldviews can be difficult to navigate, especially when money and agendas are involved, but it is essential that the voices and minds of the “global south” are heard and included as equal partners in shaping the future of healthcare missions. whether in faith-inspired missions or international politics, neocolonialism can become the “default mode” in cross-cultural partnerships. sometimes, it takes the form of, as mary lederleitner has said, “paternalism couched as accountability” or a political agenda couched as “protection of human rights.”49 the international development community must develop habits of preserving dignity and striving for mutuality in the way that we engage in “assistance” in developing country contexts. in many ways, we who come from task-oriented, highly individualistic cultures have a lot to learn from our brothers and sisters who come from highly relational, collectivistic cultures. good relationships require an investment of time, as well as money. paul farmer describes his philosophy of “accompaniment.” to accompany someone, is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end . . . there’s an element of mystery and openness . . . i’ll share your fate for a while, and by ‘a while’ i don’t mean ‘a little while.’ accompaniment is much more often about sticking with a task until it’s deemed completed by the person or person being accompanied, rather than by the accompagnateur. 50 “if you want to go fast, go alone. if you want to go far, go together.” african proverb . references 1. devaux c. small oversights that led to the great plague of marseille (1720–1723): lessons from the past. infect genet evol. 2013;14:169-85. https://doi.org/10.1016/j.meegid.2012.11.016 2. watson w. the sisters of charity, the 1832 cholera epidemic in philadelphia and duffy's cut. u.s. cathol hist. 2009;27(4):1-16. 3. beal-preston r. the christian contribution to medicine. triple helix. spring 2000:9-14. http://admin.cmf.org.uk/pdf/helix/spr00/11history.pd f. 4. fitzgerald, r. 'clinical christianity': the emergence of medical work as a missionary strategy in colonial india. in health, medicine and the empire: new perspectives on colonial india. harrison p, editor. london: sangam books. 2001. https://doi.org/10.1016/j.meegid.2012.11.016 http://admin.cmf.org.uk/pdf/helix/spr00/11history.pdf http://admin.cmf.org.uk/pdf/helix/spr00/11history.pdf 117 jansen june 2020. christian journal for global health 7(2) 5. anderson gh. peter parker and the introduction of western medicine in china. mission studies. 2006;23(2):203-38. 6. robins n. the corporation that changed the world: how the east india company shaped the modern multinational. asian affairs. 2012;43(1):12-26. http://dx.doi.org/10.1080/03068374.2012.642512 7. samuel vc. christianity in modern india (18th century to present). divyabodhanam book series: 1986;19:1-90. available from: http://divyabodhanam.org/uploads/questions/153025 9741zweakwkf188380.pdf. 8. grundmann c. sent to heal! about the biblical roots, the history and the legacy of medical missions. christ j global health. 2014;1(1): 6-15. http://dx.doi.org/10.15566/cjgh.v1i1.16 9. benge j, benge g. ida scudder-healing bodies, touching hearts, ywam publishing, seattle, wa, 2003. [isbn:13:978-1-57658-285-10] 10. wilson dc. the legacy of ida s. scudder, intl bull mission res.1987 jan; 26-30. 11. harper sb. ironies of indigenization: some cultural repercussions of mission in south india. intl bull mission res. 1995;1(1): 13-7. available from: http://internationalbulletin.org/issues/1995-01/199501-013-harper.pdf 12. gladwin m. mission and colonialism in the high imperial phase, 1870-1914. wolfe j, zachhuber j, editors. in the oxford handbook of nineteenthcentury christian thought,1st ed. [oxford handbooks]. oxford: oxford university press london mathematical society. [ p.. 282–307]. https://doi.org/10.1093/oxfordhb/9780198718406.01 3.4. 13. woodbery r. the shadow of empire: christian missions, colonial policy, and democracy in postcolonial societies [doctoral dissertation]. chapel hill: unc. 2004. available from: https://www.researchgate.net/publication/35219503_ the_shadow_of_empire_christian_missions_colon ial_policy_and_democracy_in_postcolonial_societi es 14. zinkin t. christian missionaries under fire in india – archive, 1956 [cited 2019 feb 9] guardian. 1956 july 20. available from: https://www.theguardian.com/world/2017/jul/20/chri stian-missionaries-india-hinduism-1956. accessed 2/9/2019. 15. mcgilvray j. the quest for health and wholeness. tűbingen: german institute for medical missions. 1981. available from: https://difaem.de/fileadmin/dokumente/publikatione n/dokumente_aerztliche_mission/webthe_quest_f or_health_and_wholeness.pdf 16. booth b. sustainability of christian mission hospitals in india and nepal: impact of history. healthserve, 2002;(7). 17. aruldas v, awale a, zachariah p. sustainability of church health care in india. world council of churches and the christian medical association of india, 1997. 18. calvi r, mantovanelli f. long-term effects of access to healthcare: medical missions in colonial india. j dev econ. 2018;135:285-303. 19. phillip v. on the wings of dawn: medical mission in india today. varghese p, editor. bangalore, india: evangelical medical fellowship of india, primalogue publishing media private limited. 2015. 20. asante r. sustainability of church hospitals in developing countries: a search for criteria for success. geneva: world council of churches. 1998. 21. alexander pv, alexander ap. developing healthcare infrastructure in remote areas in response to local needs. chrismed j health res. 2014;1(1):40-4. http://dx.doi.org/10.4103/23483334.126790 22. singh m. gender, thrift and indigenous adaptations: money and missionary medicine in colonial india. women hist rev. 2006;15(5):70-717. https://doi.org/10.1080/09612020600938541 23. richman b, udayakumar k, mitchell w, schulman k. lessons from india in organizatio0nal innovation: a tale of two heart hospitals. health affairs. 2008;27(5). http://dx.doi.org/10.1377/hlthaff.27.5.1260 24. yathish t, manjula c. how to strengthen and reform indian medical education system: is nationalization the only answer? online j health allied sci. 2010;8(4). 25. flessa s. future of christian health services — an economic perspective. christ j global health. 2016;3(1):25-35. http://dx.doi.org/10.15566/cjg.v3i1.104 http://dx.doi.org/10.1080/03068374.2012.642512 http://divyabodhanam.org/uploads/questions/1530259741zweakwkf188380.pdf http://divyabodhanam.org/uploads/questions/1530259741zweakwkf188380.pdf http://dx.doi.org/10.15566/cjgh.v1i1.16 http://internationalbulletin.org/issues/1995-01/1995-01-013-harper.pdf http://internationalbulletin.org/issues/1995-01/1995-01-013-harper.pdf https://doi.org/10.1093/oxfordhb/9780198718406.013.4 https://doi.org/10.1093/oxfordhb/9780198718406.013.4 https://www.researchgate.net/publication/35219503_the_shadow_of_empire_christian_missions_colonial_policy_and_democracy_in_postcolonial_societies https://www.researchgate.net/publication/35219503_the_shadow_of_empire_christian_missions_colonial_policy_and_democracy_in_postcolonial_societies https://www.researchgate.net/publication/35219503_the_shadow_of_empire_christian_missions_colonial_policy_and_democracy_in_postcolonial_societies https://www.researchgate.net/publication/35219503_the_shadow_of_empire_christian_missions_colonial_policy_and_democracy_in_postcolonial_societies https://www.theguardian.com/world/2017/jul/20/christian-missionaries-india-hinduism-1956.%20accessed%202/9/2019 https://www.theguardian.com/world/2017/jul/20/christian-missionaries-india-hinduism-1956.%20accessed%202/9/2019 https://www.theguardian.com/world/2017/jul/20/christian-missionaries-india-hinduism-1956.%20accessed%202/9/2019 https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/webthe_quest_for_health_and_wholeness.pdf https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/webthe_quest_for_health_and_wholeness.pdf https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/webthe_quest_for_health_and_wholeness.pdf http://dx.doi.org/10.4103/2348-3334.126790 http://dx.doi.org/10.4103/2348-3334.126790 https://doi.org/10.1080/09612020600938541 http://dx.doi.org/10.1377/hlthaff.27.5.1260 http://dx.doi.org/10.15566/cjg.v3i1.104 118 jansen june 2020. christian journal for global health 7(2) 26. wilfred f. the oxford handbook of christianity in asia. wilfred f, editor. oxford: oxford university press. 2014 [isbn 978-0-19-932906-9.] 27. schram r. britain's contribution to health and medicine in tropical countries through medical missions. t roy soc trop med h. 1981;75(supp):56-8. 28. emmanuel hospital association. annual report 2018. available from: https://eha-health.org/aboutus/reports/2017-2018. 29. jansen g. christian ministry of healing on its way to the year 2000: an archeology of medical missions. missiol intl rev. 1995;23(3): 295-307. 30. flessa s. christian milestones in global health: the declarations of tübingen. christ j global health. 2016;3(1): 11-24. http://dx.doi.org/10.15566/cjgh.v3i1.96 31. world health organization. building from common foundations — the world health organization and faith-based organizations in primary healthcare. geneva: who. 2008. 32. litsios s. the christian medical commission and the development of the world health organization’s primary health care approach. am j public health. 2004;94(11):1884-93. http://dx.doi.org/.10.2105/ajph.94.11.1884 33. johns hopkins. carl e. taylor: 1916-2010. available from: https://www.jhsph.edu/news/stories/2010/carltaylor.html. 34. rao ks, nundy m, dua as, delivery of health services in private sector. in financing and delivery of health care services in india [ncmh background papers]. new delhi: national commission of macroeconomics and health. 2005. available from: https://www.who.int/macrohealth/action/report%20 of%20the%20national%20commission.pdf 35. hornbeck c. rebekah ann naylor m.d. — missionary surgeon in changing times. garland, texas: hannibal books. [isbn 978-1-934749-04-3]. 36. chinoy rf. medical ethics: relationships between doctors. indian j med ethics. 1997;5(4). available from: https://ijme.in/articles/medical-ethicsrelationships-between-doctors/?galley=html. 37. hindu american foundation. hinduism basics. available from: https://www.hinduamerican.org/hinduism-basics 38. world health organization. maternal mortality[ internet]. who.int. 2018 feb 16.. https://www.who.int/news-room/factsheets/detail/maternal-mortality 39. world health organization. global health workforce shortage to reach 12.9 million in coming decades. geneva: who.2013 nov 11. available from: https://www.who.int/mediacentre/news/releases/201 3/health-workforce-shortage/en/ 40. dublin declaration of human resources for health: building the health workforce of the future. dublin, ireland: fourth global forum on human resources for health. 2017 nov 12-17. available from: https://www.afrehealth.org/documents/reports/dublin -declaration-on-human-resources 41. wilson c, heffron w. christian mission hospitals as family practice educational resources. fam med. 1994;26:571-5. 42. kingsnorth a, gyoh s. is it possible to train surgeons for rural africa? a report of a successful international program. world j surg. 2012;36(6):1439-40. 43. van essen c, steffes b, thelander k, akinyi b, li h, tarpley m. increasing and retaining african surgeons working in rural hospitals: an analysis of paacs surgeons with twenty-year program follow up. world j surg. 2019;43(1):75-87. 44. unicef. trends in maternal mortality: 1990-2015. world health organization, unicef, un population fund and the world bank [internet]. geneva: who. 2015. available from: https://data.unicef.org/topic/maternalhealth/maternal-mortality/ 45. united nations inter-agency group for child mortality estimation [un igme] internet]. unicef.org. 2018. available from: https://data.unicef.org/topic/child-survival/underfive-mortality/ . 46. unaids data 2018. joint united nationals programme on hiv/aids [internet]. geneva, switzerland. available from: https://www.aidsdatahub.org/sites/default/files/publi cation/unaids_data_2018.pdf 47. hutton g, tanner m. the sector-wide approach: a blessing for public health? b world health organ. 2004;82(12):891-970. available from: https://eha-health.org/about-us/reports/2017-2018 https://eha-health.org/about-us/reports/2017-2018 http://dx.doi.org/10.15566/cjgh.v3i1.96 http://dx.doi.org/.10.2105/ajph.94.11.1884 https://www.jhsph.edu/news/stories/2010/carl-taylor.html https://www.jhsph.edu/news/stories/2010/carl-taylor.html https://www.who.int/macrohealth/action/report%20of%20the%20national%20commission.pdf https://www.who.int/macrohealth/action/report%20of%20the%20national%20commission.pdf https://ijme.in/articles/medical-ethics-relationships-between-doctors/?galley=html https://ijme.in/articles/medical-ethics-relationships-between-doctors/?galley=html https://www.hinduamerican.org/hinduism-basics https://www.who.int/news-room/fact-sheets/detail/maternal-mortality https://www.who.int/news-room/fact-sheets/detail/maternal-mortality https://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/ https://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/ https://www.afrehealth.org/documents/reports/dublin-declaration-on-human-resources https://www.afrehealth.org/documents/reports/dublin-declaration-on-human-resources https://data.unicef.org/topic/maternal-health/maternal-mortality/ https://data.unicef.org/topic/maternal-health/maternal-mortality/ https://data.unicef.org/topic/child-survival/under-five-mortality/ https://data.unicef.org/topic/child-survival/under-five-mortality/ https://www.aidsdatahub.org/sites/default/files/publication/unaids_data_2018.pdf https://www.aidsdatahub.org/sites/default/files/publication/unaids_data_2018.pdf 119 jansen june 2020. christian journal for global health 7(2) https://www.who.int/bulletin/volumes/82/12/editorial 21204html/en/ 48. green a, shaw j, dimmock f, conn c. a shared mission? changing relationships between government and church health services in africa. int j health plan m. 2002;17: 333-53. available from: https://www.ncbi.nlm.nih.gov/pubmed/12476641 49. lederleitner m. cross-cultural partnerships: navigating the complexities of money and mission. downer’s grove, illinois: intervarsity press. 2010. 50. harvard magazine. paul farmer: “accompaniment” as policy [internet]. 2011 may 5. available from: https://harvardmagazine.com/2011/05/paul-farmeraccompaniment-as-policy other sources not specifically cited benge, j., benge, g. (2004). ida scudder: health bodies, touching hearts. christian heroes: then and now. ywam publishing. asin b00qnacix8 wilson, dc. (1987). the legacy of ida s. scudder. international bulletin of missionary research. 11(1), 26-30. https://doi.org/10.1177/239693938701100108 mckay a. towards a history of medical missions. cam j med hist. 2007;51(4):547-51. cueto m. the origins of primary health care and selective primary health care. am j public health. 2004;94(11):1864-74. http://dx.doi.org/10.2105/ajph.94.11.1864 zakus d, bhattacharyya o. health systems, management and organization in lowand middleincome countries. boston: harvard school of public health. 2012. https://cdn1.sph.harvard.edu/wpcontent/uploads/sites/114/2012/10/rp248.pdf govindaraj r, chawla m. recent experiences with hospital autonomy in developing countries-what can we learn? data for decision making project [internet]. boston: harvard school of public health, department of population and international health. 1996 sept. available from: http://www.frankshospitalworkshop.com/organisatio n/management_documents/recent%20experiences% 20with%20hospital%20autonomy%20in%20devel oping%20countries%20%20harward%20school.pdf. peer reviewed: submitted 26 aug 2019, accepted 3 mar 2020, published 22 june 2020 competing interests: none declared. correspondence: dr. perry jansen, usa. perry.jansen@africanmissionhealthcare.org cite this article as: jansen p. health systems strengthening through the faith-based sector – lessons from india: critical analysis of facilitators and inhibitors of nationalization of mission hospitals. christian journal for global health. june 2020; 7(2):104-119. https://doi.org/10.15566/cjgh.v7i2.319 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://www.who.int/bulletin/volumes/82/12/editorial21204html/en/ https://www.who.int/bulletin/volumes/82/12/editorial21204html/en/ https://www.ncbi.nlm.nih.gov/pubmed/12476641 https://harvardmagazine.com/2011/05/paul-farmer-accompaniment-as-policy https://harvardmagazine.com/2011/05/paul-farmer-accompaniment-as-policy https://doi.org/10.1177/239693938701100108 http://dx.doi.org/10.2105/ajph.94.11.1864 https://cdn1.sph.harvard.edu/wp-content/uploads/sites/114/2012/10/rp248.pdf https://cdn1.sph.harvard.edu/wp-content/uploads/sites/114/2012/10/rp248.pdf http://www.frankshospitalworkshop.com/organisation/management_documents/recent%20experiences%20with%20hospital%20autonomy%20in%20developing%20countries%20-%20harward%20school.pdf http://www.frankshospitalworkshop.com/organisation/management_documents/recent%20experiences%20with%20hospital%20autonomy%20in%20developing%20countries%20-%20harward%20school.pdf http://www.frankshospitalworkshop.com/organisation/management_documents/recent%20experiences%20with%20hospital%20autonomy%20in%20developing%20countries%20-%20harward%20school.pdf http://www.frankshospitalworkshop.com/organisation/management_documents/recent%20experiences%20with%20hospital%20autonomy%20in%20developing%20countries%20-%20harward%20school.pdf http://www.frankshospitalworkshop.com/organisation/management_documents/recent%20experiences%20with%20hospital%20autonomy%20in%20developing%20countries%20-%20harward%20school.pdf mailto:perry.jansen@africanmissionhealthcare.org https://doi.org/10.15566/cjgh.v7i2.319 http://creativecommons.org/licenses/by/4.0/ poetry dec 2022. christian journal for global health 9(2) present sufferings, future glory oyebode dosunmu a a msc, pharmacist, bowden university teaching hospital, ogbomosho, nigeria there are days, and there are days in this world we experience days of pains, days of suffering other days, as we wait, god intervenes to reveal glory in the life of his as we’re becoming more like him there are days, and there are days in this world, we eagerly hope our person for glorious days hoping right here on earth to experience god to his own reveals his plan as we’re becoming more like him there are many such days in this world, we earnestly pray with our heart and spirit, we pray and the spirit for us intercede with groans god the intercession gloriously honor as we’re becoming more like him yes, in this world we may suffer and in the body pains, we’ll feel but in heaven is the greatest hope we have and with the greatest of glory, we’ll be filled oh how most glorious heaven for us will be! when like the god of glory we’ll look. peer reviewed: submitted 5 july 2022, accepted 8 aug 2022, published 20 dec 2022 competing interests: none declared. correspondence: oyebode dosunmu, bowen university, nigeria pharmaseyist@gmail.com cite this article as: dosunmu o. present sufferings, future glory. christ j glob health. dec 2022; 9(2):33. https://doi.org/10.15566/cjgh.v9i2.687 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:pharmaseyist@gmail.com https://doi.org/10.15566/cjgh.v9i2.687 about:blank short communication july 2021. christian journal for global health 8(1) exercising to enhance the efficacy of covid-19 vaccines qais gasibat a a, pt, bsc, msc, lecturer at faculty of medical technology, misurata, libya and phd student at university putra, malaysia (upm) introduction vaccination is the best and the most costeffective strategy for tackling infectious diseases and their complications.1 a successful vaccine elicits a strong and durable immune response in the body to protect against illness. according to the u.s. food and drug administration (2020), any candidate for a severe acute respiratory syndrome coronavirus 2 (sarscov-2) vaccine will be approved if it decreases coronavirus-19 disease (covid-19) cases by at least 50% in comparison to placebo (i.e., 50% efficacy). based on the preliminary reports, the efficacy level of pfizer– biontech and moderna vaccines are ~95%.2 the speed with which these vaccines have been developed is highly impressive.3 vaccine development is dependent on various factors related to the nature of the vaccine, but also characteristics of vaccine recipients and people at risk of illness. stress, rampant during the pandemic, can not only reduce vaccine efficacy but also promote more immediate and transient side effects, such as fatigue and low mood. however, many of these factors are modifiable and thus may be important intervention targets as the world prepares for widespread immunization. exercise and immunogenicity physical activity promotes a strong immune system and better vaccine responses. physically fit elderly people had better antibody immune responses, but not cell-mediated immune responses, to tetanus and influenza virus vaccines compared with their less-fit peers.4 accelerometer data was collected from elderly chinese women in singapore. it showed that women who walked more (> 18,509 steps/day) for two weeks after an influenza virus vaccination possessed greater innate immune activation two days after vaccination, larger adaptive immune responses 1 week after vaccination, and greater antibody responses after a second vaccination than their less-active peers (< 10,927 steps per day).5 in another study, it was observed that elite athletes possessed specifically more immune cells for influenza after receiving an influenza vaccine in comparison to other adults who were healthy.6 in another study, it was observed that adults who were regular trainers possessed an increased antibody response compared to healthy adults who did not train well.7 if constant exercise is done after vaccination, then it is considered to prolong increased protection. researchers found that “acute bouts” of exercise, such as work outs prior to vaccination, can accelerate better function of the immune system.8 a systematic review of 20 studies showed that regular exercise and vaccination are important factors in developing the body’s response towards vaccines.9 exercising on the day of the vaccine may offer benefits as well, though there is not much proof.10 eccentric exercise shows benefits to vaccine response. it increases the antibody responses in women and enhances the cell-mediated response in men. further exploration is needed to study the eccentric exercise of the muscle at the site of vaccine 95 gasibat july 2021. christian journal for global health 8(1) administration as a possible behavioral adjuvant to vaccination.11 several studies in young healthy adults show that acute exercise can boost both antibody and cellmediated responses to vaccine antigens.12 exerciseinduced enhancement appears to be most visible in strains with weaker control responses, indicating a possible ceiling effect with stronger responses showing no further enhancement.13 during six months of follow-up, acute exercise reduced vaccine reactions but had no effect on either antibody responses or the development of influenza-like symptoms. being active close to the time of a vaccination — such as influenza or human papillomavirus (hpv), has been found to reduce the risk of suffering from adverse reactions to the injection.14 edwards et al. observed the greater immune response to low-dose pneumococcal vaccine in those who exercised simply with 15 minutes of moderate resistance band exercise; the exercise task was performed in sets of 30 seconds of exercise followed by 30 seconds of rest.15 participants performed three exercises in a row: lateral raise, upright row, and chest press. each movement was performed with instruction and encouragement to perform “as many as you can.” participants alternated movements and performed each 5 times, completing 15 minutes of exercise. resistance band strength was adjusted to remain challenging while still allowing for 30 seconds of exercise. exercise for covid-19 vaccines according to a february lancet study, people who engage in "moderate-intensity exercise before vaccination" have higher rates of efficacy and more antibodies to covid-19 vaccines. however, the evidence was never fully conclusive because other studies found no discernible difference.16 exercise as an adjuvant provides an avenue that could potentially improve the protective efficacy of vaccination programs in at-risk, immunecompromised populations or even provide a route for dose sparing or a reduction in booster requirement. critically, this behavioral approach avoids costly clinical trials, is inexpensive and simple to administer, is well understood and accepted by the general public, and has no side effects other than mild muscle soreness. of course, correlation between exercise capacity and immune function could be due to pre-existing health status. thus, it appears timely to investigate the possibility of using acute exercise as an adjuvant, especially in at-risk populations. references 1. havers f, sokolow l, shay dk, farley mm, monroe m, meek j, et al. case-control study of vaccine effectiveness in preventing laboratory-confirmed influenza hospitalizations in older adults, united states, 2010–2011. clin infect dis . 2016 nov 15;63(10):1304-11. https://doi.org/10.1093/cid/ciw512 2. mahase e. covid-19: moderna vaccine is nearly 95% effective, trial involving high risk and elderly people shows [internet]. bmj. 2020 nov 17;371. https://doi.org/10 .1136/bmj.m4471 3. knoll md, wonodi c. oxford–astrazeneca covid19 vaccine efficacy. lancet. 2021 jan 9;397(10269):72-4. https://doi.org/10.1016/s01406736(20)32623-4 4. keylock kt, lowder t, leifheit ka, cook m, mariani ra, ross k, et al. higher antibody, but not cell-mediated, responses to vaccination in high physically fit elderly. j appl physiol . 2007 mar;102(3):1090-8. https://doi.org/10.1152/japplphysiol.00790.2006 5. choon lim wong g, narang v, lu y, camous x, nyunt ms, carre c, et al. hallmarks of improved immunological responses in the vaccination of more physically active elderly females [internet]. exerc immunol rev . 2019 jan 1;25. available from: http://www.eir-isei.de/2019/eir-2019-020-article.pdf 6. ledo a, schub d, ziller c, enders m, stenger t, gärtner bc, et al. elite athletes on regular training show more pronounced induction of vaccine-specific t-cells and antibodies after tetravalent influenza vaccination than controls. brain behav immun . 2020 jan 1;83:135-45. https://doi.org/10.1016/j.bbi.2019.09.024 https://doi.org/10.1093/cid/ciw512 https://doi.org/10%20.1136/bmj.m4471 https://doi.org/10.1016/s0140-6736(20)32623-4 https://doi.org/10.1016/s0140-6736(20)32623-4 https://doi.org/10.1152/japplphysiol.00790.2006 http://www.eir-isei.de/2019/eir-2019-020-article.pdf https://doi.org/10.1016/j.bbi.2019.09.024 96 gasibat july 2021. christian journal for global health 8(1) 7. de araújo al, silva lc, fernandes jr, matias md, boas ls, machado cm, et al. elderly men with moderate and intense training lifestyle present sustained higher antibody responses to influenza vaccine. age. 2015 dec;37(6):1-8. https://doi.org/10.1007/s11357-015-9843-4 8. edwards km, booy r. effects of exercise on vaccineinduced immune responses. hum vaccin immunother. 2013 apr 1;9(4):907-10. https://doi.org/10.4161/hv.23365 9. pascoe ar, singh ma, edwards km. the effects of exercise on vaccination responses: a review of chronic and acute exercise interventions in humans. brain behav immun . 2014 jul 1;39:33-41. https://doi.org/10.1016/j.bbi.2013.10.003 10. edwards km, burns ve, reynolds t, carroll d, drayson m, ring c. acute stress exposure prior to influenza vaccination enhances antibody response in women. brain behav immun . 2006 mar 1;20(2):15968. https://doi.org/10.1016/j.bbi.2005.07.001 11. edwards km, burns ve, allen lm, mcphee js, bosch ja, carroll d, et al.. eccentric exercise as an adjuvant to influenza vaccination in humans. brain behav immun. 2007 feb 1;21(2):209-17. https://doi.org/10.1016/j.bbi.2006.04.158 12. edwards km, burns ve, adkins ae, carroll d, drayson m, ring c. meningococcal a vaccination response is enhanced by acute stress in men. psychosom med . 2008 feb 1;70(2):147-51. http://doi.org/10.1097/psy.0b013e318164232e 13. edwards km, campbell jp. acute exercise as an adjuvant to influenza vaccination. am j lifestyle med . 2011 nov;5(6):512-7. https://doi.org/10.1177%2f1559827610395486 14. bohn-goldbaum e, pascoe a, singh mf, singh n, kok j, dwyer de, et al. acute exercise decreases vaccine reactions following influenza vaccination among older adults. brain behav immun health . 2020 jan 1;1:100009. https://doi.org/10.1016/j.bbih.2019.100009 15. edwards km, pung ma, tomfohr lm, ziegler mg, campbell jp, drayson mt, et al. acute exercise enhancement of pneumococcal vaccination response: a randomised controlled trial of weaker and stronger immune response. vaccine. 2012 oct 5;30(45):638995. https://doi.org/10.1016/j.vaccine.2012.08.022 16. hull jh, schwellnus mp, pyne db, shah a. covid19 vaccination in athletes: ready, set, go. lancet respir med. 2021 may 1;9(5):455-6. https://doi.org/10.1016/s2213-2600(21)00082-5. https://doi.org/10.1016/j.ijinfomgt.2015.07.001 peer reviewed: submitted 7 may 2021, accepted 29 may 2021, published 30 july 2021 competing interests: none declared. correspondence: qais. faculty of medical technology, misurata, libya. drqaiss9@gmail.com cite this article as: gasibat q. exercising to enhance the efficacy of covid-19 vaccines. christ j global health. july 2021; 8(1):___. © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org https://doi.org/10.1007/s11357-015-9843-4 https://doi.org/10.4161/hv.23365 https://doi.org/10.1016/j.bbi.2013.10.003 https://doi.org/10.1016/j.bbi.2005.07.001 https://doi.org/10.1016/j.bbi.2006.04.158 http://doi.org/10.1097/psy.0b013e318164232e https://doi.org/10.1177%2f1559827610395486 https://doi.org/10.1016/j.bbih.2019.100009 https://doi.org/10.1016/j.vaccine.2012.08.022 https://doi.org/10.1016/j.ijinfomgt.2015.07.001 mailto:drqaiss9@gmail.com about:blank introduction references original article june 2020. christian journal for global health 7(2) a quantitative assessment of the need for offering counseling services to medical students at the university of zambia school of medicine gretchen slovera, kelsie martinezb, and kathrin barnes c a ms, psyd, lmft, malaw, licensed marriage and family therapist b ma, doctoral student, pre-dissertation, alliant international university, san diego, ca;. pre-doctoral internship completed with veteran’s administration pacific islands; post-doctoral internship pending with san diego veteran’s administration, san diego, california. c ba psychology; san diego christian college. currently employed as a director of client relations. abstract background: this research was birthed in 2017 during a trip to lusaka, zambia, with the purpose of offering fourth-year, medical students attending the university of zambia, school of medicine, lectures on psychology topics as part of their clinical studies. students were also offered brief therapy sessions where they could process thoughts and feelings causing them internal struggles. the subject of offering counseling on a regular basis was randomly discussed with the students. from these discussions the need for this research became evident, with the intent of becoming the launching pad to brainstorm the most effective ways of developing a plan to offer counseling services for all medical students attending the university of zambia school of medicine. methods: an-experimental research design, consisting of completion of a 12-item questionnaire administered by paper and pen. the inclusion criteria were the fourth year, medical students attending the university of zambia, school of medicine. results: the student responses revealed that most of them had little to no experience with counseling services, but a strong desire for them. discussion: the goal of this study was to simply establish a need for an on-campus counseling service, the need of which has been established by the very students who would benefit. with the acceptance of this need, the future plan is to explore the different ways in which this need can be fulfilled with minimal costs to the medical school program. conclusion: this study is the first step towards identifying the needs of the medical students and sets the ground-work for further research into the specific areas of need and mental health challenges. more specificity in the area of demographics of students will produce a more comprehensive picture of the areas of concentration for the therapists offering services. key words: campus counseling, counseling, medical students, the university of zambia school of medicine, mental health, stress, therapy 94 slover, martinez & barnes june 2020. christian journal for global health 7(2) introduction the university of zambia school of medicine located in lusaka, zambia, is an institution that offers education to those seeking a doctoral medical degree. the institutional mission statement is “to provide quality education in health sciences producing competent graduates who value lifelong learning and are well prepared to undertake specialist training programs and able to provide patient care and leadership in medical research that addresses the priority needs of zambia.”1 this study was approved by the institutional review boards (irb) of the university of zambia, school of medicine and san diego christian college, located in santee, california. the aim of this research was to identify if the medical students at the university of zambia school of medicine, believed they would benefit from an offering of oncampus counseling services if made available to them on a regular basis. fourth year medical students were chosen to participate due to the academic demands placed on them at this stage of their studies. according to a study by mwanza, cooper, et al. (2010), “to a large extent in zambia, people who are mentally ill are stigmatized, feared, scorned at, humiliated and condemned the mental health services situation in zambia could be described as critical, requiring urgent action.”2 the university of zambia falls into this category of needing urgent support, as counseling services are not readily and consistently available to students on campus. there is no research on the current topic of suicide amongst medical students in zambia. the school of medicine was chosen after interacting with fourth year medical students during their clinical studies in may 2017. a team of medical doctors, mental health professionals and students, headed by dr. cheryl snyder (deceased) organized the clinical studies, which included a component of mental health curriculum. these conversations revealed that many students lack the resources to freely speak with a therapist about concerns from past experiences and present struggles. the challenges of a medical student are many as they struggle to learn the material, balance relationships and respond to cultural obligations and expectations. the specific objectives are to assess the needs of fourth year medical students as they are facing a turning point in their studies and are challenged to complete clinical testing in order to proceed to their fifth year of studies. it is hoped that if the need is identified, a creative method of delivering services can be developed for the students. the ultimate goal would then be to produce graduates of the doctorate program who have addressed their own personal challenges and acquired valuable coping skills. when encountering patients who would unknowingly trigger a disturbing response, the treating physician will not be distracted. instead, they will have the ability to deliver their services in a more competent and concise manner. the medical program’s reputation for producing competent, caring physicians will be enhanced, which, in turn, could result in an increase in program enrollment and produce a positive financial impact. some research has been conducted, which has explored the mental health issues that challenge medical students. suicidal ideation has been the focus, and some have concluded that a medical school student is not likely to seek assistance for a variety of reasons.3 there has been little research on suicide rates in zambia. a 2004 study tracked documented suicide rates in zambia from 1967– 1971 and found the following rates (per 100,000 of the population per annum): 6·9 for all african residents, 11·2 for african males, 2·2 for african females and 12·8 for all africans above the age of 14 years.4 this study is meant to focus on one particular location, in order to first establish a need and then to implement a program using already established resources. literature review the university of zambia school of medicine has been training those in the medical field for over fifty years. throughout their medical school training, 95 slover, martinez & barnes june 2020. christian journal for global health 7(2) medical students often experience stressors rooted in academia, as well as residual and present life experiences. it is known that unresolved life issues tend to fester and grow into problems that manifest in all areas. medical school is a challenge in itself. when a student does not have the resources available to address inner conflicts and struggles, the outcome can affect both their ability to retain information, treat their patients and maintain their own physical and emotional health. in 2013, feeney, jordan and mccarron5 set out to eliminate the stigma that mental health issues could not be overcome. they implemented a recovery model to be used while teaching medical students about mental illness.5 research conducted before the study showed the common belief that individuals struggling with certain types of mental illness were “as unaccepting as lay people” and these beliefs showed an overall lack of empathy towards the patients.5 the negative connotation often associated with mental illness can lead medical students to overlook and discount the impact that mental illness can have on patient symptoms and recovery. in another study conducted by francesca vescovelli and colleagues, the increase in mental conditions such as anxiety, depression and stress seen in college students was the subject of research.6 these authors acknowledged that there should be measures taken for “the importance of devoting a special clinical attention to college students who attend medical courses.” mental health illness is a broad topic of special interest that often generates negative attitudes towards people who experience such problems. negative attitudes are not solely owned by the lay public but often extend into the academic programs that produce future medical providers, in particular, medical doctors.5 the stigma of mental illness extends into the medical school curriculum due to the lack of teaching about mental illness. “it has been argued that through such teaching, students can gain a depth of understanding of psychological distress not accessible through traditional clinical placements.”5 feeney et al. concluded that when medical students are taught “recovery principles” for mental health issues, the services they offer have better outcomes. it also helps to broaden their narrow mindset about mental illness.5 it has been stated and known that medical students have a higher risk of experiencing “depression, suicidal ideation and burnout;” however, it was also found that the nature of the medical schooling system or university in which the student attends, is one of the biggest contributors to a student exhibiting these symptoms.3 it is then crucial that the educational board deems their students’ mental health as a priority and implement preventative and reactive treatment for their students. this can be done through the implementation of “university counseling centers, community providers, and university psychiatry faculty who may be called on to consult in urgent cases.”3 through this implementation at various universities in the united states, it was shown to help students who not only felt better supported, but displayed increased accuracy and performance as well.3 there have been studies to show that due to increased stress caused by various factors, medical students experience higher occurrences of physical ailments, which could, in turn, lead to what is known as a burnout.7 the study defined burnout as, “a three-dimensional syndrome that includes emotional exhaustion, depersonalization, and reduced personal accomplishment.”7 each one of these issues exhibited in the registrar, or medical student, identified an increased inability to care for their patients or themselves to the best of their ability.7 in 2002, tyssen, and vaglum reviewed and expanded upon the impact of patient care. studies showed that a medical student or physician who had untreated personal issues were more likely to wrongly diagnose and treat their patients.8 this would not only negatively impact the patient, along with potentially diminish their health even further, but would also be a financial loss for the hospital when needing to provide two treatments due to the fact that the first treatment was not effective due to doctor’s error. because of these risks, it is crucial 96 slover, martinez & barnes june 2020. christian journal for global health 7(2) that medical students and physicians be given adequate treatment along with monitored and healthy work environments.8 the cultural and societal shifts that emphasize wellness must be considered in any counseling service offered in an academic setting.9 there are standards and guidelines that recognize best practices for these services. they have been produced by the international association of counseling services (iacas) and the council for the advancement of standards (cas).9 in a study of the differences between suicidal behaviors in austrian and turkish medical students, it was found that cultural factors play a role in the differences in behaviors and attitudes towards suicide and reactions to suicidality.10 in certain professions, suicide has become a significant health problem. doctors succumb to suicide more often than other professions, and medical students are also at great risk for suicide. often, the precursor to suicide is depression and medical students often experience depressive symptoms as a result of the performance pressures of academia. add personal relationship challenges and the result is a lethal cocktail that can be diluted with proper resources.10 the knowledge of the increased risk factors for physicians committing suicide has been linked back to 1958 in england.11 the research found that “most strikingly, suicide is a disproportionately high cause of mortality in physicians, with all published studies indicating a particularly high suicide rate in female physicians.”11 the consensus went on to state how not only identifying this epidemic, but, implementing easily obtainable treatment for risk factors such as depression, substance abuse, and anxiety, would “have a multiplier effect for medical students, residents, and patients.”11 in 2005, dahlin, joneborg and runeson delved into the outlook medical students held on the impact their environment and stressors had on their studies. it was concluded that as each year of schooling went by, the students experienced an increase in stress and toxicity levels “year 6, both the latter factors were rated highly, but year 6 students also gave higher ratings than the 2 other groups to non-supportive climate.”.12 this outlook implies that it may have been beneficial to implement assistance as early as year one for the medical students to adjust their viewpoint. through the growing awareness of the need for mental health assessments, the stigma against mental health treatment is believed to decrease. cristina vladu and her colleagues believed that through implementing mental health training for medical students, physicians and all medical staff to both undergo and perform, there will be a greater understanding of the benefits these treatments have on patients as a whole. they determined that, “a new approach to medical education should include early exposure of medical students and other trainees to behavioral sciences and to the development of interpersonal skills and team building approach to enhance the cultural competence of the health care workers.”13 increased awareness and training, in turn, allows the opportunity for change and understanding among the medical students and those under their care. as students experience psychological distress, their personal and academic development and accomplishments are negatively affected. the current study to determine the need for a counseling program for medical students attending the university of zambia, school of medicine, can effectively add to the literature of cross-cultural mental health needs and differences as there is scant literature which explores the attitudes and efficacy in this area of study. it has been established that medical students experience stressors that are unique to their academic program. this, along with the residual, unresolved mental health stressors from family/relationships, creates the perfect storm. it is projected that addressing a need for counseling assistance as a precursor for developing the resource will not only enhance the lives of medical students and patients they treat, but will also identify the university of zambia, school of medicine as leaders in their care of students. 97 slover, martinez & barnes june 2020. christian journal for global health 7(2) methods study design this is a non-experimental research design, consisting of the completion of a 12-item questionnaire administered on paper. the inclusion criteria were the fourth-year medical students attending the university of zambia, school of medicine. this choice was influenced by the critical level of their studies in the fourth year. a need for offering a structured course of therapeutic counseling services to fourth year students was identified through providing brief counseling services on a modified schedule over twenty days in may 2017 during student participation in their clinical studies program. for the purposes of this study, all other students outside the fourth year were excluded. the study site is the university of zambia, school of medicine, located in lusaka, zambia. the size of the sample was determined at the time of administration of the questionnaire, based upon the number of fourth year medical students enrolled in the university of zambia, school of medicine, as well as the number of students who voluntarily participated. results one hundred fifty two (152) fourth year medical students attending the university of zambia, school of medicine were on the official census. out of 152 students, there were 109 students who participated by completing the questionnaire, 4 students declined to complete the questionnaire, 4 students completed the questionnaire without signing the consent form and 35 students were absent the day the survey was administered. the charts below represent the responses to the questionnaires completed by students who also signed the consent form (n-109). each question required a likert scale response of strongly disagree, disagree, neutral/not applicable, agree, and strongly agree to each question. demographic questions were purposefully not included in the questionnaire due to the fact that the focus was exploratory in nature and did not require such information. the focus group solely consisted of fourth year medical students. figure 1 figure 1 reflects that many of the students had not participated in counseling themselves as a resource to discuss problems and concerns. eightyone percent of students responded with disagree or strongly disagree. those students who responded neutral/not applicable and no response did not respond with a yes or no and, therefore, were not included in calculating the response percentage. 0 5 10 15 20 25 30 35 40 45 i have previously attended counselling sessions. response 98 slover, martinez & barnes june 2020. christian journal for global health 7(2) figure 2 figure 2 signifies that question 2 cannot be accurately interpreted as 16 students reported attending previous counseling in question 1 but more than 16 students responded in agreement or disagreement regarding the benefit of their counseling experience in question 2. figure 3 as figure 3 illustrates, the students establish that their studies are a source of depression when they feel pressured. eighty-eight percent of students responded with strongly agree, agree, or neutral/not applicable. figure 4 figure 4 indicates that eighty-nine percent of students responded with strongly agree, agree, or neutral/not applicable. figure 5 figure 5 displays that ninety four percent of students responded with strongly agree, agree or neutral/not applicable. students’ answers to 4 and 5 establish that their studies can be a source of anxiety and stress. 0 10 20 30 40 50 60 70 i found my previous counseling experience to be beneficial. response 0 10 20 30 40 50 60 sometimes the pressures of my studies cause me to become depressed. response 0 10 20 30 40 50 60 sometimes the pressures of my studies cause me to become anxious. response 0 10 20 30 40 50 60 sometimes the pressures of my studies cause me to become stressed. response 99 slover, martinez & barnes june 2020. christian journal for global health 7(2) figure 6 figure 6 displays that in answer to question 6, the students demonstrate their resilience, in that they find they can function adequately in their off campus lives in spite of the pressures of their academic lives. thirty-nine percent of students responded with strongly agree or agree. sixty-one percent of students responded with disagree or strongly disagree. those students who responded neutral/not applicable and no response did not respond with a yes or no and, therefore, were not included in calculating the response percentage. figure 7 in figure 7, it can be seen that the majority of the students agreed that they are challenged by time management concerns. ninety percent of students responded with strongly agree, agree or neutral/not applicable. figure 8 figure 8 reflects that a large number of the students did not find their family problems to interfere with their studies. forty-five percent of students responded with strongly agree or agree. fifty-five percent of students responded with disagree or strongly disagree. those students who responded neutral/not applicable did not respond with a yes or no and, therefore, were not included in calculating the response percentage. 0 10 20 30 40 50 i often find it difficult to properly function even when i am not on campus. response 0 10 20 30 40 50 60 there is often not enough time to complete what is expected of me in a 24 hour period. response 0 5 10 15 20 25 30 35 40 my family situation often distracts me from my studies. response 100 slover, martinez & barnes june 2020. christian journal for global health 7(2) figure 9 figure 9 signifies that the majority of students surveyed indicated they agree that counseling services are needed. ninety-eight percent of students responded with strongly agree, agree or neutral/not applicable. figure 10 figure 10 reflects that the majority of students surveyed indicated they would make use of a counseling service on campus. ninety-two percent of students responded with strongly agree, agree or neutral/not applicable. figure 11 figure 11 reflects that over half of the students surveyed can identify a peer who could benefit from on campus counseling. eighty-eight percent of students responded with strongly agree, agree or neutral/not applicable. figure 12 0 10 20 30 40 50 60 70 80 counselling services are needed on the university of zambia, medical school campus for medical students. response 0 10 20 30 40 50 60 if such a service were established i would make use of it. response 0 10 20 30 40 50 i know of a fellow student who would benefit from a counselling service on campus. response 0 10 20 30 40 50 60 70 i believe a counselling service on campus will produce positive results for students as they progress through academic life. response 101 slover, martinez & barnes june 2020. christian journal for global health 7(2) figure 12 reveals that students overwhelmingly expressed their belief that the addition of a counselling service on campus will have a positive impact on students as they achieve the milestones of their academic careers. ninety-six percent responded with strongly agree, agree or neutral/not applicable. four (4) students answered the questionnaire, but they did not sign the consent form. their responses were not included in the result tabulations. however, it is worth noting that their responses were consistent with the responses of the general population and regarding the establishment of counseling service on campus for the benefit of all students while they are working their way through medical school. discussion and summary the student responses revealed that most of them had little to no experience with counseling services. the majority of them experience anxiety, depression and stress due to their studies. they do not have enough time in the day to complete what is expected of them. despite these struggles, they appear to have the resiliency to function off campus and nearly half of them report that family situations do not interfere with their studies. the greater majority of the students do, however, believe that counseling services are needed on the university of zambia, school of medicine campus and that they would make use of these services if they were available. the majority of students also stated that they know of a fellow student who would benefit from these services and that they believe the counseling services on campus would produce positive results for students as they progress through academic life. it would be a disservice to ignore the needs and desires of these students who are dedicating lives, time and energy to a lifetime of serving others. there is no doubt that medical school creates a unique struggle for those who are called to serve their fellow man through medicine. motivations differ as everyone has their own reasons for pursuing a career that can either help people prolong life as well as come to terms with the end of life. the fourth year medical students attending the university of zambia, school of medicine are no different in what they experience during their season in academia than other medical students, as they all have to absorb the knowledge and prove their mastery of the application in order to progress. in some ways, it may be more difficult for the zambian to achieve their goals due to cultural roadblocks, financial stressors and lack of appropriate support systems. the goal of this study was to simply establish a need for an on-campus counseling service, the need of which has been established by the very students who would benefit from it. with the acceptance of this need, the future plan is to explore the different ways in which this need can be fulfilled with minimal costs to the medical school program. the benefits of establishing a counseling program on campus has the potential to produce medical doctors who have addressed their own stressors, worries and fears. as they are exposed to patients from all walks of life, they will also have the ability to recognize those stressors, worries and fears in the patients they treat, which will, in turn, assist them in all areas of treatment. a physician who has worked through and processed events in their lives which were stress provoking will have a better outcome with patients who may otherwise trigger past memories upon contact. a mentally healthy physician will have developed the coping skills to move into their practice without the added struggle of masking their own past mental pain. this study is the first step towards identifying the needs of the medical students and sets the groundwork for further research into the specific areas of need and mental health challenges. more research in this student demography will produce a more comprehensive picture of the areas of concentration for the therapists offering services. the university of zambia, school of medicine will be known as innovators in the care of their medical students, producing physicians who are not only academically competent but mentally strong as well. the implementation of a counseling program 102 slover, martinez & barnes june 2020. christian journal for global health 7(2) for the students could also have a positive financial impact on 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gretchen slover, flagstaff, az, usa. drgretchenslover@gmail.com http://medicine.unza.zm/index.php?option=com_content&view=article&id=85&itemid=86 http://medicine.unza.zm/index.php?option=com_content&view=article&id=85&itemid=86 http://dx.doi.org/10.1080/17542863.2010.503046 http://dx/doi.org/10.1056/nejmp1803970 http://dx.doi.org/10.1037/h0094745 http://dx.doi.org/10.1037/ser0000166 https://dx.doi.org/10.1037/ser0000166 http://dx.doi.org/10.1080/10673220216218 http://dx.doi.org/10.1080/07448481.2010.482436 http://dx.doi.org/10.1007/s00127-010-0254-7 http://dx.doi.org/10.100/jama.289.23.3161 http://dx.doi.org/10.1111/j.1365-2929.2005.02176.x http://dx.doi.org/10.1111/j.1365-2929.2005.02176.x https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5225828/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5225828/ about:blank 103 slover, martinez & barnes june 2020. christian journal for global health 7(2) cite this article as: slover g, martinez k, barnes k. a quantitative assessment of the need for offering counseling services to medical students at the university of zambia, school of medicine. christian journal for global health. june 2020; 7(2):93-103. https://doi.org/10.15566/cjgh.v7i2.325 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank field reports using the bio-psycho-social-spiritual framework in holistic health and well-being: a case example of a communityand faith-based sports program morgan braganzaa & jacob oliveirab a msw, phd, assistant professor, social work, department of applied social sciences, redeemer university, canada b ba(c), psychology, redeemer university, canada abstract as in other parts of the world, canada’s citizens are confronted with biological, mental, and social crises. despite the fact that these issues can be interrelated, they are regularly studied and addressed separately. the bio-psycho-social (bps) framework was offered as an alternative approach for care because of its assumption that in order to produce a variety of interconnected outcomes relative to health and well-being, biological, mental, and social issues must all be considered. some authors have argued, however, that without a spiritual component, the bps framework is not holistic. as such, recent scholarship has explored the inclusion of a spiritual component in the framework, and social service professionals have been encouraged to consider designing interventions informed by the bio-psycho-social-spiritual (bps-s) framework. good examples of how to apply the framework in practice are limited. this case example describes how the bps-s framework was applied to design a community-, sports-, and faith-based martial arts program in ontario, canada. the program draws upon a combination of sports-, community-, and christian faith-based considerations to serve its participants, including vulnerable populations such as those with constrained access to social services due to mental health challenges, language barriers, or low levels of income. this article details some of the ways in which the operations of this program (e.g., activities, target audience, leadership) were informed by the bps-s framework. this includes some of the advantages of drawing upon this framework to foster more nuanced and holistic well-being among participants. the article concludes with some limitations of the bps-s framework and implications for applying it to other social service interventions. key words: bps-s framework, holistic health, community-based program, sports, faith 95 braganza & oliveira june 2022. christian journal for global health 9(1) introduction like others across the globe, canada’s citizens are confronted with devastating biological, mental, and social issues such as high rates of noncommunicable disease, mental illness, and social challenges.1 these issues are regularly studied and addressed separately (e.g., different service providers, systems, disciplines), despite the fact they can be intimately interconnected. mental health incorporates emotional and spiritual health and is influenced by many factors including biological health and social predictors such as home and work environment.2 given the interconnected nature of crises, increasingly, scholars and practitioners are calling for more holistic service responses to facilitate care. the bio-psycho-social (bps) framework is beginning to be more commonly discussed in health and social sciences because of its assumption that in order to produce a variety of interconnected, nuanced outcomes relative to health and well-being, biological, mental, and social issues must all be considered.3 approximately 30 years ago, scholars in some areas, especially in health and palliative care, began exploring the inclusion of a spiritual component within this framework.4,5 without it, some supporters of the bps model felt that the bps framework was incomplete—it was not holistic.4 more recently, social service professionals have been encouraged to design interventions informed by the bps-s framework yet good examples of how to apply the bps-s framework in practice are limited.6 this article responds to this gap in literature by offering a case example of an intervention informed by the bps-s framework. more specifically, the kung-fu for christ (kffc) program draws upon a combination of sports-, community-, and christian faith-based considerations to serve its participants, including vulnerable populations such as those with constrained access to social services due to mental health challenges, language barriers, or low levels of income. often, vulnerable community members struggle with multiple interconnected challenges such as ill health (biological), mental illness (psychological), social exclusion (social), and hopelessness (spiritual).7,8 although research suggests that sports, generally,9 and the combination of sports with community work can be advantageous for promoting mental health,10 little scholarship focuses on how the inclusion of christian faith within sports-based community work can facilitate holistic health. this article details some of the ways in which the operations of this program (e.g., activities, target audience, leadership) were informed by the bps-s framework. in so doing, the advantages of drawing upon the bps-s framework to foster more nuanced and holistic well-being among participants is discussed. the article concludes with implications for applying the bps-s framework to other social service interventions. when referring to the bps-s framework, the term spiritual is used. some scholars, however, contend that there is a distinction between spirituality and religion.11 spirituality can involve a search for transcendent personal meaning or purpose and connectedness, such as with others, or something beyond oneself (e.g., a deity).11 although religion includes similar attributes, it tends to incorporate a specific set of practices, ethics, and values associated with particular beliefs (e.g., about a certain god, set of sacred scriptures).11 although religion and spirituality can be expressed in similar ways, this is not always the case.11 religion can be expressed through group or private prayer, reading sacred scriptures, or engaging in worship activities while spirituality can be expressed through music or art.11 although the term spirituality will be used in order to be in keeping with the spiritual component of the bps-s framework, this article will primarily discuss the inclusion of religious activities and components within the kffc program. case example based out of ontario, canada, the kffc program uses martial arts (ma) as a conduit for fostering physical, mental, social, and spiritual health. the program, which is offered free of charge, consists of four classes a week year-round: one for braganza & oliveira 96 june 2022. christian journal for global health 9(1) children (aged seven to 15); one for adults (aged 16 and up); one for the program’s volunteer instructors; one for junior (youth) volunteer leaders. operating since 2013, the program serves around 40–60 children and 20 adults weekly in the children’s and adult’s classes, respectively.12 its participants are diversified by gender, ethnicity, culture, first language, level of education and income, ability, and religion, among other demographics. the thursday night classes were designed to build community and to teach kung-fu to children and adults in a way that reflects christian values through sport in order to intentionally expose nonchristian students to christian beliefs and values and to encourage the spiritual growth of new and mature christians. the monday night classes were designed to advance instructors in their own ma training and to teach them how to instruct others in ma and in sharing the gospel. during all classes, devotional lessons and prayer are incorporated. in order to develop kffc, program developers drew upon ma research. at the time that it was developed (in 2012), there was less research available. this article features some of the research used at the time as well as more recent research for the purposes of advancing knowledge, particularly for those who may be interested in developing a similar program. brief introduction to the sport of kungfu ma were historically used to train for war and have been practiced for centuries.13 the advent of modern weapons (e.g., guns) caused ma to become a sport used in the western world for physical training as well as for mental, social, and spiritual development.13,14 kung-fu (k-f), specifically, is considered a “traditional” ma emphasizing “philosophy and tradition, pattern practice/kata, respect, meditation, self-control, [and] non-aggression”13 (p. 10). k-f is also considered a “hard” ma because of its focus on generating speed and force in its techniques and strikes.13,14 in their typical curriculum, k-f students learn combinations of hand strikes and kicks that can be practiced with or without equipment such as punching bags.15 these techniques are also put into choreographed patterns of movements called “katas”14,15 (p. 2). through activities called “sparring,” students also practice their techniques on a partner’s body in a controlled way.15 k-f also incorporates markers of other sports such as aerobics.16 fighting techniques taught in k-f are not used to conquer or harm opponents, but rather used for artistic expression, to develop athleticism and gain physical education, to develop morality, and to “improve one’s self mentally, socially, and (potentially) spiritually”17 (p. 68). all lessons are transferrable to everyday living. case example: applying the bps-s framework to develop the kffc program biological the kffc program was designed to help students engage in a healthier lifestyle. increasingly, k-f is being used in programming for young, middle, and older adults14 because of its various positive biological outcomes such as improved flexibility, coordination, speed, and endurance.18 training in k-f can quickly facilitate physical benefits (within weeks)19 regardless of the age at which a student begins their training.14 physical activity can combat a sedentary lifestyle that can lead to obesity in childhood, adolescence, or in later life,18 and prevent diseases (e.g., cancer, diabetes) and premature, preventable death.14 drawing upon this research, in the kffc program, children, youth, middle aged, and older adults are encouraged to be physically active by engaging in weekly training sessions in order to improve their fitness (e.g., flexibility, coordination, endurance). 97 braganza & oliveira june 2022. christian journal for global health 9(1) the kffc program intentionally includes physically intense training activities. this is because the moderate-to-vigorous training intensity of k-f can contribute to many positive elements of health such as improved cardiovascular fitness, increased muscular strength and endurance, and improved skeletal status (e.g., bone strength).14 in the kffc program, students also practice techniques (e.g., kicking, punching) and katas meant to improve their coordination, flexibility and balance14 which research suggests is particularly advantageous for vulnerable populations such as older adults at risk of falls,16 or persons with visual impairments.20 some scholars suggest that for some, practicing k-f for as little as 30 minutes per session twice a week for a month can lead to improvements in balance and neuromuscular control.16 although kffc, in keeping with traditionally hard ma, was intended to be physically intense, it was also designed to allow students to train within their abilities. additionally, kffc’s belt ranking system ensures that fitness requirements increase incrementally in difficulty as students progress in their training.21 psychological the connection between ma and improved psychological well-being is well established15,22 in children, adults, and older adults.23,24 as such, the kffc program designers incorporated activities meant to increase students’ psychological health and well-being. more specifically, kffc students learn and practice k-f techniques such as sparring, self-defence, and katas that the research suggests can increase their cognitive functioning such as attention, working memory, long-term memory, speech, intelligence,16,25 judgement, planning, and conflict resolution.15,22 improvements in cognitive functioning were expected to span all ages and developmental stages. additionally, it was expected that psychological improvements would be realized quickly since some researchers have found that after only a few months of training, older adults see improvements in memory,16,23 motor reaction time, and divided attention.16 during their training, kffc students also learn and practice challenging techniques that become increasingly cognitively demanding in order to facilitate improved psychological functioning. during the kffc program, students participate in what some call rituals, which are repeated practices26 such as bowing into and out of the training area before and after classes and repeatedly preforming katas. in keeping with research, it was theorized that such ritualized activities could lead to improvements in self-discipline and self-control.26 through training activities such as partner drills, kffc was designed to improve mood and emotional well-being23,27 as well as foster resilience and coping. such training activities were also built into the kffc curriculum to help students learn how to (and that they can) push themselves beyond their limits, which research suggests will give them confidence in their ability to persevere and grow through difficultly.28 in keeping with ma research, specific partner drills (e.g., self-defence, sparring) were also incorporated into the kffc program in order to increase students’ tolerance of distress since they are repeatedly exposed to stressful29 and threatening situations,30 and taught how to positively respond.28 kffc program designers intentionally included a variety of individual and partner training activities such as katas, conditioning, sparring, and self-defence based on research suggesting that such training will support those with mental illnesses. for instance, ma training is an effective methodology for supporting children with autism spectrum disorder such as by developing social skills and improving overall attitude31 and executive functioning (e.g., working memory, emotional regulation, behaviour inhibition).15 research suggests that adults who train in karate are less prone to depression,32 and ma training can improve perceived quality of life.14 kffc incorporates modelling,33 the process of learning behaviour by observing another person. in ma, it is important that instructors model positive braganza & oliveira 98 june 2022. christian journal for global health 9(1) behaviour during training (e.g., self-control, respect) so students can learn and emulate it.34,35 modelling is particularly important for students who lack positive or supportive role models (e.g., parental figures).35 kffc instructors are expected to model excellent character25 and have a combination of leadership and mentorship abilities.36 further, kffc instructors must demonstrate care toward students, such as by showing faith in their abilities35 and by offering positive feedback.37 such care can boost students’ confidence and self-esteem35 and positively influence behaviour.34 in the kffc program, positive modelling is not just demonstrated by adult leaders, but also by children and youth. as is typical in many ma programs, more advanced students are given teaching responsibilities.36 more than this, in the kffc program, children and youth can develop their leadership skills by taking a youth leadership development course and then serving as models for other students. social research suggests that ma can foster positive social functioning, which is important because effectively engaging in social exchanges (e.g., making eye contact or taking turns conversing) can be particularly challenging for some, including those with mental illnesses such as autism.38 kffc was designed to facilitate improvements in social functioning by incorporating training activities such as self-defence that would allow students to work with and give feedback to their teammates to purposely facilitate social exchanges. additionally, in the kffc program, within their first few weeks of training, students are encouraged to begin demonstrating, and even informally teaching, techniques to their peers. in the kffc program, a created sense of belonging was important for all students, including those who experience social exclusion (e.g., due to a mental illness).39 one program aim was to intentionally bring students together across demographic divides. this was to be accomplished in two ways. first, an intentional recruitment strategy was to be used to recruit program participants from neighborhoods identified as being demographically diversified. then, the program was designed to ensure that students work in groups of diversified peers to practice their techniques. relatedly, in many ma programs, including kffc, the whole family trains together. this allows parents and children to bond over a common interest.35 kffc was also designed to promote prosocial behaviours such as respect, empathy,40 and compassion28 that students demonstrate in and outside of training. in kffc, as in ma, students can learn how to remain calm under duress and regulate potentially harmful impulses.28 in kffc, students are taught through verbal lessons and k-f techniques (e.g., sparring, self-defence) how to react nonviolently37 toward others in situations when conflict is present.28 furthermore, they are taught peaceful conflict resolution strategies such as positive bystanding behaviours.37 kffc program developers were also careful to construct the program in a way that students would be explicitly taught skills to prevent aggressive or violent thinking, attitudes, and behaviours. kffc students are taught to respond to their partner at the end of a sparring match with gratitude through a symbolic touching of their gloves.28 this action teaches students that resolution and harmony can be achieved after a conflict.28 spiritual the kffc program is rooted in spirituality, which in this case, refers specifically to christian religious faith. it is, therefore, an example of a community-based program (i.e., a program interested in broad social change) that is informed by religion.41,42 this means that activities designed to promote spiritual health were intentionally interwoven within the program. kffc leaders were trained to demonstrate christian values such as love and patience in every interaction with students, families, and community members. the assumption was that by integrating spirituality, students would feel listened to and deeply appreciated, cared for, and loved. this was especially important given kffc’s target audience: vulnerable persons such as those 99 braganza & oliveira june 2022. christian journal for global health 9(1) with mental illnesses, struggles with substance use, low income, and new immigration status.12,43 spirituality was also integrated into the kffc program in light of research suggesting that it can positively impact people in a myriad ways.44 for instance, spirituality can positively influence mental health.45 for at-risk individuals, spirituality can foster positive health and mental outcomes, teach healthy coping mechanisms, and improve life satisfaction and subjective well-being.46 in keeping with traditional ma programs, kffc was designed to encourage students to develop in their character.41 the kffc program, however, articulates them in accordance with christian biblical values, virtues, and attributes. through techniques and verbal lessons (i.e., devotionals) offered at the end of classes, kffc teaches students what ma scholars would deem to be “virtuous character strengths” such as “courage, benevolence, wisdom, temperance and justice”28 (p. 2), respect, peace, and self-control.41,45 research suggests that religious engagement offers individuals the opportunity to be a part of a community, which in itself, can facilitate the formation of strong social connections. furthermore, through religious affiliations, individuals are provided opportunities to seek assistance and advice.47 by incorporating religious engagement into the program, such as through bringing together non-christian and christian-identifying students, the kffc program was designed to expand participants’ social circles. kffc was developed to facilitate communal religiosity such as by integrating group prayer at the end of each training session and offering a youth-led, bible study after class. engaging in public religiosity, such as attending religiously-based activities, can increase life satisfaction.46 engaging in group prayer and bible readings can improve social relations by increasing the ability to forgive others for wrongs and motivation to repair damaged relationships.48 kffc was also designed to encourage students to pray, read their bibles, and attend religious activities (e.g., church, bible studies, alpha courses, etc.) because spiritual growth, and more specifically, immersion in the bible and theological teachings, can facilitate spiritual maturity and discipleship.49 overlapping, interconnected, and multidimensional bps-s benefits categorizing kffc’s activities and assumed outcomes in light of the bps-s framework is challenging because in keeping with ma research, this program was intended to promote overlapping and interconnected physical, mental, social, and spiritual health.17,45 like ma, the kffc program was designed to teach students in all age groups how to overcome physical, mental, and spiritual hardships.17,50 group exercise can foster psychological development such as self-efficacy beliefs,51 and lead to social benefits such as friendship development and a sense of belonging.10 sport, in particular, can overcome barriers (e.g., communication) making it an accessible social option.10 there are also benefits to having social support when trying to increase one’s level of fitness.14 martial arts can reduce disordered behaviours associated with panic disorders, generalized anxiety disorders, social phobias, obsessive compulsive disorders, binge eating, anorexia nervosa, alzheimer’s disease, dementia, and depression.52 this is important because kffc’s target demographic includes those struggling with low income, who, research suggests, are more likely than those who are wealthy to suffer from depression due to economic stressors.53 the promotion of non-violence is another outcome of ma that is connected to various bps-s categories. philosophical underpinnings common to ma such as “respect for others, humility, confidence, responsibility, honesty, perseverance, and honor”54 (p. 1137) can enhance character development and facilitate a number of psychological and social benefits such as awareness of emotions (e.g., anger) and increased altruism.37 these philosophical underpinnings also align with braganza & oliveira 100 june 2022. christian journal for global health 9(1) spiritual well-being such those fostered by “the fruits of the spirit” (e.g., patience, peace) (see galatians 5:13–23). ma, then, can allow students to learn the biblical values needed to lead lives of faith. since spirituality is connected to other bps categories, this is important. spiritual well-being can lead to lowered onset rates of many physical conditions including coronary disease, heart attacks, emphysema, cirrhosis, liver disease, and hypertension.55 spirituality has even been positively correlated with longevity.56 additionally, the interconnected philosophical and spiritual underpinnings of the kffc program were theorized to encourage increased social and civic engagement, such as through volunteering. research suggests that persons are more likely to engage and stay involved in volunteer activities if they feel as though they are part of the team, receive regular encouragement, and have their work recognized.56 mentorship, which can be connected to volunteerism, can increase positive selfperception, increase academic performance, decrease high-risk behaviours, and improve interpersonal relationships.57 lessons learned this article offers an example of a program that was intentionally designed such that program operations (e.g., curriculum) were informed by the bps-s framework. for example, activities were incorporated into the kffc curriculum that research suggests would lead to increases in students’ biological, psychological, social, and spiritual health, as well as promote overlapping areas of health (social and spiritual). training activities such as hand strikes, kicks, and katas, in particular, can lead to biological and psychological improvements such as in strength, endurance, memory, and selfconfidence. partner training drills can advance biological, psychological, and social health. leadership development activities can foster psychological and social health. kffc leaders were instructed to teach in ways that would model prosocial behaviour. religious curricular components, such as verbal lessons and activities meant to animate religious engagement (e.g., group prayer, bible study), were incorporated to promote spiritual, social, and psychological health. by detailing some of the ways in which the kffc program was informed by the bps-s framework, this case example highlights the potential and advantages of using a bps-s framework to develop programs aimed at providing holistic care: that is, programming that considers the promotion of biological, psychological, social, and spiritual health and well-being relative to one’s self, others, and community. this programming includes supporting persons from diversified populations, including those who are vulnerable. this case example also illustrates how incorporating bps and s categories into program activities can have multidimensional impacts on health. it also overtly demonstrates the importance of adding a spiritual component to the bps framework to achieve more holistic health. implications and recommendations for the future community-, sports-, and faith-based programming which incorporate the bps-s framework, such as the kffc program discussed in this article, have the potential to contribute to social service and community development activities. because of its reach,58 assets, transferrable intervention outcomes,44 and comparatively low implementation cost,44 scholars and practitioners are urging service providers to incorporate ma such as k-f into services such as psychotherapy.28 the additional inclusion of spirituality may offer a beneficial alternative to traditional communityand sports-based programming. for students across all demographics and age categories, such a program can have nuanced biological, psychological, social, and spiritual impacts. in typical programming, each of these elements of care would be offered by separate care providers. 101 braganza & oliveira june 2022. christian journal for global health 9(1) because of its focus on pro-social behaviours, such as compassion,28 empathy, civic engagement, and leadership, a community-, sports-, and faith-based programming such as kffc can be useful for community development activities and as a strategy for teaching interpersonal conflict resolution and relationship-building. ultimately, this case example illuminates how 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2012. 32. moore b, dudley d, woodcock s. the effect of martial arts training on mental health outcomes: a systematic review and meta-analysis. j bodywork movem therap. 2020;24(4):402-12. https://doi.org/10.1016/j.jbmt.2020.06.017 33. bandura a, ross d, ross sa. transmission of aggression through imitation of aggressive models. j abnorm soc psych. 1961;63(3):575-82. https://www.apa.org/pubs/journals/abn 34. lantz j. family development and the martial arts: a phenomenological study. contemp fam ther. 2002;24(4):565‐80. https://doi.org/10.1023/a:1021221112826 35. twemlow sw, sacco fc. the application of traditional martial arts practice and theory to the treatment of violent adolescents. adolescence. 1998;33(131):505-18. https://www.worldcat.org/title/adolescence/oclc/1788 916 36. twemlow sw, biggs bk, nelson td., vernberg em, fonagy p, twemlow sw. effects of participation in a martial arts based anti‐bullying program in elementary schools. psychol schools. 2008;45(10):947‐ 59.https://doi.org/10.1002/pits.20344 37. goodman rl, burton md. the inclusion of students with besd in mainstream schools: teachers’ experiences of and recommendations for creating a successful inclusive environment. emot behav diffic. 2010;15(3):223‐37. https://doi.org/10.1080/13632752.2010.497662 38. phung jn, goldberg wa. mixed martial arts training improves social skills and lessons problematic behaviors in boys with autism spectrum disorder. res autism spec dis. 2021;83:1-9. https://doi.org/10.1016/j.rasd.2021.101758 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 103 braganza & oliveira june 2022. christian journal for global health 9(1) 39. sutton c. child and adolescent behaviour problems: a multidisciplinary approach to assessment and intervention. new jersey: wiley‐blackwell; 2000. 40. mickelsson tb. modern unexplored martial arts — what can mixed martial arts and brazilian jiu-jitsu do for youth development? eur j sport sci. 2020;29(3):386-93. https://doi.org/10.1080/17461391.2019.1629180 41. bowpitt g. working with creative creatures: toward a christian paradigm for social work theory, with some practical implications. british j social work. 2000;30:349-64. https://doi.org/10.1093/bjsw/30.3.349 42. gordon wl. the eight components of christian community development [internet]. [updated no date; cited 2021 oct 15]. available from: http://www.ccda.org/philosophy 43. gitterman a, editor. handbook of social work practice with vulnerable and resilient populations. 3rd ed. new york: columbia university press; 2014. 44. páez d, martínez-zelaya g, bilbao m, garcía fe, torres-vallejos j, vargas s, et al. religiosity, psychosocial factors, and well-being: an examination among a national sample of chileans. psychol reli spiritual. 2018;10(2):138–45. https://doi.org/10.1037/rel0000156 45. harwood a, lavidor m, rasovsky y. reducing aggression with martial arts: a meta-analysis of child and youth studies. aggress violent behav. 2017;34:96-101. http://dx.doi.org/10.1016/j.avb.2017.03.001 46. tsai j, rosenheck ra. religiosity among adults who are chronically homeless: association with clinical and psychosocial outcomes. psych services. 2011;62(10):1222-4. http://doi.org/10.1176/ps.62.10.pss6210_1222 47. braganza me, hoy s, lafrenière g. “they are my family”: exploring the usage of spiritual and religious supports by survivors of intimate partner violence. j relig spiritual soc work. 2022;41(1):23-50. https://doi.org/10.1080/15426432.2021.1955427 48. vasiliauskas sl. the effects of a prayer intervention on the process of forgiveness [doctoral dissertation]. george fox university; 2010. 49. stark r. the rise of christianity: how the obscure, marginal jesus movement became the dominant religious force in the western world in a few centuries. princeton, nj: princeton university press; 1996. 50. moore b, woodcock s, dudley d. developing wellbeing through a randomised controlled trial of a martial arts based intervention: an alternative to the anti-bullying approach. int j environ res public heal. 2019;16(81):1-18. https://doi.org/10.3390/ijerph16010081 51. christensen u, schmidt l, budtz-jørgensen e, avlund k. group cohesion and social support in exercise classes: results from a danish intervention study. heal educ behav. 2006;33(5):677-89. http://dx.doi.org/10.1177/1090198105277397 52. zschucke e, gaudlitz k, ströhle a. exercise and physical activity in mental disorders: clinical and experimental evidence. j prevent med public health. 2013;46(suppl 1):s12-s21. https://doi.org/10.3961/jpmph.2013.46.s.s12 53. taylor jj, grant ke, amrhein k, carter js, farahmand f, harrison a, et al. the manifestation of depression in the context of urban poverty: a factor analysis of the children’s depression inventory in low-income urban youth. psychol assess. 2014;26(4):1317-32. https://doi.org/10.1037/a0037435 54. trulson me. martial arts training: a novel “cure” for juvenile delinquency. human rela. 1986;39(12):1131-40. https://doi.org/10.1177/001872678603901204 55. george lk, larson db, koenig hg, mccullough me. spirituality and health: what we know, what we need to know. j social clin psychol. 2000;19(1):10216. http://dx.doi.org/10.1521/jscp.2000.19.1.102 56. kovacs pj, black b. volunteerism and older adults: implications for social work practice. j gerontol social work. 2000;32(4):25-39. https://doi.org/10.1300/j083v32n04_04 57. osterling kl, hines am. mentoring adolescent foster youth: promoting resilience during developmental transitions. child family soc work. 2006;11(3):24253. https://doi.org/10.1111/j.1365-2206.2006.00427.x 58. terry cm. the martial arts. phys med rehab clinics n amer. 2006;17(3):645-76. https://doi.org/10.1016/j.pmr.2006.05.001 peer reviewed: submitted 1 nov 2021, accepted 28 march 2021, published 20 june 2022 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank braganza & oliveira 104 june 2022. christian journal for global health 9(1) competing interests: none declared. correspondence: morgan e. braganza, redeemer university, canada. mbraganza@redeemer.ca cite this article as: braganza me, oliveira j. using the bio-psycho-social-spiritual framework in holistic health and well-being: a case example of a communityand faith-based sports program. christ j glob health. june 2022; 9(1):94-104. https://doi.org/10.15566/cjgh.v9i1.593 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank introduction case example brief introduction to the sport of kung-fu case example: applying the bps-s framework to develop the kffc program overlapping, interconnected, and multidimensional bps-s benefits lessons learned implications and recommendations for the future references commentary nov 2016. christian journal for global health, 3(2): 113-128. the emerging health paradigm in the 21st century: the formative first 1000 days of life jose miguel de angulo a , luz stella losada b a md, mph, regional director for latin america, map international, bolivia b mhpe, community health specialist, map international, bolivia abstract during the 20th century western society's thinking regarding health and wellbeing underwent profound and rapid changes. towards the end of the century, a health paradigm based on social health determinants emerged, providing a strong foundation for influencing priorities in global health. in this paper we will present evidence that supports a new paradigm. it avers that human health and development is founded on infants’ brain architecture and their capacity to transform the brains and lives of adults. neuroscience now shows how the brain architecture of the person becomes established during the intrauterine period and the first two to three years of life. this brain architecture determines the capacity of the organism to self-regulate its biological, emotional, cognitive, and interactional processes with the environment. the more robust this brain architecture, the more potential and capability that individual has to enjoy physical, emotional, and mental health as well as his/her capacity to contribute to the health and wellbeing of others. we hold that the transformative value of infants to society is biblical. this new understanding can generate a shift towards a focus on early infancy as the best strategy to foster development of healthy and sustainable societies. introduction and overview the 20th century saw thinking concerning health and wellbeing undergo profound and rapid changes. two health paradigms based on disease management influenced much of the theory and practice surrounding health in the western world. 1 both paradigms contributed to the alleviation of suffering and ill health. however, both showed an inadequacy to foster health at the level of society. towards the end of the 20th century, a third and broader paradigm based on social health determinants emerged, fostering a shift from the causes of pathology to what produces health and wellbeing. this social health determinants paradigm provided a foundation for a fourth paradigm that is positioning itself in global health thinking today. 1 this newly emergent paradigm builds on the experiences and advances achieved during the 20th century, but shifts the focus to the architectural development of infants' brains and their ability to transform the brains of adults. the social health determinants paradigm — what we call the third paradigm — placed its hope in institutions and new systems as the source of social 128 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. change and transformation. this was the approach that would resolve the inequities and lack of access to resources and livelihoods that maintain large sectors of society in poverty and vulnerability to ill health. the paradigm expected that institutions and systems held the solutions and had the power to create needed transformations. although social health determinants indeed played a role in the health and wellbeing of communities and nations, the paradigm missed the mark by excluding an important element of human reality. this missing element has become evident as a result of a new understanding of social development and social dynamics involving the development of the infant’s brain. the core concept here is that society can only become healthy when human beings develop robust and healthy brain architecture during the first days of life. this paper reviews evidence from neuroscience research demonstrating that being born human does not necessarily ensure that a child will become humane. rather, the ability to live harmoniously with other humans and with nature in a meaningful and healthy way are linked to the infant brain’s capacity to understand others, to care, to share, to listen, to value, and to be empathetic. the foundation of these characteristics is established in early infancy by the experience of being cared for, shared with, listened to, valued, and nurtured. humane caregiving fosters a brain architecture that is able to express our capacity to be humane. inhumane caregiving erodes that human’s capacity to be humane. this paper proposes a new paradigm that human health and development is founded on the infants’ brain architecture and the infants’ capacity to transform the brains and lives of adults. the development of infants´ brain architecture and perturbations in these processes can have long-term effects on the brain’s structural and functional capacity. this opens a different way of understanding human behavior and how society functions. 2,3,4,5,6,7,8,9 we will demonstrate how government and institutions need to focus on prenatal and early infancy programs and how to provide the best possible support to parents in order to fulfill their parental responsibilities for the 21 st century if we want to develop a more humane and just society for all. the report of the commission on social determinants of health from the world health organization “closing the gap in a generation” clearly states that we will not be able to overcome the large inequalities in the planet unless we focus on early child development (ecd). 10 in the section of “a more comprehensive approach to the early years in life,” the report bases its arguments on research findings like these: the science of ecd shows that brain development is highly sensitive to external influences in early childhood, starting in utero, with lifelong effects. the conditions to which children are exposed, including the quality of relationships and language environment, literally ‘sculpt’ the developing brain (mustard jf (2007). experience-based brain development: scientific underpinnings of the importance of early child development in a global world. in: young me, richardson lm, eds. early child development: from measurement to action. washington, dc, world bank, pp. 43-71). . . healthy development during the early years provides the essential building blocks that enable people to lead a flourishing life in many domains, including social, emotional, cognitive, and physical well-being (ecdkn [2007a]. early child development: a powerful equalizer. final report of the early child development knowledge network of the commission on social determinants of health. geneva, world health organization.). . . many challenges in adult society have their roots in the early years of life, including major public health problems such as obesity, heart disease, and mental health problems. experiences in early childhood are also related to criminality, problems in literacy and numeracy, and economic participation. 10 because children’s brains are substantially changed by experiences during pregnancy and the first two years, there is a window of opportunity for 115 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. programs that promote their development as healthy and productive citizens. a child’s quality of life as well as the contributions that the child eventually makes to society as an adult can be traced to his or her first years of life and how that child’s parents provided appropriate care. 11,12 if the infant has secure attachments and support for growth in language, motor skills, adaptive abilities, and social-emotional functioning during the first 1000 days of life (including the intrauterine period), the child is more likely to succeed in school, develop healthy relationships, and contribute later in life to society. 13 there are “sensitive periods,” or windows of opportunity for certain specific developments to take place. 14,15 for example, the sensitive period of phonology is from the sixth month of fetal life through the first year. 16 similarly, proficiency of language is achieved before 18 months of age. significant disparities in language-processing efficiency exist depending on whether parents talk more and use richer vocabulary and gestures in interactions with infants. 17 the zero-to-three age period is vital for the production and subsequent retention of synapses; inadequate interactions during this period can have large and lasting negative effects on subsequent development. 18 the maternal effect on stress responses in the offspring can directly affect gene expression (epigenetics) controlling the development of the brain and nervous system. 19 current research confirms how critical it is to provide infants with rich environments and rich interaction with their parents. for example, when analyzing the capacity to develop and use language, researchers have found significant disparities in vocabulary and language processing efficiency already evident at 18 months when comparing infants from higherand lowersocio economic status families. by 24 months, there was a six-month gap between socio economic status groups in their processing skills, something that is critical for language development during the rest of their lives. 20 other studies show that the so called “early catastrophe: the 30 million word gap by age 3” persists and increases throughout life, having a broad impact on cognitive development that includes nearly every aspect of language ability. 21,22,23 this reveals an urgent social need for public policies and programs that foster quality parent-child interactions and provide guidance in how to build more supportive communities. the importance of the first 1000 days should inform the development of public health policies and programs aimed toward the family. 24 it is also a call for churches, ngos and institutions engaged in community development to play a stronger role in supporting comprehensive child development. during the intrauterine period and the first two to three years of life, development of brain architecture determines the capability of the human organism to regulate its biological, emotional, cognitive, and interactional processes with the environment. the more robust an individual’s brain architecture, the more potential and capability that individual has to enjoy physical, emotional, and mental health at the personal level and to contribute through his/her life to the health and wellbeing of others. targeting public policies and programs specifically to pregnant women and parents with infants can be a shortcut to proposals to modify social health determinants. even countries that have had successes with social health determinants have not necessarily produced healthy families and communities. many people in such countries are not very healthy, but are high consumers of medicines with frequent diagnoses of diseases that require costly resource expenditures and continue to exhibit risky behaviors. they may have overcome most problems of material poverty, but face a relational poverty that generates serious mental and physical health problems. 25,26,27,28 the capacity of the individual to construct meaningful healthy relationships determines health through a variety of mechanisms. these include empathy and commitment to engage with others’ needs and problems, increased collective creativity, agreement on common goals for the 128 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. wellbeing of all, commitment to produce in teams and groups, and engagement in transformative processes aimed at reducing social, economic, and political factors that undermine the wellbeing of all. some studies, such as the “jamaica study” with a 20-year follow-up, show that even very impoverished communities can have physically and mentally healthy children if parents develop basic skills to change the way adults see, listen, and interact with infants. 29,30 other examples of effective programs that focus solely in the child instead of pursuing broad changes related to social health determinants are abecedarian, high/scope perry preschool programs, and early head start, among others. 31,32,33,34,35 although some discussions on social health determinants previously acknowledged early infancy as one more variable to consider in making societies healthier, current research shows that early infancy plays a central role. mental representations of the fetus in pregnant women have implications in the ways mothers view themselves, how they view the fetus, and how the two interact. paternal — fetus attachment also influences the way that infants will be treated. 36,37,38 negative, idealized, or incoherent prenatal representations predict postnatal parent-child relationship problems during the child’s first year. a mother’s and father’s sensitivity is linked to their ability to perceive, interpret, and affectively share and mirror their young child’s emotional states. this leads to a high capacity for responding to infant distress. 39,40 modification of mental representations of her fetus with a pregnant woman living in impoverished conditions affects the future of that mother, her mental health, and the way she interacts with the infant. this can change the child’s future without experiencing other types of interventions that involve social determinants. 41,42,43,44,45 these studies show how it is possible to bring radical changes about in the life of future generations without necessarily waiting until social health determinants can be transformed. however, poverty is not necessarily the major cause of poor socio-emotional development in infants. maternal preconceptions about parenting are predictors of a child’s temperament, sensitivity, and empathy with good pro-social behaviors, even for mothers belonging to low socioeconomic groups. 46 secure attachment is a powerful force creating an “enduring affective tie” that has a “strong reciprocal” quality (parent-to-infant and infant-to-parent) that generates changes in all those involved. 47 the power of brains to shape each other in paternal/maternal — fetus/infant interactions was unknown until this century. if social and family systems can be transformed to express full respect and empathy for infants and to respond to their efforts to communicate needs and interests, those infants will develop robust brain architecture. infants that have profound and consistent experiences of empathy during their first months of life will develop a strong capacity to experience empathy and love toward those with whom they interact in other phases of their lives. this in turn produces a framework or platform that will enable these individuals to establish trusting and responsible relationships with others, with god, and with nature. and though social health determinants play a role in this development process, strategically focusing on infants’ brain development will help to bring about the transformation of those systems responsible for social health determinants. centrality of infant brain development in the emerging health paradigm there is accumulating evidence that identifies early infancy as central to health and development. the publication, inbrief, “the foundations of lifelong health,” provides an extensive review of evidence accumulated during the last decade: a vital and productive society with a prosperous and sustainable future is built on a foundation of healthy child development. positive early experiences provide a foundation for sturdy brain architecture and a broad range of skills and learning capacities. . . advances in neuroscience, molecular biology, and genomics have converged on three 117 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. compelling conclusions. early experiences are built into our bodies, creating biological “memories” that shape development, for better or for worse. toxic stress caused by significant adversity can produce physiological disruptions that undermine the development of the body’s stress response systems and affect the architecture of the developing brain, the cardiovascular system, the immune system, and metabolic regulatory controls. these physiological disruptions can persist far into adulthood and lead to lifelong impairments in both physical and mental health. 48 dr. jack p. shonkoff, the chair of the national scientific council on the developing child, presented the conclusions of multiple years of research into the science of early childhood development. these were his main points: the healthy development of all young children benefits all of society by providing a solid foundation for responsible citizenship, economic productivity, lifelong physical and mental health, strong communities, and sustainable democracy and prosperity… relationships are the “active ingredients" of early experience. nurturing and responsive relationships build healthy brain architecture that provides a strong foundation for learning, behavior, and health. when protective relationships are not provided, elevated levels of stress hormones (i.e., cortisol) disrupt brain architecture by impairing cell growth and interfering with the formation of healthy neural circuits. 49 research conducted and published by the u.s. centers for disease control on “the relationship of adverse childhood experiences to adult health status” pushes us to completely rethink the traditional way of understanding the “history of diseases” (from the moment of exposure to causal agents until recovery or death). this research opens the door to a new way of understanding why diseases are present in society. dr. vincent j. felitti and robert f. anda are the authors of the adverse childhood experiences (ace) study. 50 this large study examined the health, social, and economic effects of adverse childhood experiences over the lifespan of 18,000 participants in the usa. an individual’s childhood experiences shaped the epidemiological profile of that child in his/her adult life, as well as the epidemiological profile of the entire nation. adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs . . . many chronic diseases in adults are determined decades earlier, in childhood. 51 the relationship of adverse childhood experiences and mental health are shown in the use of psychotropic medications in adults: the strong relationship of the ace score to increased utilization of psychotropic medications underscores the contribution of childhood experience to the burden of adult mental illness. moreover, the huge economic costs associated with the use of psychotropic medications provide additional incentives to address the high prevalence and consequences of childhood traumatic stressors. 52 linked to mental illness is the lack of empathy that children experience. empathy underlies trust, altruism, collaboration, love, and solidarity. a failure to empathize is a key part of most interpersonal and social problems, including crime, violence, war, racism, child abuse, and inequity, among others. empathy is associated with pro-social behavior, and expression of sensitivity and responsiveness by parents. infants experiencing empathy thorough the care and love of parents with secure attachment will display empathy toward other people throughout their lives. insecure and disorganized attachments obstruct the cultivation of empathy, which, on a broad social level, can easily lead to a society in which no one wants to live because of the cold, violent, chaotic, and terrifying interactions of all against all. parental sensitivity, responsiveness, and proactive involvement with infants and toddlers play a key role in their 128 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. capability to express empathy and prosocial behaviors in future stages of their lives. 53,54,55,56,57,58,59,60 the power of the infant’s brain to transform the parents’ brains because brain architecture is constructed during pregnancy and especially during the first two years of life, parents play a critical role in the generation of a robust brain architecture. research also shows how the infant’s brain connects with, synchronizes with and modulates the parent´s brain and equips the parents to become sensitive and responsive to the infant`s expressions of her developmental needs. 61 appropriate interaction with infants generates changes in the father’s and mother’s brains, fostering plasticity and new ways of thinking, interacting, and engaging with the world. for example, in bi-parental mice (raised by father and mother), there is increased neurogenesis in the paternal olfactory bulb in the prefrontal cortex (pfc) and hippocampus. these male mice can even recognize their offspring as adults if they interacted with their infant pups. 62 other research shows how engaged parents experience plasticity and how caregiving impacts their brain. its conclusion is that . . . the brains of parents are clearly different from those of non-parents, having been changed by the presence of offspring and corresponding hormonal fluctuations. available evidence suggests that structural reorganization occurs in the hippocampus and pfc (of mothers and fathers). 63 the baby’s interaction with the father “rewires the daddy brain . . . love spurs the very growth of the parental brain and even causes new brain cells to develop . . . those parental impacts on your brain begin long before birth, setting into motion major factors for your future relationships.” 64 in the first few days after birth, changes occur in the brains of both the father and the baby, depending on whether the father is engaged with the child or not. neuroscientists have helped us to understand the father-child bond, and have found a hook that makes a father stay involved after birth. 65 there are many new scientific findings from neuroscientists, animal behaviorists, geneticists, and developmental psychologists, among others, that show the profound physiological connections between children and fathers, and the profound changes this interaction generates. 66.67.68 these epidemiological studies on adverse experiences and lack of empathy — paired with research on the ingrained capacity of the infant’s brain to tune, modulate, and synchronize the adult’s brain bringing plasticity and changes in the way the adult thinks, feels, and acts — are creating fascinating new ways to understand humans and society. the application of the science of early childhood development creates opportunities for very innovative health and development programs. 69 determinants of infant brain development parental education and especially family income play a very important role in the type of brain architecture an individual is going to have. income strongly relates to brain structure among the most disadvantaged children. socioeconomic disparities are associated with differences in cognitive development and, therefore, with the type of life those individuals will have. these relationships were most prominent in brain cortex regions supporting language, reading, executive functions, and spatial skills; cortex surface area mediated socioeconomic differences in certain neurocognitive abilities. among children from lower income families, small differences in income were associated with relatively large differences in cortex surface area. 70,71,72 programs can make a large difference by engaging with impoverished sectors of society: certainly both school-based and home-based interventions have resulted in important cognitive and behavioral gains for children facing socioeconomic adversity, and small increases in family earnings in the first 2 years of a child’s life may lead to notable differences in adult circumstances. 73 119 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. the report of the task force on the family from the american academy of pediatrics states, “families are the most central and enduring influence in children’s lives. . . the health and well-being of children are inextricably linked to their parents’ physical, emotional and social health, social circumstances, and child-rearing practices.” 74 families need the support of public policies and programs that enables them to care for five key determinants of healthy brain architecture development: a) proper nutrition and access to health services, b) psycho-emotional nourishment (with strong bonding and secure attachment), c) cognitive nourishment, d) capacity development for selfagency, and e) safe and enriching environments (figure 1). 75 these five determinants of brain architecture development synergistically interact with each other, and the deficiency of one or more of these determinants may lead to serious impairments in a person’s life and health. figure 1: the central causal story 75 developing countries will not be able to overcome poverty, violence, and mental and physical illness unless there is a paradigmatic shift concerning where efforts should be focused. the lack of commitment to care for the determinants of infant brain development will maintain most of the problems 128 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. developing societies face today. the first annual report of scotland’s civil society coalition formed by 98 institutions and many researchers published on december 2014 states: our coalition is built upon three realities: 1. far too many babies and toddlers have their immediate wellbeing compromised (and their life chances diminished) by being ‘dealt a bad hand’ during the crucial developmental period from conception through age two. although later interventions can be very helpful, there is no second chance to make a good first impression on the brains, bodies and behaviors of babies and toddlers. 2. our society and systems remain too reactive – usually waiting until children have already been adversely affected and then rushing in to ‘clean up the mess.’ in 2011, the christie commission calculated that a huge amount of scotland’s resources around 40% of all public expenditures are spent dealing with problems that could have been prevented. this remains true today. 3. ‘closing the gap’ – in terms of health outcomes education attainment and other inequalities – is absolutely the right thing to do. however, ‘preventing the gap’ from opening in the first place is the urgently needed new priority. this requires dramatically increased investment in, and improved action during, the first 1,001 days of life (from pre-birth to pre-school). 76 this coalition acknowledged that governments and societies need to focus exclusively on two issues: the primary prevention of harm (i.e., keeping bad things from happening in the first place); and, caring the first 1,001 days of life (from pre-birth to preschool). that is why they chose as title of the report: “social justice begins with babies.” the new open horizon governments and institutions, especially churches, working with families with infants need to know about the key personal health determinants to develop robust and healthy brain architecture for a healthy and meaningful life. infants keep coming into most families and communities of all cultures and socioeconomic conditions, and with them enter incredible opportunities to see god´s power transforming those families through the infants. nothing illustrates this better than jesus´ followers when they really cared about the future of society and the planet by focusing on caring for our children. families need to have appropriate support to foster robust brain architecture in infants, so that those infants may develop their potential for learning, relationships, production, and engagement with nature and society in a meaningful and sustainable way. in this context, social determinants of health acquire a new dimension by redirecting them toward families’ capacity to build healthy contexts that guarantee the adequate care of the personal determinants of health for infants. nobelist james j. heckman states: a large body of empirical work at the interface of neuroscience and social science has established that fundamental cognitive and non-cognitive skills are produced in the early years of childhood, long before children start kindergarten. the technology of skill formation developed by economists shows that learning and motivation are dynamic, cumulative processes. schooling comes too late in the life cycle of the child to be the main locus of remediation for the disadvantaged. public schools focus only on tested academic knowledge and not the non-cognitive behavioral components that are needed for success in life. schools cannot be expected to duplicate what a successfully functioning family gives its children. parental environments play a crucial part in shaping the lives of children. 77 121 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. the findings described here invite the consideration of a new health paradigm. new paradigms can be “disruptive innovations” opening up opportunities to see health work in a different way: taken together, current challenges invite radical new paradigms, which have been dubbed “disruptive innovations.” specifically, bowder and christensen have introduced the concept of disruptive innovations to describe how new radical paradigms can produce simpler, more convenient, more customizable, or cheaper ways of benefiting consumers who are currently being ignored by industry leaders. 78 these considerations open the door to a new type of primary health worker with training focused on the intrauterine period and early infant development. engagement with parents as soon as a pregnancy is identified would allow collaboration with other health professionals able to provide hope and confidence to the pregnant woman and young parents. such a trans-disciplinary trained health worker could see the individual as a whole person beginning in the womb. he or she should also have the support of an inter-professional team that includes medical and mental health experts and professionals from the field of social work, child protection, economic development, etc. these considerations also invite a rethinking of population control approaches to global health. are new babies mouths to feed (burdens) or active agents of transformative change? we will not achieve population control by “demonizing an increase of baby numbers” but by facilitating the development of robust brain architecture in the new generation of children to produce strong self-agency, selfregulation, and a capacity to develop healthy relationships through life. churches have an opportunity to supplement research findings on brain development during pregnancy and the first two years of life with a theological perspective about why children are so linked to the kingdom found in scripture: "truly i tell you, unless you change and become like little children, you will never enter the kingdom of heaven.” (matt 18:21), or psalms 8:2 which announced that from the mouth of infants or sucklings god will display his power. god called a marginal nation to be holy, to serve the creator by carrying out his purposes and to be priests, as god's representatives before the world (deut. 7:6-7; ex. 19:6; deut. 28:9-10). in these passages, one priestly role was to provide health; not simply biological health of individuals, but a holistic health that implies harmony with the creator, with others, with social and political structures, and with nature. this was the meaning of shalom. one of the highest commitments a jesus follower may have in any shalom ministry is to foster that shalom in the most critical period of human life: the intrauterine period and the first years. god desires shalom not only for the hebrew nation but for all humankind. in john 20:21-23, jesus appointed the church to be not only the ''object" of god's redemptive activity, but also the "subject," bringing god's salvation to all of humanity. the church has been sent by the lord and equipped by the holy spirit to continue what jesus began during his ministry on earth. many passages in the gospels show how salvation implies entering into christ's kingdom and beginning to produce the fruits of that kingdom (matt 4:23; mark 1: 14-17; luke 4: 18-21). jesus clearly delegated to the church the responsibility of bringing god's kingdom to all places in the world in order to extinguish the empire of death (john 17:18; luke 12:31-32). 79 in order to fulfill the calling of partaking in the announcement of the kingdom, people need first to learn more about that kingdom by becoming like a child. those who are willing to enter into the magnificent world of a child have the opportunity to learn profound truths that even thinkers and academics could not understand. when adults see and experience all an infant can do in the life of parents and other adults, they learn to understand the multiple languages infants use to communicate their needs and interests. when they also have developed skills to respond promptly, appropriately, and loving128 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. ly to those infants, they experience a greater hope about god’s moving in the world. as never before, humanity today has the opportunity to repent and join god’s strategy for restoring shalom in individuals, families, societies, and nature, partaking of the emergence of these new types of human beings full of grace and empathy toward all. final words there is a new agenda in efforts for building healthy societies that requires governments, families, institutions, and societies in general to address the origins of what can make people healthy. as the public health agency of canada talking about “the greatest potential to positively influence health in the population” summarizes: a population health approach maximizes its potential by directing efforts and investments ‘upstream’ to address root causes of health and illness. . . upstream investments are interventions aimed at the root causes of a population health problem or benefit. root causes are often identified by determining the most immediate and direct causes, and working backwards from there. in many cases, upstream action addresses social, economic and environmental conditions. the population health approach is grounded in the notion that the earlier in the causal stream action is taken (i.e., the more upstream the action is), the greater the potential for population health gains and health-related cost savings. it is often true, however, that these root causes are more difficult to change, requiring more time, more resources and more will. 80 this emerging new paradigm shows that the brain is not mature at birth, but rather organizes itself through experiences and through the interaction of genes that respond to the local environment and especially to the interactions with the “meaningful other.” a person’s potential to manifest god's image and likeness throughout life has a lot to do with the love and care that person experiences during infancy or with the neglect, intrusive interactions, and violence that person suffers during infancy. the primary responsibility of the family is to provide healthy conditions for infant brain development, because it will facilitate not only the development of healthy relationships with other fellows though their lives, but also to develop a genuine spirituality with the loving heavenly father. our early development is like a very dynamic dance between the biology given us by god and our interactional experiences in our first years of life. the early years of a child’s life critically impact a range of outcomes throughout life’s course, especially the way in which that child will relate with other people. today’s science and jesus’ teachings about infants open our understanding to an incredible new horizon that brings healing and hope to a world full of suffering and inequalities. the environment a young child experiences, especially the type of bonding he or she experiences, literally sculpts the brain and establishes the long-term trajectory for cognitive and social-emotional outcomes that will determine learning capacities and productive expressions throughout that child’s life. if we want to improve outcomes in schools and in adult life, we must focus intently on the child’s brain development during the early years. this new focus has profound implications for public policy, for family health, for nurturing environments for children, and for preschool programs. investing in early childhood is a sound economic investment. in fact, it is the best investment society can make — not only for prevention of pathologies, social problems, and crime, but also for developing each child’s highest human potential. the previous findings are creating a new horizon, which in one or two generations could bring profound transformation to the way persons express their potential as human beings. larger capacities to learn and to establish healthy relationships could come about without having to wait several generations to see modification of social health determinants. impoverished communities could rapidly initiate transformational processes in their 123 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. communities by raising citizens with a larger capacity for learning, greater ability to establish solid and enriching relationships, increased innovations and creativity, and skills for advocacy and effective interaction with government authorities and outside institutions. all of these things can rapidly create change with regard to the different social health determinants, as well as increase wellbeing for present generations. as we are seeing, science is showing how comprehensive early infancy development during the first 1000 days of existence must become the first priority for private and public sectors if we want to construct healthy, peaceful, prosperous, and sustainable families, communities, and countries. 81,82 similarly from the theological point of view, we need to engage in one of the most urgent theological reflections on the scripture passages dealing with infants and other teachings about children. it also requires a broader understanding of god’s missionary strategy for entering into the drama of human history as a fragile living infant to bring hope. as leonardo boff stated talking about god’s radically different logic: “every boy wants to be a man; every man wants to be a king; every king wants to be god; only god wanted to be a child.” 83 the full comprehension of jesus’ ministry and sacrificial death cannot be achieved without the historical moment of god’s incarnation as a vulnerable infant, and we will better understand this when we become humble and willing to enter into the world of the infant. god’s tender love and patience can be beautifully understood by the tenderness and patience of infants´ steadfast expression of love and grace regardless of the intrusive and neglecting behaviors of adults. when couples begin to discover the beauty and wholeness of their infant, they will begin to see their own beauty and wholeness as individuals, couples, and families, bringing resiliency to all the brokenness they have been receiving and carrying since their own infancy. infants’ endless forgiveness of adults’ neglectful or intrusive and controlling behaviors, and disdaining of god’s channel of grace, are living signs of god’s obstinate love for us. learning about what science is discovering in the child’s brain allows us to have a new understanding of isaiah 9:6: “for unto us a child is born.” in this way, we can better experience the profound truth that we cannot find god, it is god who finds us, coming to us as a child — a poor, harmless, crying baby. only those who become 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http://cbpp-pcpe.phac-aspc.gc.ca/population-health-approach-organizing-framework/key-element-4-increase-upstream-investments/ 128 de angulo & losada nov 2016. christian journal for global health, 3(2): 113-128. peer reviewed competing interests: none declared. correspondence: jose miguel de angulo, map international, plurinational state of bolivia. mapbol@verizon.net cite this article as: de angulo jm, losada ls. the emerging health paradigm in the 21st century: the formative first 1000 days of life. christian journal for global health (nov 2016), 3(2):113-128. © de angulo jm, losada ls this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:mapbol@verizon.net http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ poetry dec 2022. christian journal for global health 9(2) the backward glance brian quarantaa a md, ma, assistant professor of radiation oncology, duke university school of medicine; faculty affiliate, theology, medicine, and culture initiative, duke university divinity school, durham, nc, usa we're the people who don't kill other people. in common cause we've spread across the earth. our code forbids the fatal pill or needle, we see in every life it’s source of worth. we claim our place with ancient oath and token, red cross, or staff with serpents intertwined; signs before which locked gates are thrown open, if sickness unto death should lurk behind. a peerless singer lost his precious wife to the prick of a wicked serpent’s bite; determined to give all to save her life, he journeyed to the kingdom of the night. hell itself could not resist his singing, so with him made a solemn, dreadful pact; he might walk his bride back to the living, if he could lead the way and not look back. like orpheus we've sworn to use our art to give to those we serve a second chance; like him we’ll find our life’s work fall apart if we give death it's longed-for backward glance. peer reviewed: submitted 13 oct 2022, accepted 1 nov 2022, published 20 dec 2022 competing interests: none declared. correspondence: dr. brian quaranta, duke university, north carolina, usa brian.quaranta@duke.edu cite this article as: quaranta b. the backward glance. christ j glob health. dec 2022; 9(2):34. https://doi.org/10.15566/cjgh.v9i2.711 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:brian.quaranta@duke.edu https://doi.org/10.15566/cjgh.v9i2.711 about:blank short communication oct 2020. christian journal for global health 7(4) covid-19 pandemic in libya: what do we know so far? qais gasibata, musab gasibatb a pt, bsc, msc, lecturer at faculty of medical technology, misurata, libya and phd student at university putra malaysia (upm) b bds, president of the misurata university students' union the first coronavirus disease 2019 (covid19) case was officially confirmed in tripoli, libya on 24 mar 2020 which confirmed the spread of the pandemic to libya.1 libya was extremely vulnerable during the pandemic because it was already affected by the libyan civil war. this pre-existing dire humanitarian condition in the country had destroyed the healthcare infrastructure of the nation, leaving it susceptible to the pandemic. libya has been going through the collapse of the healthcare system even before the spread of the pandemic in the country.2 steps such as closure of markets, businesses, and schools have been taken by the government of national accord (gna) to control the spread of covid-19 which further stressed the fragile economy. libya’s first confirmed covid-19 case arose from a 73-year-old man who came back to libya from saudi arabia on 5 march 2020.1 since then, the number of cases has increased steadily, and, by april 16, the number of confirmed covid-19 cases in libya rose to 49. this was considered a relatively small number, compared with countries in the region and in the world. up to that time, only 1 death had been reported of a woman who tested positive for sars cov-2. the low number of cases in april and may was thought to be due to government efforts, few airports, cool climate, bcg vaccination, limited testing kits, or cultural aversion to getting tested.3 eastern libya confirmed its first case on 7 april 2020. however, by that time further cases had been confirmed in the country, mostly in western libya. a 24-hour curfew was imposed for 10 days by the gna on 17 april 2020.3 some 51 cases were found during april which made the total number of cases to be 61. the number of recovered patients increased to 18, while three patients died. there were 40 active cases at the end of the month. in may, 95 new cases were observed making the total number of confirmed cases to be 156. the death toll increased to 5. at the end of the month, there were 99 active cases in which the number of recovered patients increased from 34 to 52. however, in june, within two weeks, the cases literally doubled. increased armed conflict included targeting of healthcare facilities, and this made the medical teams struggle to respond.4 as of 7 june 2020, there were 270 confirmed cases of covid-19 reported in libya, including five deaths, and a total of 53 people had recovered. on 21 june 2020, the libyan national centre for disease control (ncdc) reported 571 confirmed cases, including 10 covidrelated deaths, a total of 98 people had recovered. in response to an increasing number of confirmed cases, the gna announced a curfew from 8 p.m. to 6 a.m., starting 17 june 2020 for 10 days, with a 24hour curfew on weekends with no travel allowed between cities, as confirmed cases increased to 713. there were 668 new cases in june, raising the total number of confirmed cases to 824. the death toll rose to 24. the number of recovered patients grew to 209, leaving 591 active cases at the end of the month. in july, the number of confirmed covid-19 cases in libya more than quadrupled, increasing from 824 to 3,621 confirmed cases, with 2867 new cases. at the end of that month, the number of active cases was 2,929 where the number of recovered patients increased to 618 whilst the death toll increased to 74. the majority of new covid-19 cases were identified in tripoli, misurata and sebha. 45 gasibat & gasibat oct 2020. christian journal for global health 7(4) in august, the number of confirmed covid19 cases increased rapidly, from 3,621 at the end of july to 14,624 by the end of august. the new cases were detected after the ncdc received 1,481 suspected samples, adding 23 more patients who recovered and five more who died, increasing the total recoveries to 1,333 and the total death toll to 231. on 19 september 2020, the ncdc reported 715 covid-19 cases, and the total confirmed cases in the country exceeded 27,949. the total number of covid-19 cases in libya by end of september was 32,364, including 18,128 recoveries and 520 deaths, the center confirmed.5 (figure 1) figure 1. total confirmed covid-19 cases in libya through september 2020 the director of ncdc warned that the number of new confirmed cases of covid-19 in the capital, tripoli, and the city of misurata, was on the increase. the number of cases requiring medical attention in tripoli and misurata has also risen. according to the director of the ncdc, the laboratories at the centre carried out 1,000 to 1,500 tests per day but should have been testing 10,000 people each day. covid19 was threatening both the health, livelihoods, and protection needs of libyans, refugees, and migrants with a rising number of confirmed cases. the majority of libya's municipalities have officially spiked from phase 3 to phase 4 of the pandemic, leading to a massive increase of infected and suspected cases which makes it difficult to track and control the spread of the pandemic. by not following the guidelines set by the ncdc, the number of infected cases will continue to rise due to the negligence of the public regarding social distancing which is an essential strategy for controlling any infectious disease, especially if the disease is a respiratory infection. in our opinion, failing to wear masks, attending social gatherings, and not obeying the guidelines set by the ncdc is the main concern because this virus is transmitted by droplets and close contact. many people have asymptomatic or pre-symptomatic infections, and if they wear a face mask, this can prevent droplets that carry the virus from escaping and infecting others.6 the phrase "you protect me and i protect you" is very apt in this situation. references 1. daw ma. preliminary epidemiological analysis of suspected cases of corona virus infection in libya. trav med infect dis.l 2020 mar 20;35:101634. https://doi.org/10.1016/j.tmsod.2020.101634 2. daw ma. corona virus infection in syria, libya and yemen; an alarming devastating threat. trav med infect dis. 2020 apr 2;101652. https://doi.org/10.1016/j.tmaid.2020.101652 3. gasibat q, raba aa, abobaker a. covid-19 in libya: fewer cases so far. any speculations? disaster med public health prep. 2020 may 29:1-2. https://doi.org/10.1017/dmp.2020.177 4. aljazeera news. libya: tripoli hospital attacked by ‘haftar’s missiles’. 14 may 2020. [internet] available from: https://www.aljazeera.com/news/2020/05/libyatripoli-hospital-attacked-haftar-missiles200514110305740.html 5. national centre for disease control-libya. coronavirus (covid-19) situation by (who). [internet] available from: https://ncdc.org.ly/ar/situation-by-who/ 6. world health organization. advice on the use of masks in the context of covid-19: interim guidance, 2020 june 5 [internet]. world health 0 5000 10000 15000 20000 25000 30000 35000 april may june july august sept total cases 46 gasibat & gasibat oct 2020. christian journal for global health 7(4) organization; 2020. available from: https://apps.who.int/iris/handle/10665/332293 submitted 2 sept 2020, accepted 12 sept 2020, revised 27 sept 2020, published 9 nov 2020 competing interests: none declared. correspondence: qais. faculty of medical technology, misurata, libya drqaiss9@gmail.com cite this article as: gasibat q, gasibat m. covid-19 pandemic in libya: what do we know so far? christ j for global health. nov 2020; 7(4):44-46. https://doi.org/10.15566/cjgh.v7i4.451 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:drqaiss9@gmail.com https://doi.org/10.15566/cjgh.v7i4.451 http://creativecommons.org/licenses/by/4.0/ references editorial are you oil or sand? resolving conflict in christian global healthcare david stevensa a md, ma(ethics), ceo, christian medical and dental associations, usa before we left for our first term of service in kenya in 1981, a former missionary gave me some sage advice. he said, “david, one of the greatest blessings you will have in missionary services will be through the deep relationships you develop with your fellow missionaries and national colleagues. it is just as true that your greatest conflicts will come because of your relationships with your fellow missionaries and national colleagues!” i soon found that both assertions were true. in christian global healthcare, you usually don’t get to pick your friends. you live, work, play and worship with a group chosen for you by others in a pressure cooker environment of too much work, too few resources and profound interdependence. it is a recipe for problems. it is no wonder the most common reason in my experience that christian healthcare professionals return to their home countries is interpersonal conflict. add to that the significant cultural difference between expatriate staff from different countries and national staff from different tribal or ethnic groups, and there is more potential conflict poured into the pot due to varying worldviews or long term prejudices. during my language training, a man from the tribal group we worked with made a disparaging remark about someone from an adjacent tribe. when i asked why, he immediately responded, “they’re black! they eat fish! their men are uncircumcised. there is nothing worse than being uncircumcised.”i naively responded, “but you have dark skin.” he retorted, “but he is really black!” and this pressure cooker is often placed inside a larger pressure chamber of political differences, economic tensions, religious extremism, corruption, crime and even armed conflict. almost all christians serving in global healthcare are providing care in the midst of some level of conflict. conflict at the interpersonal level ultimately impacts the effectiveness of teams, organizations, institutions, governments and nations. remember that there are only two kinds of conflict. the first is the type you can help prevent and often resolve within your community. the second is the type you can only hope to ameliorate and is often due to ethnic, tribal, religious or political struggles. as i help train new healthcare missionaries to deal with conflict, i draw upon the excellent principles taught in the peacemaker: a biblical guide to resolving personal conflict by ken sande.1 the book is an excellent source reminding us that it is each christian’s responsibility to be a “peacemaker” rather than a “peace taker.” we should not cause, endure or ignore conflict. as james 1:2-4 reminds us, god uses conflict to reveal, exercise, mature and strengthen our faith. almost all conflict is caused by our unmet expectations and desires to have our own way. because of that, my first obligation in a conflict is to examine myself. “what causes fights and quarrels among you? don’t they come from your desires that battle within you? you want something but don’t get it…” (james 4:1-2).2 resolving conflict starts with allowing the great physician to do a personal heart exam and then therapy. his intention for us is clear, “i’m telling you to love your enemies. let them bring out the best in you, not the worst. when someone gives you a hard time, respond with the energies of prayer, for then you are working out of your true selves, your god-created selves” (matthew 5:44-45).3 you first need to let god work in you to cleanse your heart of anger and selfish motives and then give you a genuine love for the person with whom you have a conflict. dr. ernie steury, the founder of tenwek hospital in kenya, was my mentor for many years. i remember one situation when he was dealing with another senior missionary who had caused many problems and publically attacked him. “he had every reason to be angry and upset, but he wasn’t. he told me why. he said, ‘dave, i’ve learned if i genuinely pray for god’s best for the person i’m having a problem with, it changes my attitude towards them. i don’t ask for god to change them. i ask god to overflow my heart with love for them.’”4 luke, the physician, quoted christ who summed up what we should do in the midst of conflict, “…love your enemies, do good to those who hate you, bless those who curse you, pray for those who mistreat you”(luke 6:27-28). 3 global health workers involved in conflict often think they are doing well if they just tolerate the other person, but god set a much higher standard in his demand for genuine love, and he is the one who enables each person to do it. in situations of conflict, people often interpret every action, word and even the body language of the person they are upset with in the worst light. they are eager to add fuel to the fire of their anger to justify their thoughts and actions. christ tells us we are not to do that, even when the other person is at fault or has failed. the message puts it into clear everyday language and says, “don’t pick on people, jump on their failures, criticize their faults—unless, of course, you want the same treatment”(luke 7:1-2).3 after these steps, it is time for some successful soul surgery by the great physician. even before we try to deal with the conflict or they ask for forgiveness, we are to unconditionally forgive the person who wronged us. it is not easy, but it is necessary, to have our heart empty of malice, resentment and the desire to triumph in the situation. just as god forgave us, we are to forgive those who have offended us (colossians 3:13, galatians 6:1).3 we didn’t deserve his forgiveness, but he freely forgave our sins by paying the price for them. if you are struggling with this step of dealing with your anger, bitterness or rage, find a friend with whom you can be completely honest. don’t focus on the person you are having the conflict with; instead, honestly share your own heart. saying how you feel out loud often has a therapeutic effect. add prayer and god can flood your heart with forgiveness. as ken sande recommends, honestly ask yourself, “is the offense seriously dishonoring god? has it permanently damaged a relationship? is it seriously hurting other people? is it seriously hurting the offender himself?”1 if you can answer in the negative to each of these questions, let the problem roll off our back like water off a duck! forgive and forget. if you answer “yes” to any of these questions, you need to deal with the conflict in the right way. your goal should be restoration. pursue that with gentleness, mercy and good intent by approaching the issue in a winsome way. you want to renew and even strengthen your relationship. if you meet with the person intending to show them they are wrong, there is little chance that true restoration will take place. commit the approaching conversation to prayer, asking god to give you wisdom, grace and humility. you want to communicate in a spirit of love and that is not easy, but we are given an example on how to proceed as the apostle paul writes in ephesians 6:19-20, “and don’t forget to pray for me. pray that i’ll know what to say and have the courage to say it at the right time....”3 in extremely difficult situations, you may want to rehearse what you plan to say and even ask a trusted friend to critique it to ensure you are using the right strategy, the right words and even the right tone. if you were on the other end of the conversation, ask yourself what would you want the other person to say to you and how. it is now time to ask to meet, and it is often best to do that in a neutral place with few distractions, interruptions and people to overhear. you do not want either person to feel trapped or be distracted. you may want to ask if you can meet for a cup of coffee or tea because something you want to talk to them about something. then work to relax and find peace in your heart. you have done all the hard work and the result is not dependent on you but on your heavenly father. god expects us to obey his admonishing to deal with conflict and then promises to be with us as we do. if you don’t get to a resolution and the problem is serious, the next thing is to follow the guidance in matthew 18:16 which says, “if he won’t listen, take one or two others along so that the presence of witnesses will keep things honest, and try again.” 3that person may be a senior missionary or a national leader who is trusted by both people in conflict. in a situation where you are still unsuccessful–and sometimes you will be–rest in the fact that you have done your part to make things right. continue to pray for the other person and work to love them. in the community health work i started in kenya, our slogan was “bir mat ko lo! ”it is an old kipsigis proverb that admonishes to “beat the fire while it is far” if you want to avoid your house or livestock being consumed by fire. with good training and leadership, you can beat the fire of conflict before it becomes a forest fire. leaders need to recognize smoldering conflict and get involved early. they also need to avoid the trap of ignoring conflict out of fear that trying to solve it will make matters worse and someone will get mad and leave the organization. as leaders, they need to hold those they lead accountable to resolve disputes and then assist them as a mediator when necessary. conflict is inevitable and is only exacerbated by the parameters of missionary service and the stresses of healthcare globally. the bottom line is: are we going to be the oil in the gears among your colleagues or the sand? are we going to prevent and solve conflicts or be the cause of them? the goal is productive, cooperative and sustainable work leading to widespread healing impact and witness. god is clear in his instructions to promote peace and vitality. we just need to follow them. references sande k, the peacemaker: a biblical guide to resolving personal conflict. 3rd ed. grand rapids: baker books; 2004. the bible, new international version, grand rapids: zondervan; 1984. peterson eh, the message: the bible in contemporary language. version 2.0 colorado springs: navpress; 2002. stevens dl, beyond medicine: what else you need to know to be a medical missionary. bristol: christian medical & dental associations, 2013. competing interests: correspondence: dr. david stevens, christian medical and dental associations, bristol, tn, usa  executive@cmda.org  cite this article as: stevens dl. are you oil or sand? resolving conflict in christian global healthcare. christian journal for global health (may 2015), 2(1): 3-6. © stevens, dl. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ short communication nov 2020. christian journal for global health 7(4) pandemic, pandemonium, and psalm 91: in search of ultimate protection and deliverance ayokunle fagunwaa, omololu ebenezer fagunwab a ms, phd (agricultural engineering), ordained minister in redeemed christian church of god, and principal research officer, federal institute of industrial research, oshodi, lagos, nigeria b mth, phd (theology), federal ministry of health, abuja, nigeria, and microbiology phd candidate (microbiology) at the university of huddersfield, uk abstract: people used psalm 91 during times of pandemic with the notion that its use will ultimately save them and their love ones. however, many get disappointed particularly when they lose their love ones despite using the psalm. this had caused many to lose their faith in the word of god. but then, it is worthwhile for christians to know that beyond the promise of deliverance as stated in psalm 91, there is an everlasting protection promised by god. this is the ultimate deliverance that will ensure we escape the eternal separation that will come upon the world on the last day. this will count us worthy to reign forever with christ in heaven where there is no sickness or diseases. key words: pandemic, psalm 91, protection, deliverance, prayer introduction the ongoing coronavirus pandemic has moved many countries and organisations to adopt different approaches to understand the virus, survey its spread, and find safe and efficient treatments. medical research is occupied with covid-19 medication and clinical vaccine trials; technological tools such as contact tracing apps hold great promise. in addition to medical and technological interventions, christians have found the scriptures to be a vital tool. psalm 91 is one of the passages in the bible to which people turn in times of pandemic. we have personally received hundreds of messages from family and friends with quotes from this scripture. no doubt the words of psalm 91 are some of the most beautiful and reassuring words in the bible. let’s consider them for just a moment: 1. he who dwells in the secret place of the most high shall abide under the shadow of the almighty. 2. i will say of the lord, “he is my refuge and my fortress; my god, in him i will trust.” 3. surely he shall deliver you from the snare of the fowler, and from the perilous pestilence. 4. he shall cover you with his feathers, and under his wings you shall take refuge; his truth shall be your shield and buckler. 5. you shall not be afraid of the terror by night, nor of the arrow that flies by day, 59 fagunwa & fagunwa nov 2020. christian journal for global health 7(4) 6. nor of the pestilence that walks in darkness, nor of the destruction that lays waste at noonday. 7. a thousand may fall at your side, and ten thousand at your right hand; but it shall not come near you. 8. only with your eyes shall you look, and see the reward of the wicked. 9. because you have made the lord, who is my refuge, even the most high, your dwelling place, 10. no evil shall befall you, nor shall any plague come near your dwelling; 11. for he shall give his angels charge over you, to keep you in all your ways. 12. in their hands they shall bear you up, lest you dash your foot against a stone. 13. you shall tread upon the lion and the cobra, the young lion and the serpent you shall trample underfoot. 14. “because he has set his love upon me, therefore i will deliver him; i will set him on high, because he has known my name. 15. he shall call upon me, and i will answer him; i will be with him in trouble; i will deliver him and honor him. 16. with [f]long life i will satisfy him, and show him my salvation.” (nkjv bible) it is amazing how these are great words of comfort, speaking of god as the protector of those who trust in him. they gave comfort and enhanced recovery for some, including dr. adaora okoliigonoh, who was infected with ebola virus while she was treating the index case in nigeria in 2014. adaora, while receiving the best medical treatment said, “every morning, i began the day with reading and meditating on psalm 91.”1 however, the words which gave adaora such comfort might seem less efficient or untrue to some who lost loved ones during this current pandemic. suffering looms as a big question. if god promised protection from evil and satisfaction with long life, why do christians who have meditated on the scriptures including psalm 91 suffer, or even die? are the words in the psalm or the entire bible really true? can we trust the bible for comfort? yes, we can! let’s take a walk where we can see that psalm 91 can be a great comfort. that when we face life-threatening circumstances, such as a pandemic, we can be sure that god will deliver us, whether in life or in death. an example is when satan quoted psalm 91:11-12 at the time of jesus’ temptation in the wilderness. satan challenged jesus to throw himself from the top of a hill, trying to convince jesus that he will get divine deliverance according to the psalm. jesus didn’t fall for the temptation because he knew that the promise of psalm 91 had to be fulfilled in his life through his suffering and death on the cross of calvary. psalm 91 was not jesus’ excuse for avoiding the cross; rather that scripture was his reason for going to the cross. for background, the author of this psalm emphasizes god’s protection for those who know him personally. but god never promised in the new testament that we will escape sickness, suffering, or even death. rather, we are promised god’s grace and strength to face whatever comes our way (luke 21:16-18). paul demonstrated this in his own life. during his first imprisonment, he anticipated “deliverance” from prison (philippians 1:18-21). however, when he wrote his second letter to timothy, he knew he was facing potentially deadly treatment at the hands of the evil roman emperor. at that time, he anticipated “ultimate deliverance” to be with christ and looked forward to receiving “the crown of righteousness” (2 tim 4:6-8). the last 2 verses of psalm 91 summarise the aim for god’s protection — to save us eternally. god has made provision for the greatest rescue and honour. there remains a sure guarantee to satisfy us with everlasting life and show us his salvation. while there are many testimonies of recitation and meditation on psalm 91 and perhaps recovering from sickness, the psalm applies to ultimate recovery: salvation. when we face life-threatening situations, such as the covid-19 pandemic, we can rest assured that for those who dwell under the shadow 60 fagunwa & fagunwa nov 2020. christian journal for global health 7(4) of the almighty god, there will be deliverance and recovery whether in life or in death. the comfort in psalm 91 is not a long, trouble-free, pandemic-free life on this present earth, but assurance that those who receive the lordship of christ will escape the wrath of god which transcends our present experience. references 1. okoli-igonoh ac. from the valley of the shadow of death — surviving the dreaded ebola disease. christ j global health. 2014.1(2):81-8 2. https://doi.org/10.15566/cjgh.v1i2.44 submitted 10 oct 2020, accepted 21oct 2020, published 9 nov 2020 competing interests: none declared. correspondence: ayokunle fagunwa, lagos, nigeria. ayokunlefagunwa@yahoo.com cite this article as: fagunwa a, fagunwa oe. pandemic, pandemonium, and psalm 91: in search of ultimate protection and deliverance. christ j glob health. october 2020; 7(4):58-60 https://doi.org/10.15566/cjgh.v7i4.461 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.15566/cjgh.v1i2.44 mailto:ayokunlefagunwa@yahoo.com https://doi.org/10.15566/cjgh.v7i4.461 http://creativecommons.org/licenses/by/4.0/ introduction references field report the battle belongs to the lord: healthcare amidst conflict in kashmir k. sarah nageshwari let me start with my testimony. i was born into a staunch hindu family. there was always a question in my mother’s mind: “why are there so many gods? who will take me to heaven?”  finally her quest ended in a mission hospital in rajhmundry, andhra pradesh. after a meeting with dr. susheela, my mother underwent an appendectomy operation.  i was 6 years old then. after seeing dr. susheela’s life, my mother desired in her heart that her first born should become a missionary doctor (that’s me). she didn’t even pray, but still our good lord fulfilled that desire. i accepted him as my personal savior after dr. latha paul (odc) led me to salvation in 1978. god helped me to repent deeply for my fallen nature and wicked thoughts and to restitute stolen things. now regarding our , john bishop memorial hospital is a 110 year-old maternity hospital situated in anantnag, jammu-kashmir, india. during the militancy uprising in 1989, the hospital faced a severe setback, so much so that the hospital remained closed for almost seven years. after much prayer, the president of laymen’s evangelical fellowship, mr. joshua daniel, sent dr. joseph daniel, an orthopedic surgeon, from st. stephen hospital, delhi.  he stayed for 3 months, and later, he and i took over responsibilities in 1997. before coming here, i worked as a senior gynecologist in a maternity hospital, narsapur, andhra pradesh for 17 years. i came to kashmir the first time for a month in january 1996 to survey the hospital. during that time, the hospital staff (a few old muslim staff) had suffered much due to lack of salaries while the hospital was closed.  nevertheless, they tried to guard the campus and prevent the equipment from being taken away. i did 75 tubectomies and 3 caesareans and paid their salaries. one day as i was alone in the hospital, some militants from hizbul mujahideen suddenly entered our hospital and took away our land rover. later on, they left it some 17 km away. but, as it was my first visit, i did not dare to inform the police. years later, we found a bullet lodged in the top of that car. there were many troubles in reviving the work. i returned the second time with the intent to remain permanently. forty days after my arrival, 4 ikwans (surrendered militants) attacked us and took away cash and valuables at gunpoint, threatening us not to inform the police. after this incident, the government gave us security, first jammu kashmir police and later central reserve police force during the iraq-us war. at present, we don’t have them (except two jammu kashmir police) as they have been sent elsewhere. once, i was given porridge mixed with finely-crushed glass pieces to eat, but miraculously i was unharmed. gradually, they started understanding us. our work started increasing, slowly but steadily.  people began having a lot of trust in this hospital. god has given me good christian staff with a definite calling and sacrifice. some of them even resigned their government jobs and joined us. god helped us reopen the nursing school, which had been closed for 15 years due to militancy. now, it has 54 muslim students (both auxilliary nurse midwives and graduate nurse midwives) all residing inside the campus. recently, the district commissioner visited our hospital and appreciated our work; he requested us to start a b.sc. nursing program. under the shelter of the hospital work, the lord has been enabling us to freely share the gospel before our daily ward rounds. we witness very boldly, giving tracts (in urdu) to the needy and praying for them. in fact, they request our prayers as they acknowledge jesus as one of their prophets but strongly deny his sonship and deity. the foundation of christian faith “that christ died for our sins” is learned in reverse by every muslim from their elementary stage. we rarely come across people who are deep thinkers. even if some dare to think, the fear of society restricts them. this heart-breaking daily struggle against the powers of darkness continues. one should venture into such an arena with good discipline and training at home, a thorough aptitude for learning, and, most importantly, a 100 % assurance of his calling. conditions here are highly unpredictable. any political upheaval that concerns the locals affects us badly. at times, the religious leaders warn people not to visit us and announce it in mosques. all our efforts to provide education, free medical help, and gathering children for christmas last only a few weeks. in 2008, during the anantnag land transfer controversy, we faced constant intense situations for two months. on one occasion, we, the female staff, thought of leaving at midnight and even kept our vehicles ready, but god guided us not to move an inch from the place, and he alone gave us the strength to stay back. in the year 2010, we witnessed violent activities and continuous strikes for five months. every week, the hurriyat leaders structured a resistance calendar which was followed strictly. even basic essentials were not available. several private properties were damaged by rioters, and the 15th was declared a black day. the lord stood with us, and no one approached our gate. the indian army called for curfews, but the rioters did not care. once we were told to keep our gates open, so that rioters could hide inside our compound. the lord protected us and gave us the courage to refuse. prayer alone sustained us. sometimes, with the escalation of violence, we even had to live without lights. the rain is always a big welcome as it keeps rioters indoors. once when we prayed, god sent heavy rain and scattered the rioters. on 13th september 2010, after the threat to burn the korans in florida, we saw the worst violence in the past 14 years. that day, several christian schools and churches were burnt down. that same night, two violent crowds with diesel cans approached to burn our institution.  all women and children gathered in my hall to pray, and brothers were guarding the compound. at about 10:30 pm, that mob had a disagreement within itself and scattered. after that came a second crowd that wanted to stone us, but the shopkeeper across the road yelled at them and warned them not to cast a single stone. the crowd dispersed with the voice of just one man. except for a window, not a single soul was harmed that night. this has been just one of the many incidents where the lord has kept us according to his grace. we do have many well-wishers in this area. kashmiri muslims brought us essentials and food in our time of need. some of our nursing students called us up and tearfully requested us to temporarily vacate and return to our native places. thus, in the midst of all this, god is showing us that all are not the same. several vicious activities were aimed to stop our work because of our faith. amidst all these, god is doing his work despite our little faith. in the past, some militants came to me and asked me to conduct abortions for their wives, but i refused and told them that it is a sin to kill an unborn fetus. they became furious and left, but later on, i came across a couple of them in the market place carrying their babes, and they even smiled and wished me well. so often has it been that a huge bomb would explode just within minutes after our people or vehicles have left that particular spot. work among these people is truly a work that “pricks you, scratches you, nearly bleeds you to death, but the fruit is very sweet” (prickly pear – by eric g fisk). for we wrestle not against flesh and blood, but against principalities, against powers, against the rulers of the darkness of this world, against spiritual wickedness in high places (eph. 6: 12 kjv). the more we face troubles and violence, the more we grow in faith and prayer. please pray for us that nothing should deter us from doing god’s will. this article was originally published in the mission and conflict issue of the christian medical journal of india, vol 27, no 4, oct-dec 2012.  available at: http://issuu.com/cmai/docs/cmji_vol.27_no.4_october-december_2012_ competing interests: none declared. correspondence:: k. sarah nageshwari   jbmhkashmir@gmail.com cite this article as: : nageshwari, ks. the battle belongs to the lord: healthcare amidst conflict in kashmir. christian journal for global health (may 2015), 2(1): 63-65. ©nageshwari, ks. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ conference report engage disability conference sylvia naomi jamesa,nathan grillsb,jubin varghesec aconference coordinator, engage disability, india bpublic health physician, nossal institute for global health, university of melbourne. consultant emmanuel health association (eha), australia cdeputy director of community health and disability program manager, emmanuel health association, india the engage disability conference was held at crowne plaza, rohini, new delhi from 25th to 27th september 2014. this conference was designed to inspire and strengthen our efforts to see people, regardless of ability, engaging with our faith communities. we had senior representation from most major christian health organizations and various churches in india including wvi, chai, cbm, ncci, tlm, eha, cmc vellore, compassion, tear fund, and jaf, equip india, bible colleges, and various programs working on disability. over 400 people participated with great enthusiasm, and the delegates included 210 pastors/ theologians/ church leaders and 154 members from various ngos working in cbr and other disability programs. the conference opened with the leaders praying for the conference and then signing the conference banner with a hand print. all delegates later signed the same banner, and the final conference declaration was signed over the top of this kaleidoscope of colored hand prints. this was a beautiful representation of all christians giving a hand to work towards the declaration: to see those with disability accompanied, loved, and included in the body of christ! sessions sessions were divided into 4 logical sections that progressed from looking up at god, into our church, around us at our families and out to the world: disability and theology (looking up at god) a number of superb speakers covered what jesus, the church, and the bible says about disability. topics included “how can the church be more inclusive’ by kenneth campbell and some excellent overviews by prince david (tearfund), rev. christopher raj kumar (head of the ncci disability movement), dr. father tomi thomas (chai), and dr. ben rhodes. all gave a compelling framework for christians to love and include those with different abilities. rev. l.t. jeyachandran, rzim, who himself was challenged in preparing these studies, explained how being created “in the image of god” meant that we should take pride in our ability and disabilities as they reflect god. the inclusive church (looking inwards) this session covered how bible colleges, pastors, and church members can work together so that people with disability are included in all aspects of church life. brian mckinney spoke about the need for social ramps, referring to the church examining social and attitudinal barriers and not just physical barriers. dr ben rhodes introduced the beyond suffering course that gives a christian approach to disability. jayakumar christian (wvi) challenged the church to transform india by its love for the most marginalized. pastors shared their stories about inclusion. one church in nepal had 50 people who had mobility issues, and another church had sign language interpretation at every service and special services reaching out to the deaf. there were also stories of congregations in mumbai where churches were competing to be the most inclusive church. inclusion was not seen as a burden but something to be cherished and aspire to. a recurrent theme was that this was not the job of a few inspired pastors, although we heard from many, but the role of every christian in india! we are the church! disability and families in this session, the focus was on the lived reality (looking around) of parents, siblings, and caregivers. there were many heart-wrenching stories of exclusion, but an equal number of stories of families being welcomed and helped by the christian community in india. the plenary session had a powerful testimony from pastor sanjeev who explained how his church had come to accept and now even celebrate the uniqueness of his child who has autism. jessica paulraj spoke about how their adoption of a child with severe disabilities had transformed their family and impacted the community around them who asked “why do they love that child?” there can only be one answer for the paulrajs. there were not many dry eyes left after these keynotes. a session on caring for families with disabilities, chaired by mr. george abraham, dr. nathan grills, dr. judy, lenny vasanthan, and raj kumar, spoke about the simple things like buddies and random acts of kindness that christians can do to care for families. faith and disability inclusive development (looking out to the world) the final day was opened by dr. dave mccomiskey, the international head of cbm, who delivered a challenging message on how including the most marginalized had transformed communities and made society a better place. we heard challenges from mr. brian mckinney, geeta mondal, dr. charles kingery (provision asia), ms. pramila balasundaram (samadhan), melody murray (joyn), and others about how we can reach out to india through disability inclusive health, education, and vocational training. many well-known christians gave their greetings and well wishes including joni eareckson tada (joni and friends), nick vujicic (beyond limits), ravi subbaiah (nmtv), bear grylls, and mr. george abraham (founder of blind cricket). george gave us a live onstage demonstration of blind cricket. the breadth of the christian community came together to sign a petition to the government demanding they fully enshrine the un convention on the rights of the people with disability into indian law. two well-known disability advocates are arranging to present this to the prime minister of india, mr. narendra modi. regional networking (facilitated by the community health global network) the conference had intentional networking sessions where people from different regions were grouped together, shared ideas, appointed regional facilitators, and planned a way forward at the local level. this resulted in 13 regional sub groups: nepal north 1 (uttarakhand) north 2 (jammu & kashmir, himachal pradesh, punjab, haryana, chandigarh) north east (assam, arunachal, sikkim, nagaland, meghalaya, manipur, mizoram, tripura) delhi, uttar pradesh central madhya pradesh, chhattisgarh east 1 (bihar, jharkhand) east 2 (west bengal, odisha) west (rajasthan, gujarat, goa, maharashtra, daman & diu, dadra, nagar haveli) south 1 (tamil nadu, kerala) south 2 (telangana / hyderabad) south 3 (karnataka, lakshadweep, andaman & nicobar, pondicherry, andhra pradesh) these regional networks have the contact details of their members and will be facilitated to create a platform for unity, prayer, and synergy. we are asking each region to steward the momentum in the coming months by engaging their regional brothers and sisters. many regions have already had meetings and correspondence. the way forward the conference was concluded by challenging words from dr. sara varughese (director of cbm) and rev. dr. abraham mar paulose, bishop, marthoma church. dr. santhosh mathew (director of eha) presented “where to from here.” “this cannot just be a conference but must be a movement!” he outlined how the strategic advisory committee and key conference delegates had met during the evenings to collate ideas and create a vision for the way forward. to see this happen, the following were outlined: focus on supporting the regional hubs (ncci to lead) a communication hub (world vision to lead) was created to facilitate intra-regional, interregional, and international communications a resources hub (chai to lead) to compile and create different tools to help the christian community move towards inclusive christian communities a coordinating hub that supports and facilitates the functioning of the other hubs below are 4 action steps we would like each region to take in the next four weeks, during which members of engage disability partners will be in further communication: kindly work towards scheduling the 1st gathering for the purpose of prayer, growing friendships, and deciding movement for the next quarter. email the facilitators from your region to arrange meeting/cooperation and plan future activities. email everyone in your region to update them on progress and arrange a forum for discussions. be in prayer. finally, a declaration that had been drafted by conference delegates was signed by leaders of the partner organizations:  . . . we, the body of christ, affirm that everyone, including persons with disabilities are created by god, in the image of the triune god; and therefore have the potential to be full and active members of the church, communities and the society at large. the mission of god is an imperative; and therefore, the mission along with and for the disabled is a participatory mission to accompany the persons with disabilities so as to ensure their full contribution to our churches . . . (extract from declaration) we wish to thank the conference organizing team (dr. charles, ms. meena, ms. sylvia james, ms. jubin, rev. ben richards, dr. nathan grills), our mc mr. ka jayakumar, the volunteers, the churches, and the generous conference partners (below) for making this dream a reality.  most of all, we want to thank and praise god for bringing this together for his glory — a glory that we see clearly displayed through the inclusive christian community. glossary: wvi: world vision india, chai: catholic health association of india, ncci: national council of churches in india, tlm: the leprosy mission, eha : emmanuel hospital association, cmc vellore: christian medical college, jaf: joni and friends, rzim: ravi zacharias international ministries, chgn: community health global network, cmai: christian medical association of india. competing interests: none declared. correspondence: sylvia naomi james, engage disability conference, sylvia.engagedisability@gmail.com cite this article as: james sn, grills n, varghese j. engage disability conference report.  christian journal for global health (april 2014), 2(1):___. © james sn, grills n, varghese j. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ commentary dec 2020. christian journal for global health 7(5) the population health model: a timely approach for mission hospitals richard k. thomasa, niels frenchb a ma(sociology), ma(geography), phd (medical sociology), affiliate faculty, university of tennessee health science center, memphis, tn, usa b ma(economics), director, mission integration division, methodist le bonheur healthcare, memphis, tn, usa abstract mission hospitals have long provided a source of care, healing, and spiritual support for populations around the world, often serving the disadvantaged and rural residents not served by other facilities. yet the future of mission hospitals has been thrown into doubt, and options for repurposing these institutions must be explored. the approach of mission hospitals to healthcare delivery has historically differed from those of other health systems (including many faith-based facilities) due to their isolated locations in lower-income countries. the multi-purpose attributes of mission hospitals make them excellent candidates for adopting a population health approach. the population health model, as now being developed in the united states, represents a radical departure from traditional clinical practice and reduces the system’s dependence on clinical care as a means to improving community health. the population health model emphasizes treatment of populations rather than individuals, a holistic approach to the provision of care (addressing social determinants in the process), and the involvement of the community in multi-sector collaboration for collective impact. mainstream hospitals have had difficulty in implementing a true population health model for a variety of reasons, but mission hospitals appear to represent an effective vehicle for putting this model into practice. a population health approach appears to complement the philosophy of mission hospitals, and mission hospitals appear positioned to advance the population health movement. key words: mission hospitals, population health introduction a certain man was going down from jerusalem to jericho, and he fell among robbers, who both stripped him and beat him, and departed, leaving him half dead. by chance a certain priest was going down that way. when he saw him, he passed by on the other side. in the same way a levite also, when he came to the place, and saw him, passed by on the other 83 thomas & french dec 2020. christian journal for global health 7(5) side. but a certain samaritan, as he traveled, came where he was. when he saw him, he was moved with compassion, came to him, and bound up his wounds, pouring on oil and wine. he set him on his own animal, and brought him to an inn, and took care of him. on the next day, when he departed, he took out two denarii, and gave them to the host, and said to him, ‘take care of him. whatever you spend beyond that, i will repay you when i return.’ (luke 10:30– 35, web) the parable of the good samaritan is one of the best-known examples offered by jesus to exemplify his perspective on human relationships. what the samaritan did for the robbery victim went beyond the fact that he “bound up his wounds.” he provided transportation for the injured man, obtained lodging, and attended to his physical and emotional needs. further, he provided funding to the appointed caregiver with instructions to provide whatever the victim needed. within his limits, he was applying the population health model, a response more reflective of the approach of mission hospitals than of hospitals controlled by other entities. hospitals in the united states (u.s.) and around the world are faced with a changing environment for the delivery of health services. trends can be observed in the u.s. and other highincome countries that are having a serious impact on the ability of healthcare systems—however structured—to address contemporary health conditions.1,2 these trends include the growing mismatch between the services provided and the needs of the population, the misallocation of resources to high-end services, and—in the u.s. in particular—stark inequities in the availability and provision of care.3 there is growing concern over the ability of modern western medicine to bring about improvement in community health.4 the more cynical would argue, in fact, that the system—at least as it operates in the u.s.—may be doing more harm than good. indeed, in the u.s. today, medical errors are the third leading cause of death (after heart disease and cancer).5 the population health model is being championed in the u.s. in response to these developments because it recognizes the three components involved in community health improvement: clinical medicine, mitigation of the negative aspects of the social determinants of health, and policy reform.6 the healthcare system is generally only concerned with the first of these and is limited in its ability to address the other two components even if so inclined. mission hospitals, on the other hand, are commissioned to address the first two components and, where possible, the policy component. the changing context for healthcare for two or three decades after world war ii, there was a comfortable fit between the healthcare system and the needs of the population it served.7 health status steadily improved with significant credit being accorded to the healthcare system. public health measures were responsible for much of the improvement in health status but never received the accolades showered on feats of “heroic” medicine. but the air of confidence surrounding the u.s. healthcare system in the 20th century has now been eroded by the realities of the current healthcare environment. the key developments contributing to the current dilemma are summarized below. changing patient characteristics the various trends that played out over the last quarter of the 20th century dramatically reshaped the patient population and had major consequences for the healthcare enterprise.6 the aging of the population contributed to an epidemiological transition through which chronic diseases and debilitating conditions replaced acute conditions and communicable diseases as the major health threats. this transition was further influenced by changing lifestyles and effective public health measures. 84 thomas & french dec 2020. christian journal for global health 7(5) a changing patient profile was accompanied by the transformation of the “patient” into a “consumer”. patients came to be referred to as clients, customers, consumers, or enrollees, terms that imply different characteristics from those accorded to patients.8 this development has resulted in a shift from patients as passive recipients of healthcare to active players in the management of their own health. changing disease etiology the shift from a predominance of acute conditions to a predominance of chronic conditions was accompanied by a significant change in disease causation. the major killers a century ago (and throughout human history) were almost invariably attributed to a single factor. although noncommunicable diseases were not unknown, few members of the population lived long enough to contract so-called “diseases of civilization.” today’s major killers reflect the interaction of a variety of factors, resulting in a more complex view of disease causation that recognizes the interdependence of biological and non-biological factors. noncommunicable diseases became predominant within the u.s. population, and the rest of the world is now following suit.9 these chronic conditions arose from the combined effect of a lifetime of stress and the unhealthy lifestyles adopted by western countries. throughout much of the 20th century, it could be argued that society members were “innocent bystanders” when it came to the source of disease. with the advent of diseases of civilization, it became clear that modern society had become the source of most of the health problems of its citizens through individual choice or through the social determinants of health. changing health system challenges at a time when the healthcare environment is undergoing dramatic changes, the hospital remains the focal point of the system. the u.s. system’s inability to adapt to a changing environment has prevented society from addressing the root causes of our health problems. the health conditions that we observe in a community, it is argued, are not the problems but are merely symptoms. the real problems are poverty, housing insecurity, food insecurity, unsafe and dangerous communities, lack of educational opportunities, income inequality, and lack of parks and greenspace. no amount of clinical care can overcome these “social determinants” of health and illness. indeed, it is well documented that providing access to medical care does not necessarily lead to an improvement in health status. while the emphasis of this discussion has been on the situation in the united states, similar circumstances exist in other developed nations. in some ways, their situations may be more advanced (e.g., more advanced aging) and in others less advanced (e.g., unhealthy lifestyles), but all generally face the same issues with regard to improving community health. most developed nations do have the advantage over the u.s., in that they have more highly developed public health infrastructures and more centralized control while public health in the u.s. is being steadily deemphasized. the situation in developing countries is somewhat different in that they are typically not as far along in terms of the epidemiological transition as more developed countries. these populations are more likely to suffer from acute conditions and communicable diseases. however, analyses by the world health organization indicates that these countries are moving toward a situation similar to that in the u.s. much more rapidly than the process that unfolded here.10 in fact, the list of the top 10 causes of death globally today mirrors the distribution for the u.s. this is not meant to diminish the importance of infectious diseases in lower-income countries (and even among subpopulations within the u.s.) but to highlight global trends that have been identified. most observers believe that community health improvement is, or at least should be, the 85 thomas & french dec 2020. christian journal for global health 7(5) responsibility of the community (however community is defined).4 the collective impact of various interests in the community working with the healthcare system is considered the key to improved community health status.11 the healthcare system cannot do much about existing poverty, lack of affordable housing, or hunger, but the community may be able to do something. at the end of the day, community health status must be proactively addressed by the affected community.4 the emergence of the population health model the failure of western medicine to address contemporary health problems in the u.s. has generated growing interest in “population health” among health professionals, policy analysts, and government agencies. assessing health from a population, rather than a patient perspective, represents an opportunity to develop a better understanding of the health status of populations while offering an innovative approach to improving community health. the term “population health” has been used very inconsistently, and deprez and thomas have developed a more useful definition that involves two dimensions:4 • as a noun, population health views the health status of a population in terms of its health and well-being as measured by several populationbased measures. the emphasis is on broad measures of health focusing on attributes of the group as a whole rather than the traits of individuals. • as a verb, population health refers to an approach to improving health status that operates at the population level rather than the individual level. it focuses on social pathology rather than biological pathology and involves the “treatment” of conditions within the environment and policy realms in addition to the provision of clinical services to individual patients. the application of the population health model can be explored at two different levels. at the microlevel, a population health approach might involve identifying individuals at high risk and intervening to reduce their risks. at the macro-level, the approach might involve reducing the average risk level for the total population by initiatives or policies addressing the social determinants of health. the macro-level approach is the hallmark of the population health model. it has been argued that population health represents an amped up version of public health. the authors argue that, although the public health profession should have led the way in the development of population health, it did not. the public health infrastructure has been experiencing a decades-long decline in terms of its resources and capabilities. its functions have been reduced to the bare minimum required by law at a time when the profession should be taking the lead role in community health improvement.12 attributes of population health the authors consider the following eight attributes to characterize the population health approach. recognition of the social determinants of health problems. an understanding of the social determinants of health is critical to the population health model, and the importance of social pathology over biological pathology must be recognized. focus on populations (or subpopulations) rather than individuals. application of the population health model involves measuring the health status of the total population rather than simply compiling the clinical readings for individual patients. this assumes that community health status exists independent of the status of individual society members. 86 thomas & french dec 2020. christian journal for global health 7(5) shift in focus away from patients to consumers. over time, “patients” came to be seen as “consumers.” the trend was initiated by baby boomers who wanted the benefits of quality care as patients coupled with the efficiency, convenience, comfort, and value that they had come to expect as consumers. geography as a predictor of health status and health behavior. there is increasing recognition of the importance of the spatial dimension in the distribution of health and ill-health. where one lives is not only a predictor of health status but also a powerful determinant of the kind and amount of medical care received.13 health status as defined by the community. a community-based (participatory) understanding of the critical health issues is a prominent feature of population health. rather than defining community health status from the top down based on epidemiological metrics, the model emphasizes a bottom-up approach that reflects the perspectives of community residents. acceptance of the limited role of medical care. while the cost of healthcare to consumers influences the amount of care consumed, there is no evidence that more care translates into better health. indeed, a premise of the population health model is that health services make a limited contribution to the overall health status of the population. changes in health behavior are not ultimately individual actions. the decisions made with regard to health behavior are not the result of individual volition but reflect the impact of the individual’s social context, cultural milieu, and life circumstances. improvement in personal health status needs to be addressed within the context of the community environment in order to leverage resources for advancing health status. improvements in community health require collective impact. in accordance with the above attributes, the responsibility for health improvement falls to the larger community. involvement by a wide range of community organizations supported by the healthcare system is necessary to create the collective impact required to “move the needle” when it comes to community health improvement. mission hospitals and the population health model mission hospitals have a mandate that is broader and deeper and follows a different timeline than that of even faith-based hospitals in the u.s. unlike faith-based institutions in higher-income countries, mission hospitals have been primarily established in rural areas rather than urban centers. isolated as they are, they constantly struggle with sustainability.14 for most mission hospitals, government subsidies are meager, and already inadequate support from religious denominations has dwindled significantly in recent years.15 the mission of these hospitals encompasses the spiritual and communal aspects of life as well as the physical. of necessity, this means taking into consideration the life circumstances of individuals and families along with the social determinants that affect their health status and health behavior. indeed, religion has come to be seen as a social determinant of health in its own right.16 mission hospitals tend to be more integrated into the community, although often guided by distant denominational offices, and their policies more reflective of the needs of the community served. although perhaps not applying the population health label, they have been forced to adopt a population health approach out of necessity. in this sense, mission hospitals already reflect the major provisions of the population health model and the holistic approach highlighted in the good samaritan parable. it could be argued that the philosophy underlying the operation of mission hospitals anticipated the emergence of a population health approach making the mission hospital “system” fertile ground for the promotion of this strategy for improving community health. the potential of this approach for mission hospitals 87 thomas & french dec 2020. christian journal for global health 7(5) stands in contrast to the many barriers that limit the application of this model by hospitals in the u.s. mission hospitals already have diverse goals as they pursue restoration and social cohesion while dispensing medical care. more so than hospitals in higher-income countries, advocates for mission hospitals think in terms of populations rather than individuals. the entire population is targeted with the intent of effecting group-wide change. since mission hospitals were pursuing a population health approach before it was recognized within the broader healthcare community, they are in a better position than their counterparts in higher-income countries when it comes to implementing a population health model. the implementation of a population health model requires a change in mindset and a rethinking of the roles of various healthcare organizations. a hospital must begin to see itself not as a hospital but as a multi-purpose community resource. the dispensing of medical care remains a part of the organization but should support the holistic health of the community, emphasizing the importance of population-based initiatives. this mindset already exists within mission hospitals. while the population health model may represent a path forward for the mission hospital, the mission hospital is at the same time well positioned to promote the population health movement. mainstream hospitals have had difficulty in implementing a true population health model for a variety of reasons, but mission hospitals appear to represent an effective vehicle for putting the model into practice. the biggest barrier facing mission hospitals in pursuing a population health approach is inadequate financing and the absence of sustainable business plans. the population health model encourages and requires multi-sector collaboration in order to marshal resources from a variety of sectors for purposes of collective impact. this collaborative approach appears to represent a means for mission hospitals to pursue their mandates and support their vision. as stated by bill foege, former director of the u.s. center for disease control and prevention: it is not impossible to dream of thousands of congregations working alongside public health, sharing an understanding that health is a seamless whole — physical, mental, social, spiritual — that poverty and illiteracy and addiction and prejudice and pollution and violence and hopelessness and fatalism are forms of brokenness, diseases that require the deployment of both their assets in building whole, healthy communities.17 the good samaritan realized the importance of a holistic approach to managing the health of the robbery victim. he knew that simply binding the victim’s wounds would not make him whole again. a full range of services is required not only for patients but for all community residents in order for them to not only be cured but to be truly healed. the mission hospital appears to be uniquely positioned to advance the population health model and replicate the samaritan’s efforts on a broad scale. references 1. besterman w. the continuing abject failure of us healthcare. 2019. available from: https://validationinstitute.com/the-continuing-abjectfailure-of-us-healthcare/ 2. charan ms, paramita s. health programs in a developing country — why do we fail? health syst policy res. 2016;3:3. http:dx.doi.org/10.21767/22549137.100046 3. cowling d. inequalities in health care provision. teaching geography. 2014;29(2):56-9. 4. deprez r, thomas rk. population health improvement: it’s up to the community — not the healthcare system. maine policy rev. 2017;25(2):4452. 5. makary m, daniel m. medical error — the third leading cause of death in the u.s. bmj. 2016. https://dx.doi.org/10.1136/bmj.i2139 6. thomas rk. 2020. marketing health services. 4th ed. new york: springer. 2020 about:blank about:blank about:blank about:blank about:blank 88 thomas & french dec 2020. christian journal for global health 7(5) 7. kernahan pj. was there ever a golden age of medicine? minn med. 2012 sept. available from: http://pubs.royle.com/article/was+there+evera+%e 2%80%9cgolden+age%e2%80%9d+of+medicine %3f/1159666/124206/article.html. 8. brinkmann jt. patient, client, or customer: what should we call the people we work with? o & p edge. 2018 apr. available from: https://opedge.com/articles/viewarticle/2018-0401/patient-client-or-customer-what-should-we-callthe-people-we-work-with 9. world health organization. 2019. ncd mortality and morbidity. 2019. available from: https://www.who.int/gho/ncd/mortality_morbidity/en/ #:~:text=of%2056.9%20million%20global%20deaths ,lower%20income%20countries%20and%20populatio ns. 10. world health organization. the top 10 causes of death. 2016. available from:: https://www.who.int/en/news-room/factsheets/detail/the-top-10-causes-of-death. 11. health research & educational trust. a playbook for fostering hospital-community partnerships to build a culture of health. chicago, il: health research & educational trust. 12. johnson sr. report: public health funding falls despite increasing threats. mod healthcare. 2019 apr 24. available from: https://www.modernhealthcare.com/government/repor t-public-health-funding-falls-despite-increasingthreats. 13. roeder a. zip code better predictor of health than genetic code. 2014. available from: http://www.hsph.harvard.edu/news/features/zip-codebetter-predictor-of-health-than-genetic-code/ 14. asante rko. sustainability of church hospitals in developing countries: a search for criteria for success. amsterdam: world council of churches. 1998. 15. currat lj. the global health situation and the mission of the church in the 21st century. int rev mission. 2006;95(376/377):7-20. 16. idler el. religion as a determinant of public health. oxford: oxford university press. 2014. 17. u.s. department of health and human services. engaging faith communities as partners in improving community health. atlanta: center for disease control and prevention. 1999 peer reviewed: submitted 31 mar 2020, accepted 15 oct 2020, published 15 dec 2020 competing interests: none declared. correspondence: richard thomas, university of tennessee health science center, usa. richardkthomas@att.net cite this article as: thomas r, french n. the population health model: a timely approach for mission hospitals. christ j global health. december 2020; 7(5):82-88. https://doi.org/10.15566/cjgh.v7i5.363 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank about:blank about:blank about:blank#:%7e:text=of%2056.9%20million%20global%20deaths,lower%20income%20countries%20and%20populations. about:blank#:%7e:text=of%2056.9%20million%20global%20deaths,lower%20income%20countries%20and%20populations. about:blank#:%7e:text=of%2056.9%20million%20global%20deaths,lower%20income%20countries%20and%20populations. about:blank#:%7e:text=of%2056.9%20million%20global%20deaths,lower%20income%20countries%20and%20populations. about:blank about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v7i5.363 https://doi.org/10.15566/cjgh.v7i5.363 about:blank key words: mission hospitals, population health introduction the changing context for healthcare the emergence of the population health model mission hospitals and the population health model references book review health, healing and the church’s mission: biblical perspectives and moral priorities, by willard m. swartley, ivp academic, 2012 ronald f. halbrooksa am.d. internist and geriatrician in the duke university health system this interesting book is an update of current thoughts, trends, and ideas in the broader issues of health, healing, and the church’s mission. the biblical and moral perspectives related to these words, themes, and ideas are also discussed. willard swartley is not medically trained, although he has written other books in the health care genre. he brings both personal health issues and also those of his close family and associates to the discussion. however, these elements enhance the contents and are not a negative emotional distraction. the author brings a good balance of academic rigor and pastoral experience. he possesses a ph.d. from princeton, is a professor of new testament studies and dean and president of a seminary, but also has personal physical afflictions and is involved pastorally as an ordained minister in his church. his personal spiritual heritage is in the anabaptist tradition, i.e., the mennonite church, which he leans on and draws heavily from in both his personal and academic experiences. this is both a strength and a weakness. he demonstrates a historical understanding of the mennonite church in health care from its inception until now. he also offers keen insights in how the mennonite church in the united states currently understands, articulates, and applies its beliefs in health care reform and in helping those in need of health care. the strength of the mennonite tradition is strong biblical exegesis and application to contemporary social concerns. while the book extensively draws on the mennonite tradition, it does not mention many other past, present and future faith understandings for the united states health care system except for a few mentions of the roman catholic church. the book is divided into three sections with a total of twelve chapters. the first section is “healing,” the second section is “health care,” and the third section is “toward new paradigms.” the “healing” section is related to one of the book’s subtitles, i.e., “biblical perspectives.” this reflects both his academic background and theological rigor. he draws well from the concepts of healing in the old testament (especially the psalms), the life of jesus in the gospel, the life of paul, especially from the book of acts, and the writings of john (gospel and the epistles). he repeats these four sources of scripture throughout the book. in the first section, “healing,” he brings up the idea that healing is part of the trinity. then he has “seven theses,” which are themes for the whole book.  these are as follows:   god intends shalom and community for humans and all creation, but sin and satan play adversarial roles against us and god’s intention for us. god is god and we are weak mortal frail creatures. illness puts us into a quandary before god, for it interrupts and challenges god’s good world in personal experience. suffering means not divine absence but testing. jesus is healer-savior and leads us in faith and prayer. the spirit is healer and is the divine pledge of complete healing. the church is called to be god’s face of healing in this world he brings out significantly, in this first section, the concept of shalom.  in a concise way, he shows that this is related to the concept of community, health, peace, and our relationship to god.  it is the fracturing of this shalom relationship with god that not only fractures individual but corporate relations.  he does not believe that isaiah 53.4-5 means that we can expect healing for all who claim it today. in part two, professor swartley discusses health care more in its “moral perspective” containing historical background, which though broad is helpful. the historical aspect of health care in the church is used to support the biblical concept of shalom as god’s will and desire for all people. he also emphasizes justice, caring for the poor and marginalized, sharing material resources, and caring for those outside the church. he writes of the concept of “mutual aid” such as when paul took his offering to jerusalem. he contrasts the existing model of quality-cost-access triangle with the preferred community-mutual sharing-justice/ compassion model. he also has an entire chapter on a christian approach to disability. what is weak in this section though is that he contrasts the lack of “equal access” in the united states with the “equal access” people had to jesus in the gospels for healing.  i am not sure that jesus’ purpose was to provide equal access and not sure the two circumstances are comparable.  yet, on the whole, this section is good in addressing “moral perspectives,” especially as relates to “mutual aid,” in which the church can and does participate. the final section, “toward new paradigms” is the weakest. it essentially deals with the current united states health care system and its problems of the high cost of care, the uninsured, and what can be done about it. he suggests some important correctives to systemic problems like shalom and community, justice, service, stewardship, and vision-driven vs. funding-driven health systems. there are thoughts as well on work as worship, prayer, and healing. he has some useful ideas, but the whole section did not seem to fit with his first section on biblical healing. there are lots of facts and ideas but trying to distill his thinking is as difficult as trying to understand what his solutions are. however, it is clear he is a hardy proponent of universal health care. he tries to equate “universal access” with “equal access” with basic health care. the three are not the same, and he really doesn’t clarify the differences. overall, this book presents some comprehensive biblical foundations that can be corrective to a broken health care system.  the first section is well worth the read in understanding “biblical healing.” the second section on “moral perspectives” is worth the read to equip the church for healing action and justice in healthcare, though weaker than section one. the third section is worth the read in its application to the current united states health care system reform.  it also has application for developing countries that may follow the same mistake of relying on technology, physicians, and funding to address health issues — instead of the christian “wider, deeper theological and moral perspectives” based on community, mutual aid, the poor, justice, and service — which can be corrective toward greater health for all.  in the summary, he discusses christian voices in public debates, and volunteerism for needy patients, which gives a call to practical action for the church – god’s instrument for the healing of the nations. competing interests: none declared. acknowledgements: correspondence: ronald halbrooks, ronhalbrooks@gmail.com cite this article as: halbrooks, rf. book review: health, healing and the church’s mission: biblical perspectives and moral priorities. christian journal for global health (may 2015), 2(1): 70-72. © halbrooks, rf. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ commentary dec 2021. christian journal for global health 8(2) is vaccination against covid-19 a christian duty? a risk-analytic approach steffen flessaa a phd, professor, department of health care management, university of greifswald, germany abstract the covid-19 pandemic inspired a fierce discussion on pros and cons of vaccinations among christians. frequently, this emotional dispute is not based on facts, and this might be due to the fact that the decision situation (“to be vaccinate or not to be vaccinated”) is quite complex. in this paper we develop a risk-analytic model of the vaccination decision and explain the benefits of vaccinations against sars-cov-2 on different levels. furthermore, we show that the great commandment of love calls for avoiding all harm to the neighbor even if this harm is indirect and under uncertainty. consequently, it is a christian duty to love one’s neighbor and be vaccinated. key words: covid-19, christian duty, love, risk-analytical model, decision-making introduction a vaccination against an infectious disease is one of the most effective, efficient, and safe instruments to protect the health of a population. based on vaccines, smallpox1 was eradicated and other pandemic diseases such as measles2 and polio3 were substantially reduced. before the dawn of the vaccine era, millions of lives were lost annually, and many more were severely affected by suffering and long-term disability; these diseases have lost their horror today.4 it is estimated that measles alone killed 2-3 million children every year before global vaccination programs were introduced in the 1960s. only some 140,000 died in 2018 due to the disease—almost exclusively unvaccinated children under five.5 the only reason why measles has not been eradicated yet—as envisioned by the world health organization (who)—are niches of unvaccinated people. vaccinations are seen as the most effective, efficient, and safe form of prevention,6 and they are much more cost-effective than any treatment. as most of the “big killers” are contagious, other forms of prevention would require social distancing, which is very difficult to implement in the long run, in particular for children. treatment of patients is frequently not precise as we have only a limited portfolio of therapeutics against these viral diseases. consequently, early vaccination is the most rational approach, strongly encouraged by the united nations, who, all ministries of health, and christian organizations7-9 involved in health care. there is a steady increase of recommended vaccination targets, including rotavirus disease, human papillomavirus infection, and hopefully, malaria in the near future. after having given billions of vaccinations to billions of people in decades, we can state that there is hardly any medical intervention which has been so thoroughly analyzed, for which we have such a broad empirical basis, and which has proved to be as safe as vaccinations. in addition, vaccine technology has undergone progressive improvement such as tissue culture vaccines for rabies, high potency killed 3 flessa dec 2021. christian journal for global health 8(2) vaccine for polio, and mrna technology that promises future improvements in many areas.10 negative side effects exist, but they are a small fraction compared to the risks of contracting the respective disease. one of the most distinguishing features of vaccinations is that they can eradicate a disease completely, as long as the disease does not have other natural hosts or reservoirs. for instance, eradicating yellow fever will require eradicating the virus not only in the human population but also in the monkey population. as long as this population still serves as a reservoir, a reinvasion into the human population will always be possible. however, many other diseases, such as polio or measles, could be eradicated, such as smallpox, if we just managed to get all human beings vaccinated for several years. after the last case will have been healed or died, the disease would be gone forever and future vaccinations against it would be needless. there is nothing as sustainable as eradicating a disease—it would require “simply” the will, financial resources, and management to implement a global vaccination program without niches where the agent can persist. however, until today, these niches refuse to be vaccinated. a rather small number of people is sufficient to build up a reservoir for the disease so that it can persist and constitute a constant threat for the entire world. some of these populations have convictions that prohibit vaccinations, others are undecided and hesitate to gather sufficient information for making an informed decision. for instance, anthroposophical communities assume that a child needs viral or bacterial insults to develop properly. thus, they refuse to be vaccinated.11 other niches are communities and areas of christians who reject vaccinations for religious reasons. for instance, a few hundred thousand orthodox protestants in the so-called "dutch bible belt" in the netherlands reject vaccinations and report the highest numbers of measles cases in the entire country.12 even a simple mapping reveals that the geographical distribution of this christian group and the measles cases in the netherlands clearly shows that this group is the main driver of periodic measles outbreaks. just as described elsewhere for the situation before the introduction of the vaccine (e.g., prominently about measles in iceland), the disease comes in waves, infects almost the entire population of children without vaccination and immunity during an outbreak, and then disappears just to come back after a few years when a sufficient number of children have been born who are not immune.13 as soon as one measles case comes into the population from outside, the epidemic is likely to start again, i.e., the measles pandemic is sustained jumping from niche to niche, for instance, from the orthodox protestant christian community to christian communities all over the world. the results are not only fatal cases and severe morbidity, but also a high risk for the small population outside this community who cannot be vaccinated for health reasons. it seems that vaccine refusal is highly associated with “religious or philosophical reasons.”14 in this paper, we will argue from a social ethics perspective15, i.e., it is not our intention to provide physicians with instruments to give counselling for individual patients hesitating to be vaccinated. instead, we would like to contribute to the general discussion on a macro level and reflect on the question whether being vaccinated against a life-threatening disease is a christian duty. for this purpose, we develop a risk-analytic model demonstrating the decision situation of an individual considering only his utility or the good of others and the society based on the example of coronavirus disease 2019 (covid-19). afterwards, we will discuss the potential benefits of vaccination against covid-19. we realize that the decision to be vaccinated also depends on our understanding of the great commandment to love one’s neighbor as oneself. consequently, we analyse the scope of this commandment. the paper closes with some conclusions. risk-analytic model in this section, we would like to analyze the decision situation of an individual who has to decide to be vaccinated against covid-19 or to 4 flessa dec 2021. christian journal for global health 8(2) reject the vaccination. for this purpose, we use a decision tree as it is frequently used in medical decision making, in particular on a macro level.16,17 the purpose of this model is to increase the transparency about decisions (“arms”), probabilities, and results on a macro level. as stated before, the model is not intended to be used as a decision-making tool for individual counselling of a patient, but as an instrument to assess the nature of the decision-situation in the sense of “modelling for insights, not for numbers.”18 figure 1 exhibits the decision situation for an individual focusing only on his own utility (“selfbenefit decision”). 𝑉𝑉 stands for the decision to be vaccinated, 𝑉𝑉� for not being vaccinated. if the person is vaccinated, he can suffer from severe side effects (ss), mild side effects (ms) or no side effects (𝑆𝑆̅) with the respective probabilities (ps). in the case of severe side effects, even death (d) is possible. at the same time, the person develops immunity (im) with a probability of pim determining the likelihoods of all further events. in both cases, the person can be infected by sarscov-2, but for the immune, the probability to get infected when vaccinated (pin/v) is much lower than for the non-immune (either because he was not vaccinated at all or because he did not develop an immune response). the probability of being infected does also depend on protection measures, such as wearing of masks (which can considerably reduce the risk)19 and the contact frequency, but these interventions exist irrespective whether somebody is vaccinated or not. if the vaccinated is infected, he will get covid-19 symptoms (c) with a probability of pc/v as a mild case (mc) or a severe case (sc), but also the mild case can develop long covid (lc) with a certain probability plc/v. a severe case can be admitted to a hospital (ho) or intensive care unit (icu), and severe and mild symptomatic cases can die or develop long covid. the respective probabilities depend on the branch of the decision tree. the probability tree of a non-vaccinated person is identical with the tree of vaccinated without immune response (right-hand side) and mirrors the situation of an immunized but with different probabilities. for instance, the risk of a person vaccinated with comirnaty© (bnt162b2, vaccine against sars-cov-2 of pfizer-biontech) to get infected is about 50 % of the respective statistic of a non-vaccinated,20 the risk of developing symptomatic covid-19 is only about 30 %, the likelihood of being hospitalized is less than 20 %, of being admitted to an icu is less than 10% and of dying less than 2 % of the respective statistic of a non-vaccinated.21,22 the precise figures depend on the age and health condition of the vaccinated, the time after the vaccination and the virus variant, but in all cases, the arm of the vaccinated has much lower probabilities of developing severe disease symptoms than the arm of the non-vaccinated. however, the arm of the vaccinated also includes the branch of developing side effects of the vaccination from very mild to death. 5 flessa dec 2021. christian journal for global health 8(2) figure 1. self-benefit decision on vaccination against covid-19. source: own. 𝑉𝑉, 𝑉𝑉 vaccinated or not s, 𝑆𝑆̅ side effects or not ms mild side effect ss severe and/or long-term side effect im, 𝐼𝐼𝐼𝐼���� immunity or no immunity d, 𝐷𝐷� death or not death in, 𝐼𝐼𝐼𝐼��� infected or not infected c sick with covid-19 inf infectious nc not sick with covid-19 mc minor sick with covid-19 sc severely sick with covid-19 lc, 𝐿𝐿𝐿𝐿���� long covid or no long covid ho, 𝐻𝐻𝐻𝐻���� hospitalized or not icu, 𝐼𝐼𝐿𝐿𝐼𝐼����� icu or not ps probability of no, mild or severe/long-term side-effects pim probability of developing immunity after vaccination pin/v, pin/𝑉𝑉� probability of getting infected when vaccinated, probability of getting infected when not vaccinated pinf/v, pinf/𝑉𝑉� probability of infecting another person when vaccinated, probability of infecting another person when not vaccinated plc/v, plc/𝑉𝑉� probability of developing long covid when vaccinated, probability of developing long covid when not vaccinated pho/v, pho/𝑉𝑉� probability of hospitalization when vaccinated, probability of hospitalization when not vaccinated picu/v, picu/𝑉𝑉� probability of admission to icu when vaccinated, probability of admission to icu when not vaccinated pd/v, pd/𝑉𝑉� probability of death when vaccinated, probability of death when not vaccinated 6 flessa dec 2021. christian journal for global health 8(2) figure 1 shows the decision situation for an individual who does not consider the impact of his decision on others. we call this a self-benefit decision. however, it is a decision with uncertainty as all arms contain probabilities. there is no decision without risk, but from all that we know from the literature, the expected value of individual suffering (morbidity and mortality) is lower if a person is vaccinated. at the same time, the range of possible events, as well as the standard deviation of the results, are not higher for the vaccination arm. consequently, it is rational to go for vaccination even if one considers only his own life. however, the model clearly shows that the decision situation is highly complex. many arms have to be compared, many probabilities have to be sought from the literature, and many results of possible events have to be discussed. consequently, an individual might be overburdened with the decision situation. decision-making involving uncertainty and incomplete information can be difficult for the individual. however, very often the individual trusts experts when he is overwhelmed with a risk analysis. for instance, most people are not experts in metabolism, but they trust the medical experts that high levels of cholesterol are dangerous; consequently, they behave accordingly. trusting experts is a normal strategy to overcome uncertainty and incomplete information.23 a frequent alternative is “doing nothing”—in this case, avoiding the immunization because the risk of infection is in the future while the risk of getting side effects exists today. furthermore, an irrational decision-making process of ignoring risks might be acceptable for an individual, but it is definitely not for the policy-makers, also not for leaders of churches and christian health care organizations. they can be expected to make informed decisions for the best of the people entrusted to them. figure 2 shows the decision situation for a person considering explicitly the impact of his vaccination decision on the lives of others. he knows that once he is infected himself, he can infect others. the likelihood of infecting another person is expressed as pinf/v if the person is vaccinated and pinf/𝑉𝑉� if he is not vaccinated. there was the hope that pinf/v would be zero, but it is a matter of fact this is not valid for the delta-variant. for instance, singanyagam et al. found that there were no differences in the peak viral loads between unvaccinated and vaccinated individuals.24 likewise, brown et al. speculated that the viral load of vaccinated and unvaccinated persons infected with sars-cov-2 are rather similar.25 however, elliott et al. estimated an effectiveness of the vaccine against covid-19 infection of 49% (with an effectiveness against symptomatic infection of 59%).20 mallapaty also concludes that “growing evidence finds that they [vaccines against covid19] also substantially reduce the risk of passing on the virus sars-cov-2.”26 the reason is—most likely—that while the peak viral load between vaccinated and non-vaccinated might be similar, the overall viral load of vaccinated is lower as vaccinated people clear the virus more quickly, i.e., “within days of infection, the viral load in vaccinated people drops much more rapidly and therefore makes them much less likely to transmit [covid-19].”27 consequently, maier et al. found that “67%–76% of all new infections are caused by unvaccinated individuals” in germany (autumn 2021,)28 although merely some 30 % of the population were unvaccinated. thus, we can conclude that vaccination reduces the risk of infecting others, i.e., 0 < pinf/v < pinf/𝑉𝑉�. once another person is infected, the entire decision model starts again. as we do not know whether the other person is vaccinated or not, the model does not differentiate the two arms at the next level. this could be done, but it would make the model even more complex. the other person might himself infect another person (level 2) who himself might infect others (level 3 etc.). while the wild variant of sars-cov-2 had a much lower basic reproductive rate29,30, the delta variant has an r0 of about five, i.e., each infected person31 will— on average—infect another five. in other words: a comprehensive decision model will require considering at least the arms, probabilities, and results of five different persons. if we consider several levels of infections and take responsibility 7 flessa dec 2021. christian journal for global health 8(2) for everybody who can trace his infection back to the decision-maker, the number of infected whom we have to consider in our decision grows exponentially. figure 2. comprehensive decision on vaccination against covid-19. source: own. summarizing the insights of the risktheoretic decision model, we can state that the decision to be vaccinated or not to be vaccinated will depend on several variables: • levels: does a decision-maker consider only his situation (self-benefit decision), or does he also consider the potential impact on other people who he might infect (comprehensive decision)? • results: how does a decision-maker assess the results of a certain arm of the tree, e.g., loss of quality of life due to vaccination side effects, mild covid-19, long covid-19, hospitalization, icu, death? • uncertainty: the decision-maker faces a high degree of uncertainty, i.e., he has to consider many probabilities, e.g.: how likely is a positive immune response to a vaccination? how likely are side effects? how likely is an infection if vaccinated or not vaccinated? how likely is it to infect others if vaccinated or not vaccinated? how does the probability of being infected and on infecting others depend on different protection measures, such as wearing of masks and the resulting dose of the virus, testing, contact tracing, and community mitigation efforts? how likely are symptoms, hospitalization, icu, death, or long covid if vaccinated or not vaccinated? how likely is it that an infected person will infect other people? • complexity: can the decision-maker comprehend the situation completely? does he understand the interdependencies of different decisions, levels or analyses, and events? can he follow the dynamic changes of events and probabilities, such as changing levels of antibodies with time after vaccination?32 if not, whom can he trust? benefits of vaccinations covid-19 has negative consequences for the individual, for communities, and for societies. consequently, reducing the likelihood of being infected (by a vaccination) has a number of 8 flessa dec 2021. christian journal for global health 8(2) benefits. however, the relevance of these harms and benefits for the decision-maker depends on the decision concept. if a decision-maker focuses only on his self-benefit interest, only a few decision criteria are relevant. if he focuses comprehensively on other people, the number of criteria is manifold. table 1 shows the relevant decision variables. for the patient himself with a self-benefit concept, the prime focus is the assessment of pain, fear, sorrow, and death during the period of acute sickness and possibly during the long-term recovery as represented in figure 1. these are essential elements of intangible harm, but the patient might also face co-payments and out-ofpocket payments depending on his insurance coverage. at the same time, some indirect costs might occur. for instance, the person will be unable to work for some time and might lose income (depending on the social protection system). students might miss some classes and might have to repeat a year of training. however, the main criterion for a self-benefit decision-maker is his own health. a more comprehensive decision-maker will include those people he might infect, as shown in figure 2. thus, not only the pain, fear, sorrow, and death of the decision-maker, himself, but also of all possibly infected will have to be included. as those whom he infects will infect others again (shown as level 3 in figure 2), the decision-maker has to consider how many levels he will include in his decision, i.e., he has to decide whether he considers only those whom he infects directly or all who can trace their infection back to him. as stated above, the basic reproductive rate (r0) expresses the number of individuals one person (on average) will infect if no immunity exists. if i denotes the number of levels one person will consider, the number of infected he will have to consider is 𝑅𝑅0 𝑖𝑖 . for instance, at a level of i=2 and r0=5 (delta variant), the decision-maker will have to consider the pain, suffering, death, financial hardship, and indirect cost of 25 people, for i=3 already 125 people. for the wild variant with an r0 of about 2.5,29 the respective figures are 6.25 and 15.63, i.e., the issue of “comprehensive decision-making” and considering further levels in the infection chain has strongly been enforced by the new variant(s). a special group, which could be included in the comprehensive decision-making, are the health care services and their staff. covid-19 has brought health care staff, in particular doctors and nurses of icus, to their limits. many are overwhelmed, have experienced tremendous stress, and feel guilty in a situation where they cannot help anymore. the number of nurses who have given up their job during the covid-19 pandemic is high. others have been infected during their duty, and in particular at the beginning of the pandemic, doctors and nurses were among the highest risk groups.33,34 covid-19 does not only have an impact on the staff but also on other patients. the capacities used to treat covid-19 patients are missing to treat others, and frequently, elective surgeries had to be postponed, and other patients were not treated well as usual. any additional covid-19 case also means additional risk, hardship, and potential harm for health care staff and patients with other diseases.35 the widest concept of decision-making will consider the impact of the disease on the entire society. during the months of the pandemic, many societies have seen a negative impact on the entire society. some have developed a high degree of mistrust against the government. in germany, for instance, a movement called “querdenker” has developed. they insist that sars-cov-2 does not exist and that covid-19 is a lie of the government to control the people. thus, they fight against governmental programs to control the disease. the german intelligence service assesses the movement as extremely right-wing with the potential of conducting violence against officials. others have lost interest in politics, as they are frustrated with all the interventions against the disease.36 another societal consequence of the disease are the high costs of treating patients. some health insurances, but also hospitals, have come close to bankruptcy because the normal rebates and premiums cannot refinance the high costs of 9 flessa dec 2021. christian journal for global health 8(2) covid-19 patients. other institutions have to train new staff because the existing personnel have left their jobs. the highest societal costs are usually caused by complete lockdowns including strong subsidies for enterprises affected (e.g., tourism, entertainment). for germany alone, it is estimated that each week of lockdown cost some 3.6 billion euro37 – and the lockdown lasted for months. the long-term consequences of covid-19 are still unclear. for instance, the early and uncoordinated closing of borders between eu countries in the schengen area (e.g., between germany and france) in march 2020 caused tensions between the countries and might cause long-term damage to the international relations. table 1. consequences of an infection. source: own. patient people infected by the patient health care services society intangible harm pain, fear, sorrow, death (during recovery or longterm) pain, fear, sorrow, death (during recovery or longterm) overwhelming, guilt, stress, burn-out mistrust, right-wing movements, politics reluctance infection risk basic reproductive rate, superspreader personnel (doctors, nurses) direct treatment cost co-payments, outof-pocket co-payments, outof-pocket, financial cost for family cost of treatment for health insurance indirect cost loss of productivity, loss of education loss of productivity, loss of education reduced capacity of health care services for other patients, blocked beds, overwhelmed personnel, postponed operations etc., early retirement or resigning from job (nurses) cost of training new staff, cost of lockdown, international relations the societal costs are partly caused by each additional infection. every individual has to consider his contribution to the achievement of herd immunity, which is achieved if the net reproductive rate (n0) is less than one. n0 considers the share of the immune in the total population, i.e., 𝑁𝑁0 = 𝑅𝑅0(1 − 𝐼𝐼) where n denotes the share of the immune population. the epidemic comes to an end if n0<1 or 1 − 1 𝑅𝑅0 <n. in this case, n denotes herd immunity, i.e., the immunity level in a population that is required to * if an infection with sars-cov-2 produced lifelong immunity, the number of covid-19 cases would have to be added. however, this is not fully the case. instead, it is recommended that former stop the epidemic. for instance, a covid-19 epidemic with r0=5 will come to an end if n>0.8, i.e., at least 80 % of the population becomes immune by vaccination before the epidemic stops. assuming that existing vaccinations protect only by 90 %, the realistic vaccination rate must be at least 89%; if it protects by 80%, the entire population must be vaccinated.* consequently, if a vaccine protects by less than 80% against the infection (and being infectious) with the delta-variant, herd immunity will not be reached,38 and there is some doubt whether herd immunity could be reached at all for cases of covid-19 should be vaccinated as well after six months in order to have a full and lasting immune response. 10 flessa dec 2021. christian journal for global health 8(2) covid-19.39 does this mean that a comprehensive decision-maker should not consider the next levels of infection and his contribution towards herd immunity (even if it is never reached)? as long as pinf/v < pinf/𝑉𝑉� , we can state that a vaccination against sars-cov-2 reduces the risk of infecting others and lightens the burden of the disease for individuals and the society. protecting the contact persons of the next level, the health care services, and the society might not be perfect, and the disease might not be eradicated completely (in particular as it is not perfectly clear whether a re-invasion from the natural reservoir of bats is feasible), but everybody can contribute to struggle in the right direction. thus, a decision-maker who considers the societal harm of covid-19 will have a strong drive to be vaccinated and to contribute to herd immunity to avoid the societal harm of the disease. you shall not harm! a christian duty as stated above, every decision-maker has to decide on the level considered, the assessment of the results, the probabilities, and the way of dealing with the complexity. most crucial is the question of whether a decision should reflect only the benefits and harms for the decision-maker himself or other people as well. for a christian, it should be clear that the life of other people (“the neighbor”) is relevant as well, i.e., a purely selfbenefit decision is unacceptable for a christian. however, in reality, the situation is not as easy as the different arms of the decision tree are all subject to certain probabilities, and this decision situation seems to be unusual for many christians. like in most other ethical reflections, there is no direct commandment in the bible that gives an unequivocal instruction to be vaccinated or not. instead, christians have to reflect a decisionsituation in the light of the facts (in particular, provided by science) and biblical values. while specific commandments might be time-bound and limited in scope, the values underlying the biblical illustrations (such as peace, freedom, justice, love, forgiveness) are relevant for christians as their decision variables in a concrete situation although they will require ethical consideration.40 it is our responsibility to reflect on their relevance in a concrete situation. we assume that there is general agreement that the “great commandment“ (math. 22: 37-38) is the core of christian duty, i.e., to “love the lord your god with all your heart and with all your soul and with all your mind [… and to] love your neighbor as yourself.” the last part (“ἀγαπήσεις τὸν πλησίον σου ὡς σεαυτόν”) refers to the ancient greek agape-love (ἀγάπη) as the selfless and unconditional love, distinct from brotherly love (philia, φιλία) and sensual love (eros, ἔρως). agape is seen as the highest christian virtue. paul also writes that we have no duty except to love (ἀγαπᾶν!) each other as all commandments are fulfilled in this one (rom 13: 8). consequently, love is the only christian duty, and love is the criteria to analyze whether a christian should support vaccinations or reject them. if love calls for vaccination, it is the duty of the christian to be vaccinated and to help others to be vaccinated.41,42 however, the term love is not easy to define, and it is not operational enough to use it as decision criterion without further reflection. consequently, we have to ask what love actually means in a biblical context and what it could mean concerning a vaccination program. for this purpose, we start with an understanding of love where we can meet general agreement: murdering another person is against love. consequently, the fifth commandment (exodus 20: 13) expresses it clearly and unequivocally. the sense of this commandment for individual well-being, but also for social cohesion, is self-evident. nobody should raise his hand, ax, pistol, or rocket to cause damage to another's body that would lead to death. in the small catechism, luther extends the range of the commandment when he demands, “that we do not hurt or harm our neighbor in his body, but help and support him in every physical need.” thus, this commandment covers not only the direct and intentional murder but also careless harm or putting at risk. furthermore, it does not only prohibit human actions that are immediately and likely to 11 flessa dec 2021. christian journal for global health 8(2) lead to harm, but also anything that does not “help and support him in every physical need.” physical injury and death can also occur unintentionally, indirectly, and with a certain probability under uncertainty. the driver who drives through zone 30 in front of a primary school at 80 km/h has no intention of running over a child, nor is he sure to kill someone while driving. however, he takes (consciously or unconsciously) the risk that someone will be harmed by his action. we see this person ethically and legally responsible for damage if he caused it negligently. moreover, most people share the opinion that christian love calls for responsible action to reduce the risk to harm children. while most would agree that risking the life of a child by driving tremendously irresponsible and breaches the commandment of love, it is not as clear that any hazard constitutes a violation of the principle of love. if someone wants to avoid completely any risk of jeopardizing the life of other people, he must not participate in road traffic, restrain from most social activities, and definitely not become a doctor or nurse who are always at risk of harming other people. in particular, those activities we usually associate with love (e.g., heal, feed, visit others) increase the risk of harming and, consequently, breaching the commandment of love. it seems that we accept a risk if the damage occurs only with a certain probability and if the alternative is worse. in other words: christians have to analyze which alternative has the lowest expected value of breaching the commandment to love the neighbor. then christians have to choose this alternative in the knowledge that there is still a risk of harming others. jesus underlines the importance of love by making it a distinguishing feature of christians: “a new command i give you: love one another. as i have loved you, so you must love one another. by this, everyone will know that you are my disciples if you love one another” (john 13: 34-35). to be a christian means to love, a christian existence without love would be a contradiction in terms. the bible bases this love on the fact that god loves his creatures to the point of self-abandonment (rom. 8: 31-36; john 3: 16). the task of the christian is to pass on this love because faith without deeds of love is dead (gal 5: 13; james 2: 17; 1 john 3: 17). from a biblical perspective, however, love is primarily not an emotion, but an action, as is shown, for example, in the parable of the good samaritan (luke 10: 25-37). the narrative does not describe any emotion, but gives—despite all the complexity and challenge of the narrative43— an instruction to act in the same way. the eschatological speech of jesus (mt 25: 31-41) also emphasizes love for the weak and helpless, which is expressed in concrete actions, e.g., looking after the hungry and thirsty, taking in strangers, clothing the naked, and visiting the sick and prisoners. love appears in this—certainly not exhaustive—list as a rational act, not as an emotion. this active love even becomes the criterion for entering the kingdom at the right hand of god (mt 25: 31-36) and definitely includes rational decision-making with a comprehensive analysis of different arms, probabilities, and levels of the decision. a strong focus of the “works of mercy” is health in its wider sense. it includes the physical (hunger, thirst, nakedness), the social (visits, reception), and the mental dimension of health which are also referred to in the definition of health in the constitution of the world health organization.44 however, health in the biblical sense goes beyond these three dimensions and also includes a spiritual dimension, since "shalom" is only possible in communion with the creator.45 thus, health in the christian understanding is the goal of love, but in a comprehensive sense that includes the active creation of relationships, meaning in life, joy of life, peace, and justice as well as spirituality. love is never self-benefit, but notoriously comprehensive and people-oriented. it looks for the best for the neighbor and the entire society as a prerequisite of a healthy life for the neighbor. consequently, christian love is action-based, comprehensive, and reflective. it would be insufficient to base love on emotions and reduce it to avoid direct harm to people in front of me. in 12 flessa dec 2021. christian journal for global health 8(2) the parable of the good samaritan, the scribe originally asked: “who is my neighbor?” (luke 10: 29). so he asked from himself, from his point of view, from his intention. jesus tells the parable and then turns the question around: “which of these three do you think became a neighbor to the man who fell into the hands of the robbers?” (luke 10: 36). jesus is concerned with the experience of neighborly love from the point of view of the helpless, i.e., a rather rational and result-oriented point of view. we can, therefore, state that the endangerment of people can represent a breach of love, even if its materialization is subject to a certain probability. drivers running at 80 kilometers an hour in zone 30 in front of an elementary school are not only breaking the law, but they also violate the principle of love because they neglect the possible consequences of their actions for those whom they are called to love. an hiv-positive man who, against better judgment, has unprotected sexual intercourse with another person unaware of this risk does not only commit (attempted or completed) physical harm, but also acts in an absolutely loveless manner because he knowingly endangers the life of another person. consequently, a christian must consider the consequences of his decisions for all potential neighbors even if the risks are subject to probabilities. conclusions based on our reflections on christian love and the risk theoretic decision model of vaccination against covid-19, we can state that christians must also consider the long-term, indirect, and uncertain consequences of their decision to be vaccinated or to reject the vaccination. this reflection will also include the risks of harming other people. it is the christian duty to love one’s neighbor, but not only those standing directly in front of me and those i may damage face-to-face, but also the anonymous ones i might kill or harm with my decision. covid-19 is a disease with tremendous potential to cause suffering, sorrow, and costs on an individual and societal level. this harm can be grossly avoided by a vaccination, and the spread of the disease can be stopped if only a sufficient number of people are vaccinated. a christian must take a societal perspective in his decisions because he is called to love his neighbor. rejecting the vaccination against covid-19 is also quite haughty because it considers neither the complexity of the decision situation nor the recommendations of the experts. christians should love their neighbors in humility—and humility calls to accept the opinion of the experts in particular when they are christians themselves. if a person who is not expert in virology and epidemiology himself does not pay attention to what the experts say and simply rejects their expertise, he is guilty of arrogance that leads to a breach of love. in former times, arrogance was considered a “mortal sin”—a term that might sound obsolete. nevertheless, rejecting the expertise and good reasoning of experts breaches the commandment of love if it leads to harm, suffering, and death of our neighbor. here, we have to repeat that this paper argues from the perspective of social ethics asking the question what is generally “right” or “wrong” from a macro perspective. counselling of an individual (patient) will require totally different approaches and instruments as there is frequently a gap between societal ethics and approaches of individual behavior changes. on an individual level, addressing arrogance might lead to blaming, while neglecting arrogance on a social, nonindividual level might be misleading a decisionmaking process of high relevance for the society as a whole. therefore, it is important to distinguish individual counselling and social ethics. from a perspective of social ethics, to love one’s neighbor requires reflecting on the consequences of our decisions on them even if these consequences are subject to certain probabilities. we do this when we participate in traffic or when we engage in our professions. life is not without risks, but christians should always consider the impact of their life on others. based on love for the neighbor, christians have to apply a 13 flessa dec 2021. christian journal for global health 8(2) comprehensive concept of decision-making (see figure 2), consider the impact of their vaccination decision not only on themselves but also on the community and society (see table 1), and invest effort to reduce the risk of harm for all images of god. based on this concept of love, a vaccination against covid-19 is a christian duty. in this paper, we do only address the macro level of social ethics. more research has to be invested in the most appropriate way to convince individual christians hesitating to be vaccinated. furthermore, anti-vaccine attitudes of certain christian groups that compromise herd immunity have to be addressed in a joint effort of theology as well as political and sociological sciences.46 consequently, this paper finally calls for more collaborative research on vaccinations from a christian perspective. whether an increased theological, medical, and scientific knowledge will indeed convince these groups or whether they will be trapped in an irrational rejection of vaccinations is also beyond the scope of this paper. however, this analysis clearly demonstrates that a rational christian decision-maker will perceive vaccination against covid-19 as a christian duty. references 1. fenner f, henderson da, arita i, jezek z, ladnyi id. smallpox and its eradication [internet]. geneva: world health 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a risk-analytic approach. christ j global health. dec 2021; 8(2):2-15. https://doi.org/10.15566/cjgh.v8i2.611 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://doi.org/10.1016/j.jiph.2021.07.004 http://ijhr.iums.ac.ir/article_139055.html https://www.dw.com/de/was-kostet-der-harte-lockdown/a-55937348 https://www.dw.com/de/was-kostet-der-harte-lockdown/a-55937348 https://www.nature.com/articles/d41586-021-00728-2 https://www.nature.com/articles/d41586-021-00728-2 http://doi.org/10.1056/nejmp2113403 https://www.domradio.de/themen/corona/2021-06-04/impfen-ist-christenpflicht-theologe-ruft-der-pandemie-zu-verantwortlichem-verhalten-auf https://www.domradio.de/themen/corona/2021-06-04/impfen-ist-christenpflicht-theologe-ruft-der-pandemie-zu-verantwortlichem-verhalten-auf https://www.domradio.de/themen/corona/2021-06-04/impfen-ist-christenpflicht-theologe-ruft-der-pandemie-zu-verantwortlichem-verhalten-auf http://doi.org/%2010.1080/15265161.2017.1284914 https://doi.org/10.1177/2378023120977727 mailto:steffen.flessa@uni-greifswald.de mailto:steffen.flessa@uni-greifswald.de https://doi.org/10.15566/cjgh.v8i2.611 http://creativecommons.org/licenses/by/4.0/ abstract introduction risk-analytic model benefits of vaccinations you shall not harm! a christian duty conclusions references 1. fenner f, henderson da, arita i, jezek z, ladnyi id. smallpox and its eradication [internet]. geneva: world health organization; 1988. available from: file:///c:/users/user/appdata/local/temp/9241561106.pdf 2. moss wj, griffin de. global measles elimination. nat rev microbiol. 2006;4:900-8. http://doi.org/10.1038/nrmicro1550 3. aylward b, tangermann r. the global polio eradication initiative: lessons learned and prospects for success. vaccine. 2011;29(4):d80-d5. http://doi.org/1016/j.vaccone.2011.10.005 4. van wijhe m, mcdonald sa, de melker he, postma mj, wallinga j. effect of vaccination programmes on mortality burden among children and young adults in the netherlands during the 20th century: a historical analysis. lancet infect dis. 2016;16:592-8.... 5. masern rki ratgeber. robert-koch-institut, 2021[cited 2021 sept 11]. available from: https://www.rki.de/de/content/infekt/epidbull/merkblaetter/ratgeber_masern.html 6. bloom de, canning d, weston m. the value of vaccination [internet]. fighting the diseases of poverty: routledge; 2017:214-38. available from: https://lnct.global/wp-content/uploads/2017/10/david-e-bloom-the-value-of-vaccination.pdf 7. vaccinations in wcc member traditions [internet]. world council of churches; 2021 [cited 2021 nov 22]. available from: https://www.wichurches.org/2021/09/21/vaccinations-in-wcc-member-traditions/?utm_source=rss&utm_medium=rss&utm_campaign=vaccinati... 8. religious leaders join chorus of support for vaccination in nigeria [internet]. gavi; 2021 [cited 2021 june 12]. available from: https://www.gavi.org/vaccineswork/religious-leaders-join-chorus-support-vaccination-nigeria 9. will evangelical leaders receive the covid-19 vaccine [internet]? 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[s.l.]: gabal verlag gmbh; 2010. 24. singanayagam a, hakki s, dunning j, madon k, crone m, koycheva a, et al. community transmission and viral load kinetics of the sars-cov-2 delta (b. 1.617. 2) variant in vaccinated and unvaccinated individuals in the uk: a prospective, longitudinal... 25. brown cm, vostok j, johnson h, burns m, gharpure r, sami s, et al. outbreak of sars-cov-2 infections, including covid-19 vaccine breakthrough infections, associated with large public gatherings—barnstable county, massachusetts, july 2021. morbidit... 26. mallapaty s. covid vaccines slash viral spread–but delta is an unknown. nature 2021;596(7870):17-8. available from: https://econpapers.repec.org/article/natnature/v_3a596_3ay_3a2021_3ai_3a7870_3ad_3a10.1038_5fd41586-021-02054-z.htm 27. cdc covid report ‘no cause for panic’. the royal australian college of general practitioners (racgp), 2021 [cited 2021 nov 24]. available from: 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simmons r, et al. vaccine effectiveness and duration of protection of comirnaty, vaxzevria and spikevax against mild and severe covid-19 in the uk. medrxiv. 2021. https://doi.org/10.1101/2021.09... 33. günaydın n, küçük alemdar d. evaluation of worry level in healthcare professionals and mental symptoms encountered in their children during the covid-19 pandemic process. curr psychol. 2021:1-11. http://doi.org/10.1007/s12144-021-02142-3 34. kishk rm, nemr n, aly hm, soliman nh, hagras am, ahmed aaa, et al. assessment of potential risk factors for coronavirus disease-19 (covid-19) among health care workers. j infect public health. 2021;14:1313-9. http://doi.org/10.1016/j.jiph.2021.07.... 35. meshkani z, mosavi-negad sm, valipour yekani n, hasan negad b. assessing the opportunity costs of covid-19 patients in hospitals. int j hospital res. 2021. available from: http://ijhr.iums.ac.ir/article_139055.html 36. koos s. die „querdenker “. wer nimmt an corona-protesten teil und warum? 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http://doi.org/ 10.1080/15265161.2017.1284914 43. assel h. elementare christologie. 2. band der gegenwärtig erinnerte jesus. gütersloh: gütersloher verlagshaus; 2020. 44. who. constitution. geneva: world health organisation; 1948. 45. ewert dm. a new agenda for medical missions. brunswick: map; 1990. 46. whitehead al, perry sl. how culture wars delay herd immunity: christian nationalism and anti-vaccine attitudes. socius 2020;6:2378023120977727. https://doi.org/10.1177/2378023120977727 www.cjgh.org original article june 2014. christian journal for global health, 1(1):44-52 indian catholic church’s response to the elderly with neurodegenerative and mental illnesses h.e. msgr. vincent m. concessao a , rev. dr. tomi thomas b , anto maliekal c a emeritus archbishop of delhi, bishop responsible for pastoral care in health, catholic bishops conference of india and ecclesiastical adviser, the catholic health association of india b director general, the catholic health association of india c programme manager, the catholic health association of india abstract this article provides an overview of the status of the elderly in india, especially those who suffer from neurodegenerative illnesses. it highlights how the catholic church in india responds to the socially and economically marginalized and vulnerable among the elderly, the emerging challenges for the elderly and those involved in geriatric care, and offers recommendations for a way forward for the church. in spite of the commendable efforts, much needs to be done by the church for the elderly. the church must utilize the full potential of health care networks like the catholic health association of india (chai) and other faith-based-healthnetworks (fbhns). inculcating the culture of “involving all” in christ’s healing ministry, the church in india can facilitate the building of caring communities to enable senior citizens to live their twilight years with dignity and peace. the church can facilitate the democratization and decentralization of medical knowledge through task-shifting. this calls for the empowerment of local communities with information and skills to access health and health care as a fundamental right. introduction by 2050, in india, due to various factors in health development, the segment of the population aged 60 years and above will surpass the population of children below 14 years. 1 in absolute terms, according to the data on projected age structure of population by united nations department of economic and social affairs (undesa 2008), india had more than 91.6 million elderly in 2010 with an annual addition of 2.5 million elderly between 2005 and 2010, which is projected to reach 158.7 million in 2025. 2 the increasing number of the sick elderly suffering from neurodegenerative illnesses like dementia and mental disorders like depression is an accompanying fact. by 2050, india will have 43 million persons aged 80 or over. 3 the situation becomes significantly more challenging with rising health care costs and the facts that 80% of the elderly are in the rural areas and 30% of the elderly live below the poverty line. 4 as per the global age watch index (gawi), india ranked very poorly among the 91 countries sampled - 73 rd in the care of the elderly. 5 the message of pope francis at the xxi plenary assembly of the pontifical council for the family is significant in this context: “children and the elderly are the two poles of life and also the most vulnerable, often the most forgotten. a society that abandons children and 45 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 marginalizes the elderly severs its roots and obscures its future. whenever a child is abandoned and an old person is marginalized, is not just an act of injustice, but it also demonstrates the failure of that society. taking care of children and the elderly is the only choice of civilization.” 6 this paper gives an overview of the status of the elderly in india, especially those who are affected with neurodegenerative illnesses and mental disorders. it also provides a special emphasis on the socially and economically marginalized/excluded and vulnerable (women) among the elderly; the emerging challenges for the elderly and for those involved in geriatric care; how the catholic church (hereafter referred to as “church”) in india responds to the situation; and finally, a way forward for the church in india. growth of the elderly population the national policy on older persons adopted by the government of india in january 1999 defines “senior citizen” or “elderly” as a person aged 60 years or above. nearly 7.5% of india's population is currently aged 60 years and above. 4 it is projected to rise to 12.4% of the population by the year 2026. 7 by 2050, sustaining the existing trend of the longevity of women over men, the number of elderly women would exceed the number of elderly men by 18.4 million. health and social status of the elderly in indian society approximately 65% of the aged have to depend on others for their day-to-day maintenance. 2 seventy percent of them are women. nearly 40% of the elderly are still working (60% of men and 19% of women). in urban areas, only 39% of elderly men and approximately 7% of elderly women are economically active. in rural areas, 66% of elderly men and 23% of elderly women are working. 7 based on helpage india, 52% of india’s oldest old (80 +) are in either poor or very poor health, and 80% were without community support. twelve percent of the oldest-old are still working. 8 thirty-one percent of older persons reported facing abuse [material exploitation, financial deprivation, property grabbing, abandonment, verbal humiliation, and emotional and psychological torment]. 9 most of the cases go unreported in the name of family honor, and victims are afraid of losing even the minimal support they receive. provisions for the support of the elderly article 41 of the constitution assures public assistance in old age. the enactment of the maintenance and welfare of parents and senior citizens act, 2007 is to ensure need-based maintenance for parents and senior citizens and for their welfare. the government, through the cen tral sector scheme of the integrated programme for older persons (ipop), encourages publicprivate partnership – supporting non-state actors to maintain/organize various facilities for the elderly. the other measures are old age pensions; income tax exemption/ deduction; travel concessions; geriatric departments in medical colleges; and establishing two national institutes on aging in delhi and chennai. many of these measures, however, are not fully implemented. recently, the national policy on senior citizens 2011, and in line with it, the 12 th five year plan and national mental health programme, placed special emphasis on senior citizens suffering from severely disabling diseases. this includes various types of dementias including alzheimer’s, parkinson’s disease, depression, and other psycho-geriatric disorders. on the whole, the country is yet to put in place measures to effectively meet the impending scenario of the growing population of the elderly, especially those suffering from neurodegenerative illnesses and mental disorders. specific needs related to neurodegenerative disease and mental illness 46 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 the increased numbers of the sick elderly with neurodegenerative illnesses and various mental disorders will have a marked impact on india’s infrastructures and health care systems, which are at present ill-prepared in many regions. approximately 64 per 1,000 elderly persons in rural areas and 55 per 1,000 in urban areas suffer from one or more disabilities. 7 as per the ministry of health and family welfare, one in every four among india's elderly population is depressed; one in three suffers from arthritis, while one in five cannot hear. while one in three suffers from hypertension in india, almost half have poor vision. approximately one in ten experiences a fall that results in fracture, while two in five are anemic. 4 as per helpage india, 30 million are lonely, and one out of eight elderly feels no one cares that they exist, and 90% have to continue to work if they have to survive. 10 eighty-eight percent said loneliness can lead to physical and mental ailments like depression. 11 many researchers believe that depression is a risk factor for dementia. there are others who argue that it is an early symptom of the disease. 12 in 2010, it was estimated that there were 3.7 million affected by dementia (alzheimer disease [ad] and vascular dementia [vad]) in india, and the total societal cost was approximately rs.1,470 million. people with dementia (pwd) are expected to double by 2030, increasing the cost by three times. 13 at present, the elderly with depression and neurodegenerative illnesses are mainly taken care of by their families without much support from the public health care system, even at the primary care level. the joint family system, the traditional support system for the sick and dependent elderly people, is crumbling because of the migration of the younger generation to cities in search of better prospects. the advent of nuclear families also adds to the challenge. women, who traditionally took on the role of caregivers, are also working and cannot spend as much time caring for the elderly. 14 a neurodegenerative condition, like dementia, is considered a normal part of aging and is not perceived as requiring medical care. primary care physicians rarely deal with this condition in their clinical work. private medical care is thus preferred, and this leads to a higher out-of-pocket expenditure for care. caregivers experience significant burdens and health strain. more than 80% of caregivers are females, and approximately 50% are spouses, who are themselves quite old. most old-age homes do not admit people with dementia. the stigma of aging, arising out of neurodegenerative illnesses like dementia, de-pression, incontinence, etc., is another social barrier to accessing health care by the elderly. people with dementia and other types of neurodegenerative illnesses and mental disorders are often neglected, ridiculed, and abused. 14 the key barriers to the access to health for the indian elderly include social barriers shaped by gender, stigma, and other axes of social inequality (religion, caste, socio-economic status). the physical barrier of reduced mobility reduces their social engagement and limits the reach of the health system. health affordability constraints include limitations in income, employment, and assets, and the meager financial protection offered in the indian health system. 2 social security coverage, such as employer insurance, pension scheme, etc., covers only a negligible segment of the employed population in organized sectors. the majority of the workforce is engaged either in the unorganized sector or are self-employed. they are not entitled to formal retirement benefits. as a result, a considerable proportion of the elderly is forced to earn their living by engaging in some work to manage their lives. as 83% of health care expenses are out-ofpocket expenditures, 2 the deprivation is severe and crushing for the elderly whose need for health care increases with age. even where care is physically accessible, costs of accessing this care become beyond their reach. for the willing caregivers, especially those struggling to make both ends meet, the sick elderly become a severe economic burden. the growing comercialization of health care and the deficiencies in the public health care system also make the situation more 47 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 complex. among the elderly, women suffer most, especially widows (due to mobility, employment, property, and financial constraints). the predicament of elderly women is aggravated by a lifetime of gender-based discrimination. aging women are more likely to get excluded from social security schemes due to lower literacy and awareness levels. 15 the role of the catholic health association of india in addressing the needs of the elderly the catholic health association of india (chai) is the largest non-government health care network in india with over 3,439 member institutions. founded in 1943 by sr. dr. mary glowrey, an australian nun, chai is one of the main arms of the health commission under the bishops’ conference and comprises most of the catholic health care facilities: 746 small, medium, and major hospitals, 2,574 health centers, 107 centers for mental health, 61 centers for alternative systems of medicine, 162 nonformal health facilities, 165 leprosy centers and 6 medical colleges, 615 residential health care centers for the aged, 678 training centers and 443 rehabilitation centers involved in the preventive and curative care of people, 123 community care centers for people living with hiv/aids including 40 centers for children infected/ affected, 60 counselling centers, 82 centers for tuberculosis and terminally ill (palliative care centers), 120 nursing schools/ colleges) and 600 project-based institutions focused on certain diseases in collaboration with the government, as well as engaged in other social concerns. 16 17 18 chai provides critical health care services to the poor and marginalized with a network of over 1,000 nun-doctors, 25,000 nun-nurses, 10,000 plus nun-paraprofessionals, and 5,000 nun social workers, along with their lay collaborators. 17 one can safely assume that nearly 130,000 persons (religious, lay workers and volunteers) render services in these institutions collectively. chai’s member institutions treat more than 21 million per year. this includes 5,000 hiv patients, approximately 2,000 children affected or infected with hiv in institutional care, 15,000 cared for in community-based care, and 10,000 children with special needs who are provided with annual educational, health, and rehabilitation support. chai member institutions and their sister concerns facilitate more than two million self help group members. over 5,000 students graduate every year from chai-member nursing schools. 17 throughout india, in all its 615 homes for the aged, chai and its member institutions provide free care to nearly 18,500 elderly, who are mostly sick and abandoned by their families. however, most of these homes are located in middle-income level southern states, with nearly 40% located in the state of kerala and the rest in karnataka, maharashtra, goa, and west bengal. 18 the church renders service to more than 60,000 elderly on a daily basis, including approximately 18,500 in its homes for the aged and 1,700 in its palliative care units. this does not include the elderly supported in its project-based institutions/ organizations and those contacted daily during home visits as part of pastoral care. of late, serious efforts are being made to train nurses and other frontline health workers in geriatric care. currently, there are not many governmentrun geriatric care facilities, especially for the elderly with neurodegenerative illnesses. some for-profit, private health care providers have recently entered the field, but are not meant to cater to the needs of the elderly from marginalized sections of the community. further, none of them are ready to take care of the elderly with neurodegenerative and mental illnesses. it is in this space that the varied services offered by private not-for-profit faith-based-health-networks (fbhns) like chai and other sister concerns in the church become relevant. these fbhns can make a major difference in home-based care, palliative care, etc. recognizing the significance of fbhns and other not-for-profit organizations, india’s 12 th five-year plan and the national health mission encourage public private 48 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 partnerships (ppp) to improve health services, including care for the elderly. the dedicated service of the religious of fbhns, mostly nuns, along with lay employees and experts, offers affordable quality health care. with their training and inclination for dedicated service, they form a unique cadre of health personnel who can engage in maternal and child health care, as well as the care of the elderly, terminally ill, and mentally-ill persons in a humane and dignified manner. they effectively motivate people, including those outside the faith-community, and inculcate a culture of positive health, encouraging people to adopt healthy lifestyles. the cross-linkages with catholic social service networks and school network are also being utilized for public health activities. task-shifting to address the human resource gaps in care for the elderly with neurodegenerative and mental illnesses as is the case with any other health service, there is a severe deficiency of trained health professionals, medical practitioners as well as nurses, to take care of the elderly with neurodegenerative and mental illnesses. in this context, the concept of task-shifting is significant. task shifting involves the rational redistribution of tasks among health workforce teams. specific tasks are moved, where appropriate, from highly qualified health workers to health workers with lesser training and fewer qualifications, in order to make more efficient use of the available human resources for health. 19 for example, breakdown of complex health care interventions into simplified, smaller, and locally-relevant components that can be transferred to and performed by the less-trained, locally available health care workers/volunteers—shifting the specific tasks from physicians to nurse practitioners and from nurses to community health workers. 20 task-shifting primarily means the capacity building of caregivers at home and local community volunteers with the basics in geriatric and palliative care, a patient-centred approach, addressing the need to give extra care and happiness for the elderly to enable them to cope with suffering, to age and die with dignity. to lead the way in this direction, task shifting would here mean to capacitate, or upgrade the skills, of the nun-nurses, nun-paraprofessionals, lay collaborators of the church’s health care institutions, and the caregivers in providing geriatric and palliative care. such taskshifting is needed more in medically under-/unreached areas. as noted earlier, in the midst of rising health care costs, 30% of the elderly live below the poverty line and 80% of them reside in rural areas. task-shifting brings down the health care costs by reducing human resource costs, thereby making quality geriatric and palliative care more accessible and affordable, especially in the underserved areas, with special focus on the elderly of the socially excluded and economically marginalized sections of society. moreover, taskshifting, in fact, is a practical and radical example of the decentralization and democratization of medical knowledge. it empowers caregivers and health workers in the community, with supportive supervision from the professionals, to be more effective in caring for the elderly, especially those with neurodegenerative and mental illnesses, and to advocate their rights. enabling caregivers through task-shifting to take care of the elderly echoes the church’s vision of healthcare inspired by his compassionate love, ensuring life in its fullness (jn.10:10). 21 in contrast to the growing commercialization of geriatric and palliative care, taskshifting in a christian context encourages caregivers and local volunteers, especially the young, to be unique, to enable themselves to practice being the ‘good samaritan’ in caring for the elderly, demonstrating the compassionate care of jesus for the marginalized and vulnerable, irrespective of caste, creed, and sex (mt. 25:40; lk. 9:2; lk. 10:25-37; acts 10:38). in contrast to the growing culture of consumerism, individualism, and the abandonment of the most vulnerable, task-shifting enables one to 49 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 experience that “it is more blessed to give than receive” (acts 20:35) to bear witness that all of life is a gift from god, especially in its final stage. task shifting calls christians as caregivers and young volunteers to invest “hard loving” as bishop anthony fisher puts it, “even with the best of care, pain and death cannot be eliminated from this life. some problems in this life have no solution. then comes the really hard loving: the loving of a family surrounding their comatose child, of a husband whose wife’s alzheimer’s disease means she no longer recognizes him, of siblings playing patiently with their profoundly disabled brother, of a mother watching and weeping at the foot of the cross. sometimes the best we can do is to invest ourselves – our time, companionship, prayer, hope – in the suffering, the persistently unconscious and the dying. this is a kind of respecting and loving that no one should pretend is easy.” 22 task-shifting is thus a means to inculcate a culture of empathy among caregivers, and especially the young, local volunteers, to build them into a caring community for “the elderly who are increasingly isolated and abandoned.” 23 task-shifting empowers them as christians to declare, “old age is not the disappearance of life but its completion . . . through solidarity between the young and the old, one has a way of understanding how the church is really a family of all the generations, where each person must truly feel at home, where the logic of profit and possessing does not rule, but the logic of free giving and of love. when during the years of old age life becomes frail, it never loses its value or its dignity: every person is willed, is loved by god; every person is important and necessary.” 24 the way forward in spite of all the commendable efforts much needs to be done regarding the care of the elderly in india. the church, under the aegis of the catholic bishops’ conference of india, needs to leverage the full potential of fbhns like chai, and other christian denominations and civil society organizations. the church also needs to advocate for 1. the recognition of neurodegenerative illnesses like dementia, depression, and other mental disorders, especially affecting the elderly, as treatable under primary health care package systems in the country. 2. the availability of essential, affordable drugs for the treatment of the sick elderly with neurodegenerative illnesses and mental disorders. 3. the legalization of nurse practitioners as part of task-shifting. other areas where the church needs to get involved 1. promoting the significance of task-shifting to make care for the sick elderly and mental health care more accessible and affordable by involving accredited social health activists (ashas), trained birth attendants (dais), other frontline health workers under the national health mission, and successful lay counselors caring for the young at risk in many organizations, etc. 2. training and supporting the caregivers/family members to provide maximum home-based care to the elderly, especially those suffering from neurodegenerative illnesses and mental disorders. 3. providing refresher trainings to primary care physicians to attend to the sick elderly suffering from neurodegenerative illnesses, depression, and other mental disorders. 4. sensitizing and educating the public against stigma and discrimination of the sick elderly. 5. creating awareness among the elderly, caregivers, and youth at the community level on the national policy on older persons, legislations like “the maintenance and welfare of parents and senior citizens act 2007,” and various schemes benefitting the elderly. 6. promoting the utilization of modern technology, for instance, training frontline health workers in telemedicine, thereby making quality health care for the elderly 50 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 more accessible and affordable, especially in the rural areas. 7. promoting and undertaking research in the field of geriatric care to make it more evidence-based, accessible, and affordable for the marginalized/excluded and vulnerable among the elderly. conclusion compelled by jesus’ love and his preferential stand for the poor and marginalized, church health institutions fulfil their obligations to continue strengthening their services for the economically underprivileged, socially excluded, and vulnerable, the elderly, children and women, while expanding to more medically underserved areas. the emerging challenges and threats from not-so-friendly external factors, be it technical/ professional, legislative, social, economic, and political, call for serious introspection. the church has to contend with the lethargic, often corrupt, public health care systems as well as the excessively profit-minded private health care systems. inculcating the culture of ‘involving all’ in christ’s healing ministry, the church in india has to facilitate the building of local ownership and caring communities that support the elderly toward healthy aging with dignity and selfrespect. this endeavor has to be shared by the elderly themselves, caregivers, local community/ religious leaders, youth, teachers, professionals, and frontline health workers/volunteers. the church has to facilitate the democratization and decentralization of medical knowledge through task-shifting. this calls for the empowerment of local communities with information and skills to organize, demand, and access rights and entitlements from the perspective of 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[cited 2014 apr 23]. available from: http://www.cwla.org.au/index.php/lastestnews/item/155-book-review-catholic-bioethics-for-anew-millennium 23. pope francis. evangelii gaudium: apostolic exhortation on the proclamation of the gospel in today’s world. vatican city: libreria editrice vaticana; 2013 nov 24. [cited 2014 mar 13]. available from: http://www.vatican.va/holy_father/francesco/apost_ex hortations/documents/papa-francesco_esortazioneap_20131124_evangelii-gaudium_en.html 24. camilliani: the international day of older persons: the words of h.e. msgr. zimowski. rome: religiosi camilliani; 2013 oct 1. [cited 2014 apr 28]. available from: http://www.camilliani.org/en/the-international-day-ofolder-persons-the-words-of-h-e-msgr-zimowski/ the content of this article was presented at 28th international conference in november 2013, held in rome organized by the pontifical council for health care workers. it was published in chai e-news in jan 2014. competing interests: none declared. correspondence: rev. dr. tomi thomas, ims, the catholic health association of india, 157/6, staff road, gunrock enclave, secunderabad – 500009, andhra pradesh, india frtomithomas@chai-india.org http://www.helpageindia.org/pdf/report_elder-abuse_india2012.pdf http://www.helpageindia.org/pdf/report_elder-abuse_india2012.pdf http://www.helpageindia.org/about-us/79.html http://www.helpageindia.org/images/pdf/survey%20&%20reports/loneliness-among-older-people-in-india.pdf http://www.helpageindia.org/images/pdf/survey%20&%20reports/loneliness-among-older-people-in-india.pdf http://www.helpageindia.org/images/pdf/survey%20&%20reports/loneliness-among-older-people-in-india.pdf http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentid=102 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentid=102 http://www.alzheimer.org.in/assets/dementia.pdf http://www.who.int/mental_health/neurology/chapter_3_a_neuro_disorders_public_h_challenges.pdf http://www.who.int/mental_health/neurology/chapter_3_a_neuro_disorders_public_h_challenges.pdf http://www.who.int/mental_health/neurology/chapter_3_a_neuro_disorders_public_h_challenges.pdf http://www.thehindu.com/opinion/op-ed/the-feminisation-of-old-age/article3951968.ece http://www.thehindu.com/opinion/op-ed/the-feminisation-of-old-age/article3951968.ece http://chai-india.org/capacity-statement-of-chai/ http://apps.who.int/iris/bitstream/10665/43821/1/9789241596312_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/43821/1/9789241596312_eng.pdf?ua=1 http://www.ted.com/talks/vikram_patel_mental_health_for_all_by_involving_all http://www.ted.com/talks/vikram_patel_mental_health_for_all_by_involving_all http://www.cwla.org.au/index.php/lastest-news/item/155-book-review-catholic-bioethics-for-a-new-millennium http://www.cwla.org.au/index.php/lastest-news/item/155-book-review-catholic-bioethics-for-a-new-millennium http://www.cwla.org.au/index.php/lastest-news/item/155-book-review-catholic-bioethics-for-a-new-millennium http://www.vatican.va/holy_father/francesco/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium_en.html http://www.vatican.va/holy_father/francesco/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium_en.html http://www.vatican.va/holy_father/francesco/apost_exhortations/documents/papa-francesco_esortazione-ap_20131124_evangelii-gaudium_en.html http://www.camilliani.org/en/the-international-day-of-older-persons-the-words-of-h-e-msgr-zimowski/ http://www.camilliani.org/en/the-international-day-of-older-persons-the-words-of-h-e-msgr-zimowski/ mailto:frtomithomas@chai-india.org 53 concessao, thomas and maliekal june 2014. christian journal for global health, 1(1):44-52 cite this article as: concessao vm, thomas t, maliekal a. indian catholic church’s response to the elderly with neurodegenerative and mental illnesses. christian journal for global health (august 2014), 1(1):44-52. © concessao, vm, et al. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ original article december 2021. christian journal for global health 8(2) religion as a protective factor against adolescent smoking habits: evidence from spain jorge de andres-sancheza, angel belzunegui-erasob, sonia fernández-alisedac a phd, associate professor, chair for social inclusion, social and business research laboratory, universitat rovira i virgili, tarragona, spain b phd, director, social and business research laboratory, chair for social inclusion, universitat rovira i virgili, tarragona, spain. c msc, doctoral student, social and business research laboratory, chair for social inclusion, universitat rovira i virgili, tarragona, spain abstract background: there are a wide number of assessments suggesting that being a member of a religious community inhibits adolescents’ risky behaviours and, consequently, can act as a protective factor against the consumption of smoking substances. methods: we have analysed a structured questionnaire answered by 1935 adolescents from tarragona (spain). results: we have found that variables linked to family were the principal explanatory factors of adolescents’ smoking habits. living with two parents was a protective factor against tobacco and cannabis use since its incidence rate ratio (irr) was clearly below 1 (p<0.01). so, whereas living with one parent showed an irr>1 (p<0.05), adolescents that live without parents presented an irr close 2 (p<0.05 for tobacco and p<0.01 for cannabis). however, having a religious confession also influence smoking substance use in adolescents (irr close to 0.85 with p<0.01). conclusion: we found a clear preventive effect in belonging to a religious community. moreover, this protective effect was less intense, but not statistically significant, for catholics than for members of other confessions. key words: adolescent; religion; tobacco; marijuana; smoking; substance use introduction the relationship between religious beliefs and risk taking behaviours has been found significant in young people.1,2,3,4 religious communities make up social networks that act as role models, provide social and emotional support, and promote the use of free time engaging in safe activities.4 religious practices influence actions and attitudes of persons, including those of adolescents, thereby facilitating the transmission of usually healthy lifestyles5,6, that following who foundational document must enable “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” bartkowski & xu5 indicated that, for example, regular attendance at religious services in disadvantaged neighbourhoods generated social 17 andres-sanchez, belzunegui-eraso & fernández-aliseda december 2021. christian journal for global health 8(2) links that reinforced educational values and achievement-minded orientations. therefore, these same patterns may act as an inhibitor of risk behaviours such as substance abuse or violence.1,5 religion has proven to be a protective factor against the use of tobacco and drugs by helping teenagers belonging to religious communities to internalize messages that discourage their use as shown by empirical research.7,8,9,10,11 however, theoretical gaps and contradictory findings about whether belonging to a religious community has a deterrent effect on substance use has also been highlighted.5 although not mainstream, significant research exists that has reported a weak or null influence of religion on drug use. this research has covered cocaine,12 tobacco, and illegal drug use.13,14 on the other hand, the capability of religion to inhibit can depend on gender10,15 or ethnic differences.16 the literature has also reported that not all religions have the same protective capability. while there are reports indicating that christians consume more tobacco than muslims,17 other authors have found differences in protective capacity between religions or these effects to be very limited.11,19 there are even reports that have shown that some kinds of spirituality were not inhibitors but facilitators of marijuana consumption.19,20,21 the aim of this research is to test the impact of being a member of a religious community on the use of tobacco and cannabis by adolescents. we used a sample of 1935 teenagers of tarragona (spain). our research answered the following two questions: is religion protective against smoking habits? if so, do different religions in the sample have equal protective power? materials and methods this study used a planet youth survey. data come from a structured questionnaire answered by secondary school students of tarragona that were born in 2001 (12.3%), 2002 (42.7%), or 2003 (45%). gender distribution was 46.74% boys and 53.26% girls. the number of interviews was 1,935, and the sample error was 1.8% for a confidence level of 95% and p=q= 0.50. the data were collected between february and march 2019. the questions used in this paper are in table 1 and the frequencies of responses in every item in table 2 created using spss 20 statistical package. table 1. items of the survey used in this paper output questions answers how much have you smoked cigarettes/cannabis, on average, during the last 30 days? 1= never 2= “1-2 times” 3= “3-5 times” 4= “6-9 times” 5= “10-19 times” 6= “20-39 times” 7= “40 times or more” input questions answers gender 0=boy, 1=girl 2=other/prefer no answering are both your parents born abroad? 0=no 1=yes 18 andres-sanchez, belzunegui-eraso & fernández-aliseda december 2021. christian journal for global health 8(2) cultural status q1= what is your mother studies level? q2= what is your father studies level? 0= basic 1= secondary 2= graduate or beyond family configuration: i live with (please, choose the answer that suit you best) 1= mother and father equally 2= mother but not father 3= father but not mother 4= mother and her partner 5= father and his partner 6= grandparents and mother/father 7= only grandparents 8=i live with my friends 9= i live my own 10= i live in different arrangements family support: q1=how easy or hard would it be for you to receive the following from your parents/legal guardians? caring and warmth q2=how easy or hard would it be for you to receive the following from your parents/legal guardians? discussions about personal affairs q3=how easy or hard would it be for you to receive the following from your parents/legal guardians? advice about your studies q4=how easy or hard would it be for you to receive the following from your parents/legal guardians? advice about other issues (projects) of yours q5=how easy or hard would it be for you to receive the following from your parents/legal guardians? assistance with other things 1= very difficult 2= rather difficult 3= rather easy 4= very easy what religious community do you belong to? 1=catholic 2=lutheran 3=muslim 4=orthodox 5=baptist 6=other 7=i do not belong to any religious community table 2. frequencies of the responses to the items output variables answer tobacco use cannabis use 1= never 2= “1-2 times” 3= “3-5 times” 4= “6-9 times” 5= “10-19 times” 6= “20-39 times” 7= “40 times or more” failed/refused to answer 73.8% 5.4% 3.0% 5.8% 2.5% 1.2% 1.0% 7.4% 65.0% 7.4% 4.1% 2.8% 3.0% 2.1% 5.7% 10.0% input variables variable responses (frequency) gender boys (46.7%); girls (52.3%) parents both parents were born abroad (18%); at least one parent was born in spain (70.6%); failed/refused to answer (3.5%) 19 andres-sanchez, belzunegui-eraso & fernández-aliseda december 2021. christian journal for global health 8(2) cultural status q1 (mother) basic (15%); secondary (34.3%); graduate or beyond (26.7%); failed/refused to answer (24%) q2 (father) basic (15.2%); secondary (33%); graduate or beyond (23%); failed/refused to answer (28.8%) family arrangement lives with both parents (75.1%); lives with one parent (20.2%); other status (3%); failed/refused to answer (1.7%) family support q1 (caring and warm) very difficult (2.4%); rather difficult (8.4%); rather easy (26%); very easy (60.4%); failed/refused to answer (2.8%) q2 (discussions about personal affairs) very difficult (12.6%); rather difficult (26.7%); rather easy (31.7%); very easy (26.3%); failed/refused to answer (2.7%) q3 (advice about the studies) q4 (advice about other issues of yours) q5 (assistance with other things) very difficult (6.6%); rather difficult (12.1%); rather easy (30.1%); very easy (48.2%); failed/refused to answer (3%) very difficult (6.2%); rather difficult (16.2%); rather easy (31.3%); very easy (43.3%); failed/refused to answer (3%) very difficult (5.6%); rather difficult (11.8%); rather easy (31.4%); very easy (48.2%); failed/refused to answer (3%) religious community catholic (34.4%); lutheran (2.3%); muslim (5.9%); orthodox (1.6%); baptist/other (3%); i do not belong to any religious community (51.4%); failed/refused to answer (1.4%) those questions concerning substance consumption are by bartkowski & xu5, whereas to measure family support we used questions proposed in hwang & awkers.22 regarding ethical approval, (1) all participants and their legal guardians were informed about the study and procedure; (2) anonymity of the data collected was ensured at all times; (3) voluntary completion of the questionnaire was taken as consent for the data to be used in research, and the participants’ informed consent was implied by their completing the survey. teachers supervised the surveyed adolescents (if they and their legal guardians agreed) to be sure the questions were understood. researchers were unable to link specific respondents with a given observation. the parents of the participants were informed about the study, and in those educational centres where it was deemed necessary, parents gave written consent. the study was authorized by the ethics committee of the researchers’ institution, as it met the official college of psychologists of spain and belmont report. explained variables tobacco/cannanbis, are the ordinal variables in table 1. as control variables we consider: • sex= variable that can take 0 (girl) or 1 (boy) • country= variable is 0 (if two parents were born abroad) or 1 (otherwise) • cult_st= it is built from normalizing the sum of responses q1 and q2 . cult_st= ((q1+q2)-2)/4 • only_one_p= its value is 1 if adolescent lives only with one of the parents and 0 otherwise. • no_par= its value is 1 if teenager does not live with any parent and 0 otherwise. 20 andres-sanchez, belzunegui-eraso & fernández-aliseda december 2021. christian journal for global health 8(2) • fam_sup= punctuation for the first factor in factorial analysis of questions about family support. variables for religiosity • religious= its value is 1 if the response is between 1 and 6 and 0 otherwise. • catholic/lutheran/muslim/ orthodox= its value is 1 if the adolescent confesses belonging to that religious community and 0 otherwise. we ran two truncated negative binomial regressions over tobacco and cannanbis by using eviews 11 software. both regressions included all control variables. in the first model, we also included religion as explanatory variable. in the second model, we removed religion and included dichotomous variables linked to concrete confessions. this last regression analysis investigated the particular influence of each religion on tobacco and cannabis use and also allowed checking if different religions in the sample present the same protection capability. to accomplish this, we ran a wald test whose null hypothesis was that there is no difference between the irr of religions and smoking consumption. results in our sample there were 665 catholics (34.8%), 44 lutherans (2.3%), 115 muslims (6%), 30 orthodox (1.6%). 995 adolescents (52.1%) professed no particular confession. the fam_sup questionnaire had internal consistency since its cronbach’s alpha is 0.844. factor analysis revealed that the first factor is enough to represent this variable. table 3 shows the results by the adjustment of regression models. table 3. coefficients of negative binomial regressions input|output tobacco cannabis tobacco (2) cannabis (2) constant 2.255*** 2.319*** 2.239*** 2.298*** sex 1.132** 0.752*** 1.136** 0.752*** country 0.968 0.849** 1.004 0.854** cult_st 1.021 0.967 1.014 0.968 only_one_p 1.172** 1.226*** 1.175** 1.230*** no_par 1.998*** 1.623*** 1.968*** 1.609*** fam_sup 0.923*** 0.908*** 0.923*** 0.909*** religion 0.844*** 0.838*** ---- catholic ----0.863*** 0.848*** lutheran ----0.634 0.828 muslim ----0.630** 0.745 orthodox ----0.740 0.810 r2 0.051 0.075 0.055 0.008 adjusted r2 0.045 0.068 0.046 0.066 notes: (1) as “*”, “**” and “***” we denote that the coefficient is statistically significant at 0.1, 0.05 and 0.01 level respectively. (2) chi-squared statistic for the null hypothesis “coefficients of catholic, lutheran, muslim and ortodox are not different” in the regression tobacco (2) is 4.164 (p=0.244). in the case of cannabis (2), chi squared= 0.566 (p=0.906).. 21 andres-sanchez, belzunegui-eraso & fernández-aliseda december 2021. christian journal for global health 8(2) variables related to adolescent family environment were consistently significant. not living with both parents increased the risk of smoking any substance. so, for only_one_p, the incidence rate ratio (irr) was 1.17 and 1.23 (p<0.01) and for no_par, that irr increased to 1.6-2 (p<0.01 for cannabis and p<0.05 for tobacco). perceiving family support also acted as a protective factor (irr=0.9-0.92, p<0.01). girls were more exposed than boys to tobacco (irr=1.17-1.23 with p<0.05) and boys than girls to cannabis (irr=0.732, p<0.01). having both parents of immigrant status may have been a protective factor against cannabis consumption (irr=0.854, p<0.05), but this variable did not influence tobacco use. parents’ cultural status did not contribute towards an explanation for the use of substances. we found that belonging to any religious community was protective. for the variable religion, we fit irr=0.838-0.844 (p<0.01). likewise, all irrs of catholic/ lutheran/ muslim/orthodox are always under 1. by analysing the value of irrs of assessed religions, we concluded that they were greater for catholicism than for other confessions. so, catholicism might have a poorer inhibition effect toward assessed smoking substances. on the other hand, irr of catholics is unique with a statistical significance consistently below 1 for both tobacco and cannabis smoking (p<0.01). wald test on the equality of coefficients linked to concrete religions cannot reject either for tobacco or for cannabis and that the protective capability of religions in our sample is the same. discussion results suggest that religion serves as a protective factor for teenagers against tobacco and cannabis consumption and that the practice of any of the four tested religions has the power to inhibit smoking. therefore, our findings are consistent with the mainstream of the literature on the topic.1-12 despite the finding that only the catholic religion was associated with a statistically significant irr under 1, other religions (muslim, lutheran, and orthodox) present an irr lower than that of the catholic religion. it could be suggestive of a difference between religions in the inhibitory power against smoking as it is found in hussein et al.17 however, the failure of wald tests to show the significance of that difference might be due to low number of non-catholics in the survey. we have also checked that boys are more exposed to cannabis use whereas girls are more likely to use tobacco. this fact is in accordance with studies showing that gender is a relevant variable to explain substance use.5,11,22 we found that the configuration and support of the family are decisive factors to inhibit smoking habits.5,11,22 on the contrary, we have not found relevant cultural status of parents to prevent smoking tobacco and cannabis, which contradicts some findings.5,11,14 likewise, as in other literature,14,16 we have detected relevant cultural and ethnic differences to explain cannabis consumption, but this finding does not follow for tobacco. the findings in this paper reinforce studies which report that belonging to a religious community provides a social capital that prevents substance use. among public health policymakers, it is generally agreed that engaging in activities in secular environments, such as academic clubs and sports teams, have an inhibitory capacity. however, this does not always follow when it comes to activities in religion-based networks. health authorities should be made aware that conducting activities in religious settings can also be an invaluable way to limit substance use among young people. this study has several limitations. as we mentioned earlier, the number of responses from non-catholic religious teenagers is low, and hypothesis tests on specific religions may therefore lack statistical power. moreover, since the survey is not longitudinal, the robustness of its results may be limited over time. other experiments or further information that could strengthen this paper include 22 andres-sanchez, belzunegui-eraso & fernández-aliseda december 2021. christian journal for global health 8(2) gathering a larger cohort and conducting the survey in geographical areas with different religious distributions or socioeconomic characteristics. we should point out, however, that since tarragona’s economy is based on services and the chemical industry, our sample may be representative of similar western european cities but not, for example, of spanish rural areas. in this paper, we have analysed how adolescents’ feelings of belonging to a religious community influence their smoking of substances. 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as: andres-sanchez j, belzunegui-eraso a, fernández-aliseda s. religion as a protective factor against adolescent smoking habits: evidence from spain. christ j global health. dec 2021;8(2):16-23. https://doi.org/10.15566/cjgh.v8i2.579 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1016/j.addbeh.2004.03.022 https://doi.org/10.1007/s10943-017-0434-9 https://doi.org/10.3109/10826084.2013.799017 https://doi.org/10.1080/02791072.2011.605650 https://doi.org/10.1177/002204260803800304 https://doi.org/10.1080/08897077.2018.1449168 https://doi.org/10.4324/9781315129594-2 mailto:jorge.deandres@urv.cat https://doi.org/10.15566/cjgh.v8i2.579 http://creativecommons.org/licenses/by/4.0/ abstract introduction materials and methods results discussion references original article working holidays for overseas doctors: host perspective in mission hospitals in rural india jesudian gnanaraja adirector of medical services, surgical services initiative, association of rural surgery, india abstract many doctors are willing to spend part of the holidays helping mission hospitals. some are senior physicians who can contribute a great deal to their programs. we describe how it was possible to use their time effectively. we also describe some of the difficulties encountered and the benefits that were obtained from their efforts. junior doctors helped mission hospitals in many ways, doing a variety of studies and preparing the protocols for the hospital use. senior doctors introduced procedures like vaporization surgery and lift laparoscopic surgery that benefitted rural patients greatly. they also taught new procedures and helped with the publication of research findings. the visitors benefitted as well, a win-win situation. introduction mission hospitals in india in their heyday possessed adequate resources and skilled and committed manpower. they were able to provide ethical and appropriate healthcare to the communities they were to serve. with the withdrawal of missionary support and the paucity of funds as well as of updated and skilled medical professionals, sustainability of mission hospitals has been a concern. 1 a solution to this impasse has been to facilitate skilled healthcare professionals to be able to take time off from their busy schedules, bringing their expertise, benefitting a whole new community. 2 mission hospitals offer a great opportunity to serve the poor and the needy by using god given talents, especially for senior doctors. many senior doctors are willing to spend part of their holidays doing mission or social service. medical students and junior doctors are looking for hands on experience during their holidays. the rural and mission hospitals need to upgrade their skills and facilities to be relevant to the communities that they serve. proper planning and networking could help both visitors and hospitals to benefit greatly. we present how we were able to do this in mission and rural hospitals in india. we also present the difficulties we faced and the benefits demonstrated by the presence of both junior and senior level doctors. methods visitors to burrows memorial christian hospital [bmch] and samiti for education, environment, health and social action [seesha] during the last 12 years were recruited from the following groups: former surgeons or doctors who worked at the hospitals members of the churches of the overseas visitors or missionaries to the hospitals doctors met at various conferences where we had made presentations relatives of local staff and visitors doctors who contacted us after looking at our website or articles students who came through university exchange programs the process of recruitment or invitation involved letting the visitors know exactly what we are doing and what we expected from them well before their arrival. information on dress codes and experiences of previous visitors were sent to them [3]. we obtained donated medical supplies from places like medwish and rays of hope international.4,5 information about these sources were sent to the visitors, and the sources were informed about the visitors.  videos about the hospital were sent to the visitors.6 medwish provides disposables and other small items that can be hand carried in a suitcase. they have a handling charge of about one or two dollars per pound of supplies. we have former missionary children [now pastors, etc.] who help us obtain these items, pack them in suitcases, and send them to the visitors. most of these volunteers are non-medical personnel, and pictures of the disposable items that are needed are helpful when picking them up. we have identified items that can be used at the hospital. before we provided illustrations, many items that were brought could not be used. other than doctors of indian origin and overseas doctors with permanent licenses to practice in india, visitors require temporary registration with the medical council of india [mci]. this temporary registration is through the sponsoring hospital or institute; forms must be submitted: forms mci 07 and rs. 5000. those who come to india to learn are registered separately. the application is available from the mci website. 7 medical students, junior doctors, and others who come to learn take an on-line course to give them some background knowledge [8]. topics for their research project are assigned. completed projects are published. results visitors to bmch and seesha came from the following places [table 1] and trained in the following specialties [table 2]. table 1. counts of physicians by sending country country number of doctors usa 9 germany 3 nigeria 7 switzerland 2 singapore 2 uk 5 canada 1 australia 1 table 2. counts of physicians by specialty specialty number of doctors urologists 1 laparoscopic surgeons 4 general surgeons 3 gynecologist 2 rural surgeons 5 general physicians 3 endocrinologist 1 residents and interns 11 principles learned working alone at a mission hospital for years without much accountability can tempt surgeons to compromise to get work done more quickly or to try to manage without appropriate supplies. for example, if a sufficient number of drapes are not available they would manage with the available number. if instruments become unsterile, they might put them in cidex [gluteraldehyde] solution rather than autoclaving them and waiting. the overseas surgeons would refuse to make compromises like these. working with them helped the operating staff encourage local surgeons not to compromise. the operating room staff noticed that the visiting surgeons never seemed to be in a hurry. they seemed to have all the time in the world for the particular patient on which they were operating. this is different from the mindset of mission hospital surgeons often in a hurry to finish the operation. learning to say “no” is a very difficult thing for a mission hospital surgeon. the fact that many of the patients whom they treat have no other place to go makes saying no even more difficult. the overseas surgeons, including african colleagues, were comfortable saying no. techniques introduced overseas doctors introduced vaporization of the prostate. previously, we had performed transurethral resection of prostates. this often required that a unit of blood be obtained prior to the procedure, the anticipation of complications due to bleeding, and the risk of blocked catheters. vaporization of prostate is almost bloodless, there was no need to arrange blood, and surgeries are able to be done during surgical camps [9, 10]. because there was no significant bleeding and vision remained clear during surgery, many general surgeons were able to learn the procedure. the procedure was able to be done at 19 other mission or rural hospitals laparoscopic surgery has many advantages for poor patients. often, they are the sole breadwinners for the family and need to get back to work as soon as possible. however, the high cost of laparoscopic surgery is a major constraint in rural areas. several methods of cost reduction were attempted.11general anesthesia cost is often more than ten times that of spinal anesthesia. both hospital and patients benefitted when a team from germany came to demonstrate gasless lift laparoscopic surgeries.12,13 these procedures had benefits other than being done under spinal anesthesia. traditional open surgical instruments could be used. the equipment is sturdy and easy to use. live surgery workshops were arranged at coimbatore and midnapore medical colleges and during the association of rural surgeons of india conferences. new procedures and equipment when most of the current senior doctors in mission hospitals received their surgical training, laparoscopic surgeries were not in use in the medical colleges, and these techniques were not taught. as the numbers indicate, more laparoscopic-surgeons visited the mission hospitals to teach laparoscopic surgeries. hence, the presence of a senior laparoscopic surgeon at the mission hospital is of great help to the mission hospital surgeon. endometrial vaporization is a minimally invasive procedure for dysfunctional uterine bleeding, and its introduction to mission hospitals helped many patients.14 overseas doctors taught simple and easy techniques to perform procedures for cleft lip and palate. in mission hospitals, general surgeons often carry out orthopedic procedures and overseas orthopedic surgeons came with instrument sets they donated to the hospital. in fact, most of the overseas surgeons brought surgical instruments and taught the local surgeons how to use them. these were often donated by institutions back home. these would have been prohibitively expensive for the mission hospital to buy. such equipment included a gastroscope, laparoscopic hand instruments, electro-cautery machine, etc. publications several new, important, and useful methods have been practiced in rural mission hospitals. for instance, at bmch in the fifties, proctoscopes were used for taking biopsies from the abdomen for ruling out/confirming tuberculosis. sterile ping pong balls were used for collapse therapy when there was haemoptysis. mission hospital doctors generally do not have the time or the inclination to publish papers.  however, overseas doctors were eager to publish the findings.  they helped in writing the papers, correcting the papers, drawing out the pictures, etc.15,16 when we started doing laparoscopic surgeries, we had only a trained nurse anesthetist giving anesthesia. he was most comfortable using ether and the ebstein and macintosh of oxford [emo] machine for anesthesia. although we attempted early surgeries with our boyle’s machine, we later were forced to shift to anesthesia with ether and emo machine. we had searched on the internet to find out if anyone had done laparoscopic surgeries with ether and emo but could not find any papers. once we published about this, i received many e-mails from other parts of india and from african countries thanking us for publishing that laparoscopic surgeries were possible with ether anesthesia. table 3 lists the references for some of the publications of the visitors to the mission hospitals. table 3. collaborative publications with visiting physicians journal topics australian and new zealand journal of surgery transurethral vaporization of prostate tropical doctor appendectomy with cystoscopy single incision gas less laparoscopic appendectomies indian journal of surgery diagnostic and surgical camps international journal of infertility and fetal medicine single incision gas less laparoscopy and other mis for infertility christian journal for global health surgical work in medical missions chrismed journal of health and research surgical services initiative feasibility of laparoscopic surgeries in rural areas journal of association of physicians of india survey of diabetes in remote rural population journal of pure and applied microbiology uropathogens in tribal and tea garden workers rural surgery minimally invasive appendectomies computers for rural surgeons cystoscopic removal of esophageal coin system audit for small hospitals survey of laparoscopic facilities in rural areas md current india cost effective treatment of renal stones in rural areas instruments for lift laparoscopic surgery christian medical association of india choosing software for rural hospitals the publication topics varied from medicine to microbiology to computers to surgical procedure. the variety was, possibly, primarily due to the interest of the visitors. financial gains visiting surgeons paid their own travel expenses, some of them sponsored diagnostic camps, and many of them gave donations to specific projects at the hospital. in return, the hospital was able to arrange for sightseeing at locations not available to regular tourists. there are often remote locations where the only decent places to stay are the government tourist bungalows; local contacts are necessary for booking them. the use of hospital vehicles and the hospitality of hospital contacts made it easier for the visitors. the visitors enjoyed access to areas where tourists often are not allowed, like the inside of dams and helicopter and boat rides etc. these were possible because they came to help the poor in that area. the people who benefitted most were the poor and marginalized patients from rural areas. on an average, patients paid about rs. 12000 ($200) for laparoscopic hysterectomies or myomectomies. visiting surgeons brought a variety of scopes they used and left behind. if we had purchased them locally, just the cost of the disposable handle for vessel sealing would have cost about rs. 48000 ($800). local hospitals are unlikely to have bought them due to the high cost and unlikelihood of recouping the expense. professional gain for visitors many of the visitors were able to have hands on experience in the operating room and with diagnostic procedures like gastroscopy, cystoscopy, ultrasound examination, etc. many were happy with the opportunities for publications possible because they wrote up the work done at the hospital. new insights many mission hospitals do not consider new initiatives unless encouraged by visiting doctors. for instance, when an endocrinologist from australia visited us, she was surprised to see a thin active patient from a remote tribal area with diabetes.  after going through further records, she requested that we systematically study the remote tribal population.17 this article is quoted often, as it shows a high incidence of diabetes in a thin hard working non-sedentary tribal population. this helped the hospital plan an outreach program for those people. spiritual insights in general, when we look at a patient with a condition (say a gallstone or kidney stone) that we can cure by surgery, our faces light up. on the other hand, when we see someone with a disseminated malignancy, our faces droop. this was not so with our missionary surgeon. his face was always lit as he considered every patient a person who needs to hear the good news and get to heaven. his hugs made the patients forget their disease and become happy. we learned the power of prayer as our missionary surgeons taught us to pray always, and we learned the benefits of prayer for even the patients under anesthesia. there was a patient who had failed an attempt to remove a right renal calculus with a discharging sinus for 17 years, and we had offered a nephrectomy. during a break, the assisting surgeon decided to finish the surgery quickly but tore the few attachments to the vena cava. this resulted in great panic. the visiting missionary surgeon, in his eighties at that time, was called in to assist. he came and prayed with the patient’s son, which we did not mind. however, when he went to pray with the patient under anesthesia, we thought it was a little too much. he came in and helped us to get the bleeding under control. we realized later that our anesthetist had switched off all anesthesia medicines and was giving only oxygen and muscle relaxant. the patient eventually said that it was dr. kenoyer and his god who saved her. problems there were misunderstandings due to cultural differences, especially related to matters of papers and publications while working with the overseas doctors. they felt insulted if papers were sent to journals without their seeing the final corrections. it seemed like local doctors and staff members were not to be trusted, and they wanted personally to go through all the documents, registers, and printouts. despite not finding any discrepancies in the first paper, they still wanted to do the same thing for subsequent ones. it looked as though they felt that the indians were not sincere in presentation of the records or findings. the overseas doctors disliked using our own references in the articles. for the local doctors, it is the most convenient thing to do, as getting other references or access to a library is very difficult. comments about obesity were not taken kindly. changing the order of surgeries and not being present at the agreed upon time were considered serious offences by some visiting surgeons. although surgery lists were prepared the previous day, they were not followed strictly due to a variety of reasons. sometimes, the reasons might be trivial. unlike the indian surgeons, visiting surgeons were offended if they were called when they were not expecting a call. they did not accept approximations in timing of schedules or changes in plans. after the overseas visitors leave, there can be a large backlog of work. many patients feel that overseas surgeons are better at surgery because they have handled knives and forks from childhood and many register for surgery. the visiting surgeons are often slower and also say ‘no’ to patients. this leaves the local surgeons with a lot of work after visiting surgeons leave. the overseas surgeons were generally not aware of or bothered by cost. for instance, they would use 2 sets of tackers for a hernia repair to place 22 tacks when one set contains 20 tacks. this can mean a difference of rs. 20000 ($335) to the hospital. patients may be offered surgery at much less cost than the usual one for the sake of recruiting more patients for camps. visiting surgeons felt that tying knots by hand was better than tying using instruments. this consumed more suture material. sometimes, senior nurses would tell them that they had run out of sutures to prevent them from using too many sutures. when they found out that sutures were still present and the nurses lied to them, they became so angry that they wanted us to take serious action or even dismiss the nurses. despite being christians, the indian nurses felt that they could tell a lie for a good cause (which comes from the hindu tradition). it was difficult for the hospital to dismiss them or take serious actions because they felt that they did whatever they did with the intention of helping the hospital. however, the major problem was that sometimes, when things were not going their way, the visiting surgeon could just dump everything and walk away. when this happened during a workshop, the local surgeons had to complete the surgeries, and it was not pleasant to operate in front of many surgeons of equal or more senior seniority. it was embarrassing to explain why the visiting surgeon was not willing to continue with the surgeries and to do the surgeries when the audience actually came to see the visiting surgeon operate. there are small cultural differences that sometimes cause problems. the hospital staff was embarrassed by the reactions they got from visitors when the staff members said what they thought was innocuous, like mentioning someone is fat or asking their salaries, etc. discussion there are formal working holiday programs, like the australian one, which allows young people to work and study in australia.18 volunteering in african countries provides opportunities to serve for about a month in a teaching and training capacity, mostly in health education.19,20 organizations like medicalmissions.org offer a little more, specialized volunteering experience but still are limited to simple outpatient treatment.16 .some organizations, like missionfinder.org and operation hernia, offer links to specific professionals like cardiologists and general surgeons.18,21 the drawback of the above programs is that, most of the time, the specific expertise or talent of the visiting consultants is not utilized. often, the good work by the visiting consultant does not continue. the visiting consultants are most happy when the work they initiated continues and expands. they are also happy and continue support when they hear that the equipment they donated is fully utilized. the advantages of the working holiday model are the following: it is a win-win situation for everyone involved. the visitors are happy to contribute and enjoy special sightseeing. the local doctors learn a lot. the hospital gets monetary benefit, and many poor patients benefit. the visiting consultants’ time can be used for training others. the junior medical personnel could contribute to preparing protocols for treatment, improving the quality of services, and writing papers. the problems related to differing expectations, different cultures, and a prior mindset of visitors about indians might be resolved by an orientation for the visitors and the receiving hospital paying attention to details. we do now talk to the staff prior to the visit of senior staff regarding how to interact with them. sometimes, good friendships have been lost for trivial things, like calling someone obese or sending a revised article for publication without showing it to them first. however, all visitors, including those offended, felt they did contribute in a very significant way to help poor and marginalized patients. their time at the hospital was spent in a useful way. local surgeons felt that they learned much from the visitors but always had to be on their toes and put in a great deal of extra effort to do things they normally would not do. the hospital and the patients had nothing but positive things to say about the visitors. careful planning is necessary for achieving the objectives if there is to be benefit from the working holiday plan. although none of the visitors complained about the facilities available at the hospital, most of the time, places where we stayed during diagnostic or surgical camps were far below the standards to which they were accustomed. the facilities the visitors enjoyed were very basic. it was their love for christ, their interest in mission work, and the prayers and support of their local church that brought them to the mission hospital. many of them have continued to pray and support the mission work and to encourage others to come and visit. over the years, the visitors have made a significant contribution to church growth in the area where the hospitals are situated [24]. no specific grants or sponsorship was received for the study. references aruldas a, awale a, zachariah p. sustainability of church health care in india. world council of churches and the christian medical association of india. 1997. rexford, kofi, oduro, asante. sustainaility of church hospitals in developing countries: a search for criteria for success. world council of churches. 1998. a trip with seesha [internet] available from: http://www.karunya.edu/seesha_krch/seesha%20feed%20back%20_1_%20_2_.pdf andâ â  jacob t. experiences with god’s faithfulness in the seesha assam medical camp (april 18-21, 2011).â  available from: http://www.karunya.edu/seesha_krch/assam%20camp%20report%20_1_.pdf medwish [internet]. cleveland, ohio; available from:â  https://www.medwish.org/ rays of hope international [internet]. grand rapids, michigan. available from: http://www.raysoh.org/ burrows memorial hospital [internet].â  available from:â  https://www.youtube.com/watch?v=ca-6d0hf-hw/ medical college of india [internet]. available from: http://www.mciindia.org/ karyuna university [internet]. available from:â  http://www.karunya.edu/ gnanaraj j. gnanaraj l. transurethral electro-vaporization of prostate: a boon to the rural surgeons. australian and new zealand journal of surgery. 2007 aug;77(8):708. gnanaraj j. diagnostic and surgical camps:â  cost-effective way to address the surgical needs of the poor and the marginalized. md current india. 2014 jan.â  available from: http://mdcurrent.in/primary-care/diagnostic-surgical-camps-cost-effective-way-address-surgical-needs-poor-marginalized] gnanaraj j. laparoscopic surgeries in rural areas. challenges and adaptations: an experience of over 1300 laparoscopic surgeries. australian and new zealand journal of surgery. 2007;77(9):799-800. gnanaraj j. gasless lift laparoscopy. rural surgery. 2013 jan; 8(4):17 -9. gnanaraj j. single incision lift laparoscopic surgeries [sills]: taking modern surgery to the poor. j miss 2 (3):e11465 published online 2013 october 8 available from: http://www.researchgate.net/publication/263040390_single_incision_lift_laparoscopic_surgeries_sills_taking_modern_surgery_to_the_poor gnanaraj j, lionel j. endoscopic resection/vaporization: a patient friendly first option treatment for menorrhagia in rural areas. tropical doctor. 2008 apr. 38:103-4. gnanaraj j, cherk –yun. minimally invasive appendicectomy using cystoscope. tropical doctor. 2008 jan; 38(1):14-5. gnanaraj j, lau xe xiang j, khiangte h. high quality surgical care at low cost: the diagnostic camp model of burrows memorial christian hospital. indian journal of surgery. 2007 dec;69(6): 243-7. lau sl, debarma r, thomas n, asha hs, vasan ks, alex rg, gnanaraj j. health care planning in north-east india: a survey of diabetes, awareness, risk factors and health attitudes in a rural community. journal of the association of physicians of india. 2009 apr;57:305-9. available from: http://www.pubfacts.com/detail/19702036/healthcare-planning-in-north-east-india:-a-survey-on-diabetes-awareness-risk-factors-and-health-atti peer reviewed competing interests: none declared. correspondence:â jesudian gnanaraj, seesha, india.â  jgnanaraj@gmail.com cite this article as: gnanaraj, j. working holidays for overseas doctors: host perspective in mission hospitals in rural india. christian journal for global health (march 2015), 2(1):35-42. © gnanaraj, j.this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ commentary nov 2015. christian journal for global health, 2(2):5-9. medical rehabilitation in low and middle income countries for adult acquired disability: challenges posed by rapidity of health system change and position on the individualisticcollectivist axis karl sandin a a md, mph, clinical associate, university of chicago pritzker school of medicine; president and medical director, schwab rehabilitation hospital; chair of physical medicine and rehabilitation, sinai health system abstract chronic illness prevalence has rapidly increased in low or middle income countries (lmic) and with it, the need for medical rehabilitation for adults with acquired conditions that stem from aging and long-term conditions. while western medical rehabilitation programs have had at least two generations to develop, in lmic, postacute health care delivery change has been much more rapid. as a result, there has been little opportunity for models of medical rehabilitation to deliberately emerge in lmic that reflect societal values. while adaptation of an independence-foremost model of medical rehabilitation may succeed in non-western societies, there is a risk that adaptation of such a model will be ineffective where many value collectivism more than individualism. the rapid change in medical rehabilitation service delivery in lmic gives christian providers and organizations an opportunity to pause and reflect whether the dominant western medical rehabilitation paradigm serves lmic cultures and reflects biblical principles. introduction chronic illness incidence and prevalence continue to rise in lmics. 1 in these countries, the transition from a health system primarily concerned with responding to acute and communicable illness to one additionally focused on managing chronic disease is being compressed into a shorter time frame than was experienced by high-income countries that made and are making such transition over generations. 2 particularly in middle income countries, there has been a rapid transition from health burden related to morbidity and mortality from infectious disease to health burden related to chronic health conditions (hypertension, diabetes, obesity), which themselves increase disability prevalence. 3 outside of chronic disease management, expansion of the global health sector has led to improved trauma and critical illness care in lmic. consequently, more than 155 million 6 sandin nov 2015. christian journal for global health, 2(2):5-9. disability-adjusted life years (dalys) were lost in low and middle income countries from injury, ranking first in conditions that result in years of health life lost. 4 so, whether due to aging, trauma, advanced acute care, or chronic disease burden, many lmics have joined the west in experiencing increased prevalence of individuals with physical and cognitive impairments from acquired disability. the speed of change has not allowed deliberate, contextually appropriate development of health (and other) services to care for people with acquired disabilities that reflect the non-western ethos. absent time for due consideration of explanatory models of disability and societal position along the individualist-collectivist axis, western perspectives about medical rehabilitation are being directly copied. international classification of functioning, disability, and health the who has developed the international classification of functioning, disability, and health (icf) as the paradigm for classifying disability, itself an umbrella term encompassing impairment, activity limitation, and participation restrictions. 5 icf purports to avoid segmenting individuals into those who can and those who can’t, attempting to mainstream disability as a universal human experience. moreover, it integrates medical and social causality, recognizing some aspects of disability as internal to the individual and others as related to the environment in which individuals find themselves. the icf places disability in three domains: impairment, activity limitation, and participation restriction. impairment is loss of function at the organ level, such as paralysis due to a problem in body function or structure. activity limitation is difficulty executing a task performed daily by most people such as moving, dressing, or bathing. participation restriction is a difficulty in a social or life role such as inability to work or to parent. disability involves dysfunction at one or more of these levels. two factors modify response to disability: 1) environmental factors including social attitudes, architectural characteristics, legal and social structures, climate, and terrain and 2) personal factors including age, gender, coping styles, social background, class, education, experience resilience, and behavior. disability in cross cultural perspective and the relationship to individualism and collectivism meyer compares individualist and collectivist societies in framing disability. 6 his work builds on hofstede’s classic individualism score, a measure of the importance of the individual in any given society; the higher the score, the more individualistic the society and the lower the score, the more collectivistic. 7 meyer notes individualist cultures tend to give priority to claims of the individual, and in collectivist cultures, the claims of the group trump those of the individual. individualist societies respond at the micro-level with personalized accommodation and support and at the macro-level with societal inclusion through equal rights. collectivist societies tend in two directions: either isolating people with disabilities from public inclusion because of potential group shame or dishonor or emphasizing family or social group’s responsibility for care of individuals with disabilities. smart and smart reported on the experience of disability in hispanic families. 8 the determining influences for the families were traced to an enlarged sense of responsibility that the family felt toward the family member with a disability. the family was reluctant to allow independence on the part of a person with disability based on the perception that society would criticize the family as inhuman, insensitive, or lacking love for the individual. disability is at least in part socially constructed, so by extension, its medical treatment reflects social and cultural values. western medical rehabilitation tends, therefore, to focus on selfdetermination and achieving independence. 7 sandin nov 2015. christian journal for global health, 2(2):5-9. western models of medical rehabilitation informed by overarching importance of achieving individual independence while many rehabilitation clinicians worldwide embrace the biopsychosocial model of disability, western healthcare financing and delivery reinforces the medical model that disability is something undesirable (a state of non-health, a disease) that must be minimized or eliminated through individual care. 9 the primary american measurement of disability is the functional independence (emphasis added) measure (fim), itself an activity measure. 10 the goal of medical rehabilitation in the usa is to achieve a higher score that indicates more ability to perform activities on one’s own with less outside assistance. a low score, reflecting greater need for assistance in performing activities, is undesirable. american rehabilitation hospitals publicize large fim increases per stay and high discharge fim scores as evidence of quality. 11 the fim channels a western preference for individualism into assessment of function. medical rehabilitation approaches developed in the west when applied to lmic bring with them the perspective that the most important goal of rehabilitation treatment is maximizing what one can do for oneself. more collectivist cultures may not see individual achievement as the pinnacle of recovery; interdependence may be a more desirable endpoint than independence. a potential clash ensues when highly individualistic medical treatment worldviews are imposed upon or imported to non-western contexts that value collectivism. the fim is a seven point, eighteen item ordinal scale. a score of “1” indicates dependence in a particular task; a score of “7” indicates independence. an individual with paraplegia who is physically helped to move by someone else on uneven surfaces, such as stairs, would be scored low; the individual able to ascend and descend stairs on his buttocks using strong upper arms for propulsion would be scored high. a technological solution such as an exoskeleton or all-terrain wheelchair would decrease need for assistance resulting in a higher score for mobility on uneven surfaces. but, is it a rehabilitation failure to be physically helped up and down stairs? different cultural contexts may see interdependence as healthy (see hispanic family profiled by smart and smart previously). in many situations, it may be more desirable or appropriate that family or clan help an individual with activity limitation to execute a task: to expect that the individual with a disability would seek to perform independently as much as possible may be inappropriate in communitarian contexts. health services for people with disabilities and their relationship to societal values many societies and developed nations have implemented health and social programs and services aimed at helping people with disabilities provide become self-sufficient and participate as full members of society. while these countries often have an economic cushion that allows funding for treatment and rehabilitation, these care models at their core reflect the ascendance of the individual. the disability care system of a more collectivist society would be expected to deemphasize support for maximal individual independence and see treatment success as effective adaptation of the family and other groups to impairment, activity limitation, and participation restriction. middle income countries, in particular, are seeing rapid growth in the medical rehabilitation sector. 12 the type of care being delivered imitates western medical rehabilitation. i believe that this phenomenon is occurring because changes in healthcare delivery systems and shifts from acute to chronic disease are so rapid there has not been adequate time to develop location-specific and 8 sandin nov 2015. christian journal for global health, 2(2):5-9. cultural appropriate care models in lmic. conversely, a long held success story for healthcare delivery in lmic has been community health workers (chw). this model of care delivery for communicable diseases and maternal/child health programs was distinctly non-western at time of creation and developed in situ. 13 time will tell whether rehabilitation centers stemming from a western medical care model focused on the individual will be successful in collectivist contexts. theological perspectives along the individual-collectivist axis individualistic theology accelerated in the reformation, whose leaders dismissed the inherent inter-relatedness of each member within the church and espoused the church as the sum of individual beliefs. 14 proceeding through moody and scofield, american christianity became focused on the individual instead of a communal entity. 15 in conjunction with the american frontier myth of rugged individualism, the ninth beatitude might have been “blessed are those that do for themselves, for. . . ” koinonia, the spirit of generous sharing, can often be marginalized by an ethos that requires individual attainment. scriptural examples of individualism abound (luke 19:15), but so do examples of collectivism (acts 2). paul synthesizes elements from each perspective in 1 corinthians 12: individual parts are important as is their work together. american spirituality tends to emphasize the individual, not only in religious experience, but also in social action, including healthcare that stems from religious commitment. the church throughout the world may, or even should, resist merely imitating the individualistic western tradition. rehabilitation clinicians who practice in a christian context or ethos may need to confront the tension between achievement of independence as the prime directive in treating individuals with acquired disability and the benefits of interdependence. references 1. anderson gf, chu e. expanding priorities — confronting chronic disease in countries with low income. n engl j med. 2007;356(3):209-11. http://dx.doi.org/10.1056/nejmp068182 2. miranda jj, kinra s, casas jp, davey smith g, ebrahim s. non-communicable diseases in lowand middle-income countries: context, determinants and health policy. trop med int health. 2008; 13(10):122534. http://dx.doi.org/10.1111/tmi.2013.18.issue-10 3. field mj, jette am, editors. the future of disability in america/committee on disability in america, board on health sciences policy. washington dc: iom national academies press, 2007, p. 17. 4. ibid. anderson 5. world health organization. [internet] towards a common language for functioning, disability and health. geneva: 2002. [cited 2015 april 20] available from: http://www.who.int/classifications/icf/training/icfbeginne rsguide.pdf 6. meyer h-d. framing disability; comparing individualist and collectivist societies. comp sociol. 2010;9:165-81. 7. hofstede. world map of individualism. [internet] [cited 2015 april 20] available from: http://www.kwintessential.co.uk/map/hofstedeindividualism.html 8. smart j and smart d. acceptance of disabilities and the mexican american cultures. rehab couns bull. 1991;34:357-67. 9. drum ce. models and approaches to disability. in drum ce, krahn gl and bersani h, editors. disability and public health. washington, dc.: apha; 2009. p. 29. 10. fim® instrument. [internet] [cited 2015 april 20]. available from: http://www.rehabmeasures.org/lists/rehabmeasures/dis pform.aspx?id=889 http://dx.doi.org/10.1056/nejmp068182 http://www-ncbi-nlm-nih-gov.proxy.uchicago.edu/pubmed/18937743 http://dx.doi.org/10.1111/tmi.2013.18.issue-10 http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf http://www.kwintessential.co.uk/map/hofstede-individualism.html http://www.kwintessential.co.uk/map/hofstede-individualism.html http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889 http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889 9 sandin nov 2015. christian journal for global health, 2(2):5-9. 11. madonna.org. [internet] [cited 2015 sept 26] outcomes. available from: http://www.madonna.org/patient/rehab/continuum/acute/ outcomes.html 12. uph medical science group. [internet] [cited 2015 sept 26] available from: http://msg.uph.edu/siloamhospitals/siloam-general-hospital.html 13. kok mc, dieleman m, taegtmeyer m, broerse je, kane ss, ormel h, et al. which intervention design factors influence performance of community health workers in lowand middle-income countries? a systematic review. health policy plan. 2014;1-21. 14. lortz j. why did the reformation happen? in: spitz lw, editor. the reformation: material or spiritual? lexington ma: heath; 1961. p. 61. 15. bajis j. common ground: introduction to eastern christianity for the american christian. minneapolis, mn: light and life publishing company; 1991. [chapter 11] peer reviewed competing interests: none declared. correspondence: karl sandin, university of chicago, united states. ksandinmd@gmail.com cite this article as: sandin k. medical rehabilitation in low and middle income countries for adult acquired disability: challenges posed by rapidity of health system change and position on the individualistic-collectivist axis. christian journal for global health (nov 2015), 2(2): 5-9. © sandin k this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.madonna.org/patient/rehab/continuum/acute/outcomes.html http://www.madonna.org/patient/rehab/continuum/acute/outcomes.html http://msg.uph.edu/siloam-hospitals/siloam-general-hospital.html http://msg.uph.edu/siloam-hospitals/siloam-general-hospital.html mailto:ksandinmd@gmail.com http://creativecommons.org/licenses/by/3.0/ commentary june 2022. christian journal for global health 9(1) finding common ground for the common good: an appeal for innovative collaboration between faithand non-faith-based organizations danielle ellisa, tamara fitzgeraldb a md, mts, resident physician, general surgery, massachusetts general hospital, usa b md, phd, facs, associate professor of surgery and global health, duke university, usa abstract both faith-based organizations (fbos) and non-faith-based organizations (nfbos) make significant contributions to healthcare in lowand middle-income countries, particularly for patients with fewer economic resources. the perception that fbo and nfbo are dissimilar may contribute to there being insufficient interactions between them. but in fact, faith and humanitarianism are intimately and historically connected. as a byproduct, fbo and nfbo share both accomplishments and criticisms, including echoes of imperialism and lack of neutrality. a mutual interest approach could cultivate partnerships between fbo and nfbo, allowing them to pursue the common good of a healthier world without risking assimilation, isolation, or inauthenticity. key words: faith-based organizations, humanitarianism, collaboration, global health introduction collaborative efforts between faith-based and non-faith-based global health organizations are hindered by an incomplete understanding of their historical origins and current goals. greater awareness of their similarities in approach could facilitate collaborative partnerships and better health outcomes for people around the world. access to healthcare for individuals in low and middle-income countries (lmic) is limited. for example, 94% of the population in lmic lacks access to surgical care, compared with 15% of people in high-income countries.1 historically, much of global healthcare was established by faithbased organizations (fbos).2 healthcare delivery in lmic became a focus for non-governmental organizations, particularly following world war ii in the mid and late 20th century.3 the rise of formalized academic global health followed shortly after in the 21st century.4,5 in 2002, james wolfensohn, then-president of the world bank, famously said that “half the work in education and health in sub-saharan africa is done by the church… but they don't talk to each other, and they don't talk to us.”6 this statement highlights a perception that persists some twenty years later; although the global health landscape has come to include stakeholders from varied backgrounds, the dearth of interactions between them has not been commensurate with the volume of actors. fbo include any entity whose values are grounded in their faith/belief system and might be understood as distinct from non-faith-based organizations ellis & fitzgerald 88 (nfbos) that include non-governmental organizations and academic organizations, in that their values are secular and explicitly not faithbased. studies of relationships between fbo and nfbo that deliver healthcare services in lmic suggest that between interest and collaboration, there have been extended periods of estrangement. this is due in part to a perceived contradiction between the core values of fbo and nfbo, as well as a concern that religion, and even spirituality, ought to be relegated to the private sphere, rather than occupying discussions of medical reality.7,8 in this analysis, we discuss the important roles that fbo and nfbo play in serving the world’s sick and economically disadvantaged, the historical context contributing to the current landscape, and similarities and differences in their approach to global health solutions. by understanding this framework, fbo and nfbo may build more collaborative partnerships and, in so doing, improve the health of people around the world. the role of fbo and nfbo in modern global healthcare at least half of the world’s population does not have access to essential health services9, and in lmic, out of pocket payments comprise 30–50% of healthcare financing (compared with 14% in hic).10 there is a paucity of data exploring how fbo, humanitarian groups, and academic organizations contribute to the remainder of healthcare costs not covered by the government.8 where there is data, findings demonstrate wide variability — for example, studies have found that fbo are responsible for anywhere from 2–50% of healthcare delivery in sub-saharan africa.11–13 one study reviewing family planning and child health services to economically disadvantaged people in kenya found that 30% of patients received healthcare provided by the state, 23% by the market, 22% by fbo, and 25% by nfbo, meaning that nearly half of the patients had received care from a fbo or nfbo. though the differences were not statistically significant, they found that ngos served more of the country’s poorest people than the private sector, but fewer of the poorest people than fbo, suggesting that fbo and nfbo are particularly important for the most economically disadvantaged.14,15 to some degree, there is regional variation based on the confines within which fbo and nfbo are permitted to participate in healthcare as dictated by local and federal governments. nonetheless, one can surmise that fbo and nfbo contribute substantially to the healthcare of people in lmic, and especially to those with fewer resources, making coordinated efforts all the more important. a history of medical missions and humanitarianism fbo have participated in healthcare for centuries. hospitals as structures were created to care for sick strangers (xenodochia), pioneered by the early christian church in the 4th and 5th centuries ce.16 early christians were known for their intentional care of the sick in contrast to the social and political structures that neglected those in need.17 “medical missions” in its current form developed between the sixteenth and eighteenth centuries.18 the use of the latinized term “missions” dates back to the 16th century and refers to the institutionalized expansion of the faith by jesuit christians in the context of the conversion of distant non-christian territories.2 medical care was part of this work; missions historian, david hardiman, wrote that “from an early stage, missionaries who traveled to asia and africa sought to heal those they intended to convert.”18 in the 17th and 18th centuries, medical care became a more significant component of missions as the enlightenment popularized individual autonomy and human equality, making voluntarism popular among missionaries.18 the medical care that missionary physicians provided was not without controversy. although fbo did not necessarily uphold the systems that maintained colonial power, the link between faith89 ellis & fitzgerald june 2022. christian journal for global health 9(1) based medical missions and imperialism cultivated a sense of mistrust, much of which continues to be expressed about fbo today.13,18 the exodus of missionaries and their families to overseas destinations, many of which were by then formalized western colonies, blurred the distinction between imperial migration and voluntary mission. in light of the skepticism engendered by medical missions, humanitarian medical initiatives were developed over the subsequent decades with the explicit purpose of providing care disassociated from evangelism, most notably with the formation of the quintessential medical humanitarian organization, the red cross in 1863. many religions teach compassion and care for the sick (zakat in islam19, tikkun olam in judaism20, and vasudhaiva kutumbakam in hinduism21), and non-christian religiously affiliated humanitarian organizations have also historically contributed to medical care. for example, formalized muslim humanitarian medical care was marked by organizations like the aga khan foundation (1967) and the islamic association of north america (1967). that said, owing to its long history, some historians view that “it is christianity and christian faith-based organizations that has had the most significant influence on contemporary humanitarian action”22, rendering missions and secular humanitarianism intimately tied and christian organizations specifically the greatest recipients of skepticism and mistrust. historian michael barnett attributes this intimate connection to the fact that humanitarianism began in the 1800s as christian reform movements created a language around humanity and human rights, as well as a belief in the “possibility of using social institutions to bring progress to society and perfect the individual.”22 even today, numerous western humanitarian organizations have religious origins, and religious images like that of the good samaritan.22 one on hand, christianity was an integral component of humanitarianism’s genesis; on the other, the movement in part developed over and against explicitly christian theology and organizational practice. fbo and nfbo: proselytization and political agendas one academic group assessing modern fbo summarized the critiques around them as follows: “in liberal democracies, non-faith-based stakeholders are wary of missions organizations due to the lack of accountability, remnants of historical colonialist associations and agendas, proselytizing of vulnerable clients, and discriminatory practices.”23 another article exploring ethical issues around the activities of fbo expressed concern regarding the proselytizing work of fbo and the challenges proselytization creates for governments and vulnerable populations.24 humanitarianism is defined as that which is “motivated by an altruistic desire to provide lifesaving relief; to honor the principles of humanity, neutrality, impartiality, and independence; and to do more good than harm”22, and these principles were established as core to humanitarianism by the un general assembly in 1991.3 these ideals notwithstanding, humanitarianism has endured critiques similar to those raised about fbo, including concerns about echoes of imperialism and lack of neutrality. theorists criticize humanitarianism for participating in the governing of the poor with “rationales [that] bear a striking resemblance to those given to justify european colonialism in the nineteenth century.” revisionist critiques point out that humanitarian organizations are often political actors, lacking neutrality. these criticisms call into question the assumption that the principles of humanity, neutrality, impartiality, and independence always govern humanitarian action in practice.25 to proselytize is to “convert or attempt to convert from one religion, belief, or opinion to another.”26 proselytization is the feature of fbo that most garners skepticism. but faith-based or otherwise, most organizations are attempting to ellis & fitzgerald 90 convince people of a set of opinions. as an example, médecins sans frontières (msf) is a well-known nfbo that has improved the health of people in conflict and crisis around the world; the organization is self-described as an “international, independent medical humanitarian organization…guided by medical ethics and the principles of impartiality, independence, and neutrality…[whose members] observe neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance…[maintaining] complete independence from all political, economic or religious powers.”27 despite a neutral vision statement, msf and other similar nfbo have an underlying set of principles which are not value neutral. for example, the idea that “neutrality is not synonymous with silence,” means that msf is selectively vocal about causes they deem worthy. they also permit “extreme cases of mass violations of human rights” to prompt a violation of the principle of neutrality. one such form this has taken includes the issue of immigration, to which the response has been largely grounded in principles of liberal democracy.28,29 the authors are not implying this is a wrong position to take, only that it is not value neutral. msf also adheres to “universal” medical ethics, but because ethics are highly culturally contextual, no medical ethic is truly universal, and the one to which they refer is a specifically western bioethic.30–32 although msf and other nfbo do not attempt to convert those they serve to a particular religion, when they perform good works, they do bring a western bioethical framework and liberal democratic agenda they believe will assist populations in distress and alleviate suffering. this agenda is often effective at achieving its ends, but it is important to recognize that it is not neutral. the assertion that nfbo are completely impartial is false. for fbo and nfbo to work together, both must honestly consider their own agendas, respond to criticisms, and be willing to concede that there is value in different approaches. mutual interest: pursuing the common good fbo and nfbo have both succeeded and failed in their attempts to live up to their religious and humanitarian ideals, respectively. whenever any organization provides good works, they bring their own agenda, and the attempt to operate under the premise of neutrality will not bring organizations in separate spheres into collaborative relationships. true plurality requires each party to come to the table authentically and honestly. in recent years, there has been a shift within large, multinational nfbo to acknowledge the importance of fbo in providing healthcare services. fbo have advantages in certain communities, having been present for decades to centuries and having access to funding and a volunteer workforce.7,8 there have been successful examples of the so-called “common ground” framework of bringing fbo and nfbo into collaborative relationship, where common ground can be understood as “shared values, shared goals, and shared language.”33 the african religious health assets programme (arhap)is an international collaborative of theologians, physicians, sociologists, and anthropologists seeking to improve public health and inform health policy in africa, with an understanding of the important role of religion in health. in her discussion of this organization, jill olivier suggests the three factors required for successful interdisciplinary work are compatible personalities, common interests, and common vocabulary.33 olivier acknowledges that although developing relationships requires time and commitment from both parties, even with differing ideologies, common ground can be achieved by identifying the commonalities underlying those perspectives, such as “social justice.” the pursuit of universal healthcare by the who in conjunction with fbo was another success in which both parties were willing to come to a shared vision, much like the common ground approach olivier describes. the development of this 91 ellis & fitzgerald june 2022. christian journal for global health 9(1) shared vision and language required that fbo be willing to operate within a context that “may be criticized as a neoliberal instrumentalization of religion” and see themselves as mediators between religious communities and secular institutions rather than as polarizing forces with political theologies that hinder or reverse cooperation.8 when the united nations (un) developed the sustainable development goals in the early 2000s, there was “little attempt to engage faith actors as a distinct stakeholder group;” fbo who were included had close connections to the un such that they “were already at the table” and participated primarily as civil society actors whose “religious identity did not make an obvious difference.”34 when organizations with diverging agendas attempt to arrive at a forced shared vision, ideas like social justice or human rights become “decoupled from the practices and habits that sustain it,” reducing them to “hollow constructs, a blank sheet upon which to project a variety of perceptions.”35 each organization bears ideas too valuable – faith, freedom, fairness, compassion — to be compromised simply for the sake of a pretense of shared vision. thus, even if a common ground approach has been successful in the above cases, the integration of fbo and nfbo on a grander scale will likely require deeper insight into their historical underpinnings and present ideologies, not to fundamentally change the principles for which they stand or to arrive at a pretense of common ground, but to permit organizational and ideological authenticity such that they can collaboratively pursue the common good. salvation army international health service coordinator, dean pallant, asserts a “mutual interest” framework where people from diverse backgrounds are able to pursue the common good in ways that do not pose the risks of assimilation, isolation, or inauthenticity.36 one such example is a partnership that developed between msf and samaritan’s purse, a well-known fbo, during the ebola epidemic in west africa in 2014. the two organizations used their respective skill sets and expertise to pursue the common good in a way that held true to their values. this is an excellent example of mutual interest, although interestingly, the author refers to their partnership as “unlikely,” suggesting that these types of collaborations are an exception rather than the rule.37 similarly, the relationship the un is now developing with fbo in pursuit of the sustainable development goals (sdgs) provides another practical illustration of a mutual interest framework like the one pallant describes. the un’s proposed policies incorporate faith actors as both development partners and explicitly religious voices, inviting faith actors to provide insight on perceived tensions between sdgs and religious values. this approach includes faith actors on their terms, rather than instrumentalizing them for a priori goals, and encourages members of nfbo and governments to expand their religious literacy and understand the role of faith in the context they occupy.34 the mutual interest approach to the common good will require grit and “a significant degree of humility and dwelling in places of tension.”36 the tension that currently exists between fbo and nfbo is one of separation and has posed a challenge to the formation of productive partnerships. by contrast, the tension pallant alludes to encourages relational authenticity, inviting all parties to come as they are with their offerings to a world in great need of health, healing, and wholeness. references 1. meara jg, leather ajm, hagander l, alkire bc, alonso n, ameh ea, et al. global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. lancet. 2015;386(9993):569–624. https://doi.org/10.1016/s0140-6736(15)60160-x 2. bosch dj. 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https://doi.org/10.4103/22310770.112788 32. sharif t, bugo j. the anthropological approach challenges the conventional approach to bioethical dilemmas: a kenyan maasai perspective. afr health sci. 2015. https//doi.org/10.4314/ahs.v15i2.41 33. olivier j. in search of common ground for interdisciplinary collaboration and communication: mapping the cultural politics of religion and hiv/aids in sub-saharan africa. dr diss univ cape t. 2010. 34. tomalin e, haustein j, kidy s. religion and the sustainable development goals [internet]. 2019 apr 3 [cited 2021 dec 16];17(2):102–18. https://doi.org/101080/1557027420191608664. 35. macintyre ac. whose justice? which rationality? london: duckworth; 1988. 36. pallant d. keeping faith in faith-based organizations: a practical theology of salvation army health ministry. eugene, or: wipf & stock; 2012. 37. jansen p. the role of faith-based organizations and faith leaders in the 2014-2016 ebola epidemic in liberia. christ j glob heal. 2019 may 31;6(1):70–8. https://doi.org/10.15566/cjgh.v6i1.265 peer reviewed: submitted 28 sept 2021, accepted 21 feb 2022, published 20 june 2022 competing interests: none declared. correspondence: danielle ellis, massachusetts general hospital, united states of america. danielleimaniellis@gmail.com cite this article as: ellis d, fitzgerald t. finding common ground for the common good: an appeal for innovative collaboration between faithand non-faith-based organizations. christian journal for global health. june 2022; 9(1):87-93. https://doi.org/10.15566/cjgh.v9i1.585 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v6i1.265 about:blank https://doi.org/10.15566/cjgh.v9i1.585 about:blank abstract introduction the role of fbo and nfbo in modern global healthcare a history of medical missions and humanitarianism fbo and nfbo: proselytization and political agendas mutual interest: pursuing the common good references original article dec 2020. christian journal for global health 7(5) how christian pharmacists can maximize their potentials in healthcare delivery: adopting the prayer, faith, and action model melody okerekea, kenneth bitrus davidb, ezeofor ozioma onyedikachukwuc a bpharm, faculty of pharmaceutical sciences, university of ilorin, kwara state, nigeria b bpharm, faculty of pharmaceutical sciences, kaduna state university, kaduna, nigeria. c pharmd, faculty of pharmacy, eastern mediterranean university, north cyprus abstract: in the absence of scientific breakthrough, patients search for solutions beyond science in the quest for good health. this is because spirituality greatly influences therapeutic outcomes and healthcare delivery. healthcare providers must confront the dual needs of their patients; spiritual and health. christian pharmacists can have an integral role to play in addressing these needs by means of a specialized focus on christian faith. in this paper, we propose a prayer, faith, and action model for pharmacists who desire faith-based healthcare delivery in their professional settings. this model is worth adopting if christian pharmacists want to maximize their potential in the course of healthcare delivery. key words: spirituality, christian, pharmacist, healthcare, faith, prayer, healing introduction the saying “health is wealth” is not a cliché because in the absence of good health, everything else collapses. although the world health organization (who) defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” several christian associations, like the world council of churches, have described health in a way that encompasses the spiritual dimension of health as essential.1 in the context of the christian faith, the latter definition is more tenable. in the pursuit of good health, people resort to different kinds of interventions, some highly beneficial, others, not so much. in the quest for good health and absent scientific justification, people search for spiritual solutions. although there has not been a universal definition to the term spirituality, most of the definitions place emphasis on transcendence.2 one definition consistent with many other definitions is the one by koenig and colleagues: it is a state distinguished from other things — humanism, values, morals and mental health — by its connection to the transcendent. the transcendent is that which is outside of the self and yet also within the self — and in western traditions is called god, allah, hashem, or a higher power and in eastern traditions is called ultimate truth or reality, vishnu, krishna, or buddha. spirituality is intimately connected to the supernatural and religion, although also 90 okereke, david & onyedikachukwu dec 2020. christian journal for global health 7(5) extends beyond religion (and begins before it). spirituality includes a search for the transcendent and so involves traveling along the path that leads from non-consideration to a decision not to believe to questioning to belief to devotion to surrender.3 religion is one area where most people find spirituality. music, the arts, nature, sets of values, or a quest for scientific truths are other areas where some people find it expressed.4 in this paper, spirituality is in the context of religion: believing in the power of a supernatural supreme being or god. various studies have shown how spirituality affects the health of patients5,6,7 and how prayer heals the body of pain and diseases.8,9 even though proving the effectiveness of faith healing can be difficult, there is evidence that a significant number of patients resort to faith healing practices when faced with illhealth with many positive outcomes.6,8 although the way that spirituality affects physical health cannot be emphatically explained, it is believed that the spirit, mind, and body are connected, and the health of one affects the rest.6 healing is from within and involves all three sources. spiritual health has a way of keeping the physical body healthy as well. the bible, the anchor book for christians, has a lot to say about healing. the faith model is simply receiving healing through a prayer of faith. this can be as simple as believing that god exists and has the ability to heal. it may even be the faith of friends, family, or a healthcare provider and not necessarily that of the patient. as a healthcare provider, one should be equipped with the competencies required to administer a spiritual solution because we can only give out of the abundance of what we possess. patients in need of healthcare services should have their spiritual needs addressed as these needs can potentially affect therapeutic outcomes. the importance of addressing the spiritual needs of patients wisdom divinely given to man has contributed remarkably to the growth and advancement of modern medicine. consequently, faith-based healing does not oppose the mechanism of modern medicine, and it is paradoxical to assume that consulting modern medicine is contrary to the christian faith. because spiritual beliefs affect health, influence therapy, and affect treatment choices, the spiritual convictions of healthcare providers have a role in therapeutic management.5 in this scenario, pharmacists are not an exception. although spirituality is an important factor in the health of the patients, it is often times neglected.10 up to 77 per cent of patients want their spirituality to be considered part of their medical and pharmaceutical care; however, only about 10 to 20 per cent of pharmacists discuss the issues of spirituality with their patients.11,12 as a result of a growing interest in the aspect of spirituality, courses related to spirituality have been included in the curriculum of nearly 80 percent of medical schools in the united states of america (usa).4 however, only about 21% of pharmacy schools offer spirituality training in the usa with a lower percentage in africa.11 the pharmacist has a responsibility to make the patient aware of some practices or products that may interfere with spiritual beliefs, such as where religious beliefs forbid patients from using products manufactured from animal sources. the pharmacist should assess the spiritual status of the patient by asking questions like: “do you have any religious or spiritual beliefs that i need to be aware of as your pharmacist that might affect how you take your medications?” these arguments illustrate how important to understand the patient’s spiritual history regarding medication use and adherence. 91 okereke, david & onyedikachukwu dec 2020. christian journal for global health 7(5) the role of christian pharmacists in faith-based healthcare delivery pharmacists are some of the most trusted healthcare professionals accessible to the patient even in crises.13,14 they have a cardinal position for interacting with patients in meeting their drugrelated needs. one important factor affecting the quality of therapeutic outcomes is spirituality.5 impairment of outcomes and disease detection are apparent when spirituality and healthcare conflict. spirituality influences the way patients and pharmacists interact. spirituality matters to pharmacists both in their private and professional lives as it guides their practice, and this affects the holistic wellbeing of the patient. it has a role to play in the patients’ ability to use and comply with prescribed dosage regimen. as the role of the pharmacist shifts from a product-oriented dispenser to an information-focused and patient-centred healthcare provider, the pharmacist collaborates with other members of the healthcare team to improve the patient’s quality of life.13 this change in role provides opportunities for addressing the role of spirituality in pharmaceutical care.12 pharmacists and pharmacy students need to be educated on the concept of spirituality and how it affects their practice as pharmacists. a tenable approach is by adding courses that place emphasis on spirituality and health to the curriculum of pharmacy students and also in the mandatory professional continuing educational (mpce) courses for practicing pharmacists. there have not been any studies to assess the willingness of pharmacists to pray with patients if asked. however, from practice, there had been pharmacists who routinely prayed for and with their patients. this has, in most cases, helped relieve anxiety from the patient, giving them a feeling of hope.15 christian pharmacists can maximize their potential by utilizing counseling sessions to share the gospel with their patients (matthew 28:19). here, the relationship between prayer, faith, and healing would be made known to the patient and how these can be blended with the medical care that they receive. numerous debates have been going on in the scientific community regarding the effectiveness of faith in the healthcare delivery process. however, faith-based healthcare delivery has been experienced in different healthcare settings.7,16 to ensure a corresponding outcome in the delivery of pharmaceutical care, christian pharmacists must draw insights from these experiences. lessons from faith-based healthcare delivery in other healthcare settings in the long history of medicine, health and healing have been interpreted in a number of contexts. throughout history, spiritual purpose has been a matter of little or no consideration. yet when viewed through the prism of world religions, healers as well as the sick, have demonstrated a keen interest in the integral roles of faith in the healing process. the convergence of faith and medicine is experiencing a transition, with more attention to spiritual considerations as modern scientific theories and practices are called into question.17 more broadly, several scientists still hold the opinion that faith has no effect on health outcomes but is this entirely true?17 contrary to the popular perspective, the reality is that in various healthcare settings, faith has contributed remarkably to healing and recovery processes. for instance, in nursing, faith-based care has been fully recognized as a central and essential element.16 it was considered the pillar of nursing care by scholars such as florence nightingale and jean watson.16 in a model case highlighted by ramezani and colleagues, an eight-week preterm baby admitted in a neonatal intensive care unit was being fed through a nasogastric tube (ngt) by the mother under the supervision of a staff nurse.16 in the nurse’s absence, the mother fed the baby independently through a displaced ngt, and consequently, the baby’s chance of survival was uncertain. scientifically, the recovery or healing process was unattainable. however, the nurse 92 okereke, david & onyedikachukwu dec 2020. christian journal for global health 7(5) practiced her christian faith by encouraging the mother to ‘‘rely on god.’’ this faith model was adapted for similar cases in the hospital whose recoveries and healings were miraculous and beyond the explanation of science. faith-based care results in beneficial outcomes such as healing, psychological adjustment, patients’ happiness, fostering of nurses' spiritual awareness, and work satisfaction. the provision of faith-based care allows patients to recover and preserve the integrity of their health.16 these experiences have also been witnessed in the care of cancer patients,10 and pharmaceutical care should not be an exception. integrating prayer, faith and action into pharmaceutical care emerging global health challenges call for the full engagement and active participation of all relevant stakeholders, including christian healthcare providers.1 in order to enhance the health outcomes of patients, christian pharmacists should not be an exception. there is nevertheless much more that can be done to improve the quality of pharmaceutical care provided by christian pharmacists. while the pharmacy profession is a high calling, applying the doctrines of christianity, prayer and faith, is a higher calling when focused on healthcare delivery. as christian pharmacists, biblical principles and values influence the decisions being made in professional settings. for christian pharmacists, ethics influence the way patients are counseled or how medications are dispensed. in addition to that, stories of faith can serve as a beacon of hope to encourage real-life applicability. after being transferred to a chinese tertiary teaching hospital for his clinical internship, guyarmel bounda, a clinical pharmacist, shared how his fervency in several weeks of prayer helped him to pull down several barriers that affected the healthcare delivery process in the hospital.15 the prayer strengthened his faith as well as that of his surgical patients, and their health experienced a miraculous improvement and recovery. while prayer is a tool with healing and life-changing benefits, christian pharmacists should also be reminded that “faith without works is dead” (james 2:26). a hands-on approach during healthcare delivery/pharmaceutical care is further necessary after prayer and faith have been practiced, as prayer and faith are two complementary processes. consequently, and as we have been assured, the patient will enjoy good health even as the soul is getting along well (3 john 1:2), and god will bring health and healing; and let them enjoy abundant peace (jeremiah 33:6). conclusion as healthcare providers, christian pharmacists can maximize the healthcare delivery process by adopting the prayer, faith, and action model if unprecedented recoveries and healings are desired within the healthcare environment. references 1. strand ma, cole a. framing the role of the faith community in global health. christ j global health. 2014. available from: file:///c:/users/user/appdata/local/temp/19article%20text-427-2-10-20141109.pdf 2. macdonald da, friedman hl, brewczynski j, holland d, salagame kk, mohan kk, et al. spirituality as a scientific construct: testing its universality across cultures and languages. plos one. 2015 mar 3;10(3):e0117701. https://doi.org/10.1371/journal.pone.0117701 3. koenig h, koenig hg, king d, carson vb. handbook of religion and health. oup usa; 2012 feb 29. 4. anandarajah g, hight e. spirituality and medical practice: using the hope questions as a practical tool for spiritual assessment. am fam physician. 2001 jan 1;63(1):81. 5. puchalski cm. the role of spirituality in health care. in: baylor university medical center proceedings. taylor & francis. 2001 oct 1;14(4):352-7. https://dx.doi.org/10.1080%2f08998280.2001.11927 788 6. dalmida sg. spirituality, mental health, physical health, and health-related quality of life among https://doi.org/10.1371/journal.pone.0117701 https://dx.doi.org/10.1080%2f08998280.2001.11927788 https://dx.doi.org/10.1080%2f08998280.2001.11927788 93 okereke, david & onyedikachukwu dec 2020. christian journal for global health 7(5) women with hiv/aids: integrating spirituality into mental health care. issues in mental health nursing. 2006 jan 1;27(2):185-98. https://dx.doi.org/10.1080%2f01612840500436958 7. ripamonti ci, giuntoli f, gonella s, miccinesi g. spiritual care in cancer patients: a need or an option?. curr opin oncol. 2018 jul 1;30(4):212-8. https://doi.org/10.1111/inr.12099 8. yates jw, chalmer bj, james ps, follansbee m, mckegney fp. religion in patients with advanced cancer. med pediatr oncol. 1981;9(2):121-8. https://doi.org/10.1002/mpo.2950090204 9. brady mj, peterman ah, fitchett g, mo m, cella d. a case for including spirituality in quality of life measurement in oncology. psycho‐oncology: j psych, social behav dimen cancer. 1999 sep;8(5):417-28. https://doi.org/10.1002/(sici)10991611(199909/10)8:5%3c417::aidpon398%3e3.0.co;2-4 10. vanderweele tj, balboni ta, koh hk. health and spirituality. jama. 2017 aug 8;318(6):519-20. https://doi.org/10.1001/jama.2017.8136 11. cooper jb, brock tp, ives tj. the spiritual aspect of patient care in the curricula of colleges of pharmacy. am j pharm educ. 2003 mar 1;67(1/4):327. https://doi.org/10.5688/aj670244 12. campbell j, blank k, britton ml. experiences with an elective in spirituality. am j pharm educ. 2008 feb 15;72(1). https://doi.org/10.5688/aj720116 13. david kb. pharmaceutical care approach to hearing loss. int j health life sciences; 2020;6(2):e1033406(2). https://dx.doi.org/10.5812/ijhls.103340 14. okereke m, adebisi ya, emmanuella n, jaber hm, muthoni l, barka nb. covid-19: community pharmacy practice in africa. int j health life sci. 2020;6(2). https://dx.doi.org/10.5812/ijhls.104517 15. bounda ga. integration of faith and pharmacy: a smile that strengthened faith of a heart surgery’s patient [internet]. 2013[cited 2020 aug 30];16(1):69. available from: https://www.cpfi.org/assets/docs/c-andp/2013/cp_2013v16_1_p6-9.pdf 16. ramezani m, ahmadi f, mohammadi e, kazemnejad a. spiritual care in nursing: a concept analysis. int nurs rev. 2014 jun;61(2):211-9. https://doi.org/10.1111/inr.12099 17. hutch ra. health and healing: spiritual, pharmaceutical, and mechanical medicine. j relig health. 2013 sep 1;52(3):955-65. https://doi.org/10.1007/s10943-011-9545-x peer reviewed: submitted 30 aug 2020, accepted 5 oct 2020, published 21 dec 2020 competing interests: none declared. correspondence: melody okereke, university of ilorin, kwara state, nigeria. melokereke30@gmail.com cite this article as: okereke m, david kb, onyedikachukwu eo. how christian pharmacists can maximize their potentials in healthcare delivery: adopting the prayer, faith, and action model. christ j global health. december 2020; 7(5):89-93. https://doi.org/10.15566/cjgh.v7i5.447 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://dx.doi.org/10.1080%2f01612840500436958 https://doi.org/10.1111/inr.12099 https://doi.org/10.1002/mpo.2950090204 https://doi.org/10.1002/(sici)1099-1611(199909/10)8:5%3c417::aid-pon398%3e3.0.co;2-4 https://doi.org/10.1002/(sici)1099-1611(199909/10)8:5%3c417::aid-pon398%3e3.0.co;2-4 https://doi.org/10.1002/(sici)1099-1611(199909/10)8:5%3c417::aid-pon398%3e3.0.co;2-4 https://doi.org/10.1001/jama.2017.8136 https://doi.org/10.5688/aj670244 https://doi.org/10.5688/aj720116 https://dx.doi.org/10.5812/ijhls.103340 https://dx.doi.org/10.5812/ijhls.104517 https://www.cpfi.org/assets/docs/c-and-p/2013/cp_2013v16_1_p6-9.pdf https://www.cpfi.org/assets/docs/c-and-p/2013/cp_2013v16_1_p6-9.pdf https://doi.org/10.1111/inr.12099 https://doi.org/10.1007/s10943-011-9545-x mailto:melokereke30@gmail.com https://doi.org/10.15566/cjgh.v7i5.447 http://creativecommons.org/licenses/by/4.0/ introduction references commentary systems thinking in short-term health missions: a conceptual introduction and consideration of implications for practice robert chad swansona and brian j thackerb ado, mph, founder, st4c health, affiliate faculty, brigham young university barizona college of osteopathic medicine, midwestern university abstract a strong tradition of short-term health missions (sthms) exists around the world. sthms have positive and negative effects on local health systems, and these consequences are often unanticipated and unintended. conceptualizing local health systems as complex adaptive systems (cass) may help global health actors approach global health activities, including health missions with a greater appreciation for local cultural and environmental context, leading to increased local capacity and impact while minimizing unintended negative consequences. for some, this might entail a shift in practice as it relates to short-term humanitarian work. in this paper, we introduce readers to health as a complex adaptive system (cas). we then consider implications for practice, including adopting a “learning health system approach,” that engages local stakeholders in an ongoing, iterative process of mutual learning and self-organization. introduction short-term health missions (sthms) to lowand middle-income countries (lmics) have become a popular global health activity for many health care providers and public health professionals. while we are not aware of any consensus on the definition of sthms, we have modified the definition that martinuik et al applied to short term health missions:1 an sthm refers to a short trip of 1 day to 2 years by a health professional to an lmic to provide direct medical care or a public health intervention to the population. at least 6,000 trips take place each year, each with many volunteers.2 program planners, researchers, advocates, physicians, dentists, nurses, pharmacists, students, and others embark on a wide range of health activities, including delivering medical care, planning and implementing public health interventions, organizing local community organizations, and performing research. in this paper, we refer to these participants in sthms as global health actors (ghas). volunteers embarking on sthms face many challenges in resource-poor settings, including language and cultural barriers, low patient access to follow-up care, lack of resources and technology, high overall monetary cost, and dependence of host countries on foreign intervention.1 health systems sometimes react to sthms in unpredictable ways. in this paper, we define health systems broadly: the diverse actors that interact to impact health and wellness (including spiritual wellness). as such, the health system is much more than just hospitals and doctors and nurses; it includes community members, educators, politicians, businesses, religious leaders, and many others, all with their complex patterns of interaction and social norms. health professionals are motivated to participate in sthms because they might see an opportunity to focus on caring for those that have more acute and significant needs than those in higher income countries (hics). sthms are also sometimes seen as a way to gain exposure to tropical diseases or conditions not often encountered in hics. participants experience life in another country while making a difference in the lives of others (volunteer tourism1 or “voluntourism.”3). finally, ghas may have a number of other motivations, ranging from religious to academic. ghas involved in sthms impact the host community’s health system, sometimes unknowingly, and the net result may be positive or negative. the positive health effects of sthms are myriad and significant, including performing cataract and cleft lip repairs and responding to epidemics, such as ebola. negative effects may not be so obvious, as participants may be unaware of local cultural context, the multifactorial causes of disease, and the complex interactions between diverse stakeholders that make up a health system, leading to some of the unintended consequences that we discuss in this paper.4 health systems are inherently complex and under some approaches to sthms (as well as many other global health interventions)5 –that are not always designed to address complexity by engaging local stakeholders in long-term collaboration and shared learning – impact may be limited and sustainability is sometimes lacking.2,5-9 this paper describes health systems as cass, discusses why some sthm practice might lead to unintended consequences, and proposes a way forward that could lead to increased local innovation and long-term capacity in health. while the concepts outlined in this paper could (and many argue should10-14) be applied by larger global health organizations and initiatives, in this paper we focus on their specific application to sthms. health systems as complex adaptive systems a complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents.15 social systems, such as health, are complex and adaptive because there are many local actors or agents –including public health workers, physicians, nurses, patients, indigenous practitioners, politicians, community leaders, members of churches and other faith communities, educators, and others –continuously interacting and altering their decisions over time in response to what they learn from system conditions or other actors. all of the actors are inter-dependent in their roles because they belong to the same system, yet each actor brings a unique set of perspectives to the system.16-18 diverse perspectives can contribute to the unpredictability of system behavior because each actor’s perspective informs how he or she will react to the ideas and actions of others. sthm donors, planners, and volunteers may assume, for example, that community members in lmics will use mosquito nets to prevent malaria. locals, however, may have other ideas that are more contextually relevant; they may use the mosquito nets to catch fish. diverse perspectives are especially relevant to ghas involved in sthms. for example, christian health professionals participating in aid ministries may have a number of objectives that might compete with other objectives for time or resources, including witnessing of christ, providing short-term relief from disasters, increasing local capacity long-term, experiencing an exotic place and culture, completing professional responsibilities, performing research, etc. our purpose in this paper is to provide a framework so that ghas can consider the impact that their actions (that are informed by their motivations) have on local health systems. motivations that lead to the most dominant perspectives will determine the boundaries of the system, defining “subsystems.”16 leaders within the system use their perspective to define who is “in” the system, and who is not. decisions about who to include in the sthm program planning (topic experts? local leaders? local community members?) are examples of how boundaries in systems are created in global health. for example, ghas may exclude traditional practitioners in their program planning and vice-versa. people in systems respond to the behavior of other actors, and their perspective guides their responses.16,19 feedback that returns to the initial person influences future action. this adaptive quality of cass results in self-organization and unpredictable emergence of new (and sometimes surprising) ideas, processes, networks, relationships, and roles. self-organization is seen when, for instance, local people form health promotion groups spontaneously in response to what they learn from visiting sthm teams. history is significant in a cas because whatever took place in the past influences the context in which system actors make decisions.20 for instance, past policy changes may require ghas and local practitioners to operate within new constraints. this will affect future action, effectively changing local context. cass are also non-linear, meaning that some actors are more influential than others, inputs in one place and time may not have the same effect as inputs in another, and some inputs may have large impacts on the system, while other similar inputs may not have any measurable impact.20-21for example, enlisting the help of influential people in the community to plan and implement an intervention could result in a large impact because negative unintended consequences could be minimized and long-term capacity enhanced. the trust local actors may have for community leaders and the number of influential connections possessed by leaders increases the likelihood of a larger impact. actors in cas are influenced, enabled, and constrained by multiple layers of organizational, political, and social structures. multiple and diverse organizations such as public health agencies, non-governmental organizations, research institutes, and others influence health.22 indigenous health workers and community leaders are part of the local culture, and influence people’s beliefs and actions. social determinates of health such as the distribution of power, legal policies, social norms such as gender equality, economic systems, access to resources, and others play a significant role in determining health status. ghas involved in sthms may not be aware of these other actors, organizations, or structures. timely interventions at high-leverage structural issues (such as mobilization around political or organizational reform or coordinating activities) may have a larger impact on health than more direct patient care or public health programs.23 the more ghas can understand and harness the local structures, organizations, and health determinates, the more sthms will lead to long-term positive change. because cas behavior is unpredictable, future activities are difficult to foresee, as some inputs will bring unintended consequences. this is especially true when agents make decisions based on their own needs and fail to consider their impact on the system as a whole, a phenomenon termed “sub-optimization.”24 sub-optimization might occur when a sthm that focuses on one surgery or disease diverts local professionals from other health activities.25 the focused disease or surgical activity is deemed successful, though the impact on the over-all health of the community might be compromised. “systems thinking” is a collection of disciplines, theories, and methods that help us to understand the characteristics of complex systems such as interrelationships between actors with diverse perspectives, boundaries between those actors, feedback, self-organization, history dependency, non-linearity, and sub-optimization and to improve the way that we function in such systems. systems thinking ideas and approaches have been applied successfully to business, engineering, biology, and other fields. a consideration of all of the various systems thinking perspectives – such as systems dynamics, complexity theory, and cybernetics – is beyond the scope of this paper (though the interested reader might want to glance over brian castellani’s dizzying map of the field).26 herein, we have focused on those concepts we have found most relevant and applicable to global health practice – specifically, using a complex adaptive systems lens. the application of cas principles, and the degree to which individuals and organizations do so, varies widely on a continuum. for those interested in learning more and applying these ideas, we have found williams’s 3 key elements of a systems approach: inter-relationships, perspectives, and boundaries a good starting point.16 figure 1. note: top-down or blueprint design strategy. promotes learning by interest groups, policymakers, and planners, as well as managers and providers, but prevents learning by the producers of health: communities and households. action that determines health happens at the community level, but the learning does not.8 top down, blueprint approach to global health for decades, reductionist thinking (the view that a system is nothing more than the sum of its parts) has led to what has been described as the dominant approach to global health: a top-down, blueprint model (figure 1).5,8,20 in this approach, interest groups and planners from hics (high-income countries) drive the agenda, while communities and households in lics are treated like recipients8 as opposed to collaborators. planners, providers, and managers learn and communicate what works within the context of narrow, often disease-specific, initiatives so that interest groups will continue to provide necessary funding. those that produce health locally through behavior change, social influence, political advocacy, etc. –the communities and households – are denied the opportunity to learn. disease-specific programs, such as the us president’s emergency plan for aids relief (pepfar), have been described as such initiatives in global health. when targeting a well-defined problem, some of these programs have been effective in reaching focused goals, but sustainability has remained elusive due to the complex adaptive nature of health systems.5,14,20 sthms are often planned and executed in the same way, from the top down.3,6-7,17-18,27 unintended consequences approaching complex health challenges (such as building local capacity or addressing diseases with multiple context-specific determinates and possible approaches to prevention or treatment, such as aids) with a top-down blueprint approach (and, therefore, without taking into account their inherent complexity) too often results in unintended consequences. one major unintended consequence of the blueprint strategy is the exclusion of communities and households from learning what works and what does not, leaving this opportunity for the interest groups, providers and managers, planners, and providers. the local communities, households, or individual patients may be treated as a challenge that needs a quick remedy, rather than a partner with whom to be fully engaged and cooperate and from whom to learn. the gains experienced as a result of global health interventions are not sustainable when needs are met only temporarily. leveraging the potential of the households and communities to take long-term ownership of interventions may be a missed opportunity. our review of the literature identified many other unintended consequences of sthms, especially as they relate to medical and surgical trips (see box 1). other types of sthms, such as public health interventions, may have other types of unintended consequences, though their documentation is less abundant. there will, of course, always be unforeseen negative effects of all actions in systems such as health. systems practitioners aim to create an environment where the over-all positive effect is maximized. box 1. some unintended consequences of short term health missions consequences of mission trip brevity patients experience complications after teams are gone and have no available follow-up care options.17> consequences of working in resource-poor settings life-threatening complications sometimes arise which would be treatable in a us hospital, but not with limited mission resources. patients have died as a result.17 anesthesia is not able to be safely monitored or administered using evidence-based techniques.28 in the case of cleft lip and palate surgery, patients may receive cleft lip surgery but wait years for palate surgery because another mission may not arrive until then.6 ethical consequences members of the team may face the ethical issue of whether to provide care for which they are not qualified (medical students, for example).29 patients who are not good candidates may have surgery anyway in order to reach a goal body count by the end of the mission trip.6 consequences related to scope of interventions medical teams are expected to care for patients whose conditions are beyond the scope of the mission’s experience, abilities, or training. for example, a cleft lip/cleft palate mission may be prepared to operate, but be unable to effectively address complications.30 consequences directly impacting local health system visiting teams set precedent that cannot be followed by local practitioners, such as providing services that are not normally available.28 mission teams may use too much space in a clinic or hospital, inhibiting the work of the local physicians on other cases.31 relationships with local providers may suffer when visitors leave all post-operative care responsibilities to local colleagues.6 local colleagues may be alienated when volunteers fail to cooperate or work closely with them.6 patients sometimes misuse medications or fail to fill prescriptions due to cost or lack of understanding.7 locals may become dependent on foreign intervention.18 this includes waiting to seek medical care until the next team arrives.28 local providers’ self-worth suffers when patient levels drop due to unavailability of modern technology and services after volunteer teams leave.32 inequitable relationships between locals and international global health actors become entrenched.3 short-term health missions as events in systems sthm trips are often viewed as isolated events – one-time interventions that have limited impact beyond the patients being treated or the program being delivered. viewing such trips as events within the local health system and seeking to understand system-wide effects of such events can help to maximize the positive effects of sthms. hawe et al explain that interventions are just like any other system event; they take place at particular times in various activity settings, often through social networks, and persist for discrete durations of time.33 this perspective demonstrates a recognition of the importance of considering local context. as interventions such as sthms take place, system actors such as local health practitioners, community members, politicians, church leaders, and others participate and respond. those actors less involved in the intervention will value it differently than those closely participating. each actor’s perception of intervention results will determine his or her response16. even seemingly isolated and focused sthms, such as surgical interventions or disaster relief, can impact larger systems by influencing the response of actors in ways that are not always readily evident. for example, community members may not mobilize and advocate for local surgical training if the need is already being met by foreign experts. interventions often introduce people into new settings and to new people. this broadening of local social networks facilitates self-organization and emergence of new “opportunity structure” for households and community members.33 when sthms occur, there may be a shift in the distribution of resources and indigenous providers’ current activities may be discontinued in favor of new intervention-related activities. these phenomena are examples of changing local ecological context. hawe et al identify four implications of viewing health interventions as events in systems. first, while the function of an intervention may need to be similar in all locations, the form an intervention takes does not necessarily need to be consistent.33 local context can determine what an intervention looks like in different communities. fidelity of interventions is not tarnished by differences in form. second, degree of attitude and behavior uptake is not the only measure of intervention success. rather, building individuals’ capacity and enabling individuals to make positive health choices by improving his or her position in social networks are also successes because empowerment within the community social structure leads to increased access to resources, both material and nonmaterial, especially information.33 third, evaluating system context while interventions are taking place enables ghas to redirect efforts towards strategies that are working well and to identify positive and negative feedback mechanisms. once identified, attempts can be made to encourage positive feedback mechanisms and mitigate the effects of negative feedback mechanisms.33 finally, less focus on program evaluation and more time to evaluate changes in context after interventions are over could lead to an increased understanding of the larger system and context.33 this process of discovering patterns in system behavior and identifying persistent needs has the potential to be a productive starting point for ongoing capacity-building efforts. implications for practice–adopting a cas lens figure 2. note: in stacey’s zone of complexity, both certainty of outcomes and agreement about outcomes are relatively low. 19 ralph stacey has developed a model (figure 2) to appreciate the level of complexity of health improvement activities based upon scientific certainty about outcome and social agreement about outcome.19 where there is certainty about outcome and agreement among stakeholders about outcome, command and control works well because the situation is predictable. because certain actions or methods are known to produce predictable outcomes, it is easy for those involved to agree on approaches. however, where certainty about outcome is low, agreement on the approach will also be low. this presents a chaotic situation in which approaches cannot be based on rules because it is impossible to determine what will result from any given action. between this realm of chaos and that of simplicity, we find complexity. figure 3. notes for figure 3: the cynefin framework based on dave snowden’s four domains35 introduces the concept of simple, complicated, complex, and chaotic realms of existence. complex systems require pattern management rather than best or good practice implementation. coupled with the stacey diagram, snowden’s cynefin framework34 (figure 3) can be used to determine the best way to approach a problem based on the level of environmental complexity. the framework depends on understanding that different contextual environments require different approaches. some problems are simple because there are relatively few steps required, and the certainty of outcomes is high, requiring straightforward categorization of information before response. snowden’s domain of simplicity calls for implementation of best practice: for example, immunization against childhood diseases (though the delivery of vaccination programs is quite complex because of the need to challenge erroneous assumptions about immunizations, ensure effective supply chain management, consider human resource effects, and other issues!). other problems are complicated because there are multiple steps, requiring analysis of information before response. the complicated domain calls for use of good practice. best practices do not apply to complicated problems because there is more than one suitable solution available. the complex domain requires first probing, then sensing what happens, then responding. snowden calls the appropriate response for the complex domain “emergent practice” because the solution only becomes evident after observing the dynamics of the system and its emerging patterns. complex problems and situations are impossible to solve using best practice as too many components are in flux. examples of complex health challenges include: local capacity building; healthcare reform; and addressing diseases, such as obesity, with many determinates and possible approaches to improvement. while this categorization of health challenges and interventions is helpful in theory, we have found that all health activities have some degree of complexity because of the human capacity factor. intervening in health systems (cass) assuming that the environmental context is simple or complicated will lead to frustration when best practices fail to bring desired results. this might be why interventions bring varied results in different communities; environmental context varies depending on location due to each health system’s set of unique actors. implementation of practices tailored to each emerging pattern of system behavior allows actors to keep up with dynamic system behavior. applying best practices to complex situations in the form of vertical blueprint interventions could result in negative unintended consequences. toward a learning health system figure 4. learning organization approach to global health intervention notes: it is driven by stakeholder participation in learning the roles of other stakeholders and by the household production of health.8 a non-linear systems thinking approach to facilitate learning by households and communities during global health interventions has been proposed by korten36, and adapted by mosley (figure 4).8 this “learning organization approach’ centers on the learning that takes place by each stakeholder group: households and communities; managers and providers; policymakers and planners; and interest groups. households and communities learn about the outputs of programs and interventions that the managers and providers implement. they might be more aware of unintended consequences as they are more aware of local attitudes, beliefs, and practices, as well as the decisions being made by policymakers and planners. a significant challenge that health systems face is ensuring that there is adequate feedback from local, indigenous households and communities. this can happen through organized, formal organizations or though less formal cultural shifts. providers and managers need to understand the needs of the households through ongoing feedback. they also develop competencies through training funded by and organized by policymakers and planners. in return, needed tasks are communicated back to policymakers and planners. policymakers need to know the tasks that managers and providers need, as well as the needs of communities and households.8 interest groups do not drive this learning organization from the top down. rather, each stakeholder is engaged in an iterative cycle of trial and error where learning emerges based on the needs of the households and communities. this focuses the attention on building capacity at the household and community level where health is produced and, thereby, the health system is strengthened. in this process, the value of engaging local governments, health agencies, and business cannot be overstated. indigenous community leaders (many times unexpected, informal leaders) that are health advocates, change agents, and social influencers should be identified and supported. the challenge in using this model is learning to allow local stakeholders to learn from experience and make mistakes. learning at the community level for health leads to technical capabilities such as learning to diagnose and treat disease and learning to recognize and respond to emerging disease patterns. “soft”capabilities such as navigating complexity, learning collaboratively, engaging politically, and being self-reflective are at least as important as the technical capabilities, though they are too often not adequately considered in health planning.21 this learning organization approach can enhance the impact and efficacy of global health interventions, like sthms, by preventing unintended consequences that invariably result when communities and households are disregarded in the learning process. a complex systems paradigm shift adopting a complex adaptive systems lens has the potential to transform sthms from isolated, episodic interventions into a global network of shared learning and positive innovation. for those interested in making such a shift, significant self-reflection will be required: what is the ultimate goal of the sthm trip? our experience suggests that most involved in sthms are very interested in contributing to long-term, sustainable change that results in local capacity enhancement. if so, more questions may be worth asking, and we have listed some in box 2. ghas may need to complement technical, medical, and public health skills and knowledge with others that can lead to health improvement such as community psychology and community organizing; economic development and systemic business management principles; educational initiatives that teach systemic thinking; cultural anthropology; ecology; etc. they may also find it necessary to commit to strengthening health systems rather than exclusively focusing on one activity, moving away from “quick-winsâ€� or “quick-impactâ€� strategies and towards longer-term, sustained efforts.5,33 ultimately, a systems thinking approach will lead to the ghas becoming part of the local system long-term. box 2. some questions for reflection in short-term health missions pre-mission planning do the planned sthm activities further the organization’s long-term objectives? for example, many might have “building local capacity” or “empowering locals” as important long-term objectives, while sthm activities (disease-specific interventions, surgeries or disaster relief) might not contribute to those objectives. to what extent are locals in lics involved in pre-mission planning? how frequent and extensive is the communication between sthm planners and local stakeholders? are sthm participants knowledgeable about local culture, history, politics, and social norms? is there a new cadre of participants with each sthm, or do the same professionals participate, thereby, enhancing iterative learning and relationship building? to what extent do sthm planners learn from previous experiences? mission implementation are plans adapted to respond optimally to local circumstances, or are they rigid? are activities more focused on technical interventions (such as public health programs, surgical activities, or disaster relief) or on building relationships? to what extent do ghas identify and support sometimes unexpected local leaders that challenge the status quo to improve health? to what extent do ghas facilitate an environment where local self-organization and innovation is encouraged? to what extent are unexpected positive local roles, processes, and structures that emerge identified and supported? to what extent do ghas learn from negative ones? post-mission activities to what extent do sthm participants and planners follow-up on their activities? do short-term relief missions consider ways to empower communities to prevent or respond to future disasters? implications for practice taking a cas approach to sthms will not be achieved by following a list of prescriptive rules. instead, systems thinking must become a mindset – a paradigm which influences the way ghas make decisions. box 3 contains implications for practice adapted from the european centre for development policy management based on complex systems thinking principles. box 3. implications for practice in complex settings37 focus on ownership. ownership is critical to any capacity development process, because change is fundamentally political. approach capacity development as a process of experimentation and learning, rather than as the performance of predetermined activities. take an evolutionary approach to design. recognize that good design means being clear about the desired direction of change, leaving space for adaptation along the way. engage local stakeholders in the determination of needs and strategies. invest more in understanding context in terms of the political, social, and cultural norms and practices that shape the way a country or organization understands capacity, change, and performance. give greater attention and recognition to less visible aspects of capacity, such as values, legitimacy, identity, and self-confidence, as well as other, non-monetary forms of motivation that may nonetheless be critical to outcomes. be prepared to accept a higher degree of risk and failure as a means of encouraging learning and innovation. invest in relationship-building. the implementation of capacity development support depends tremendously on the relationships forged between local stakeholders and outsiders. be more realistic about the scope of external intervention. in the end, external partners are marginal actors, as compared to the influence exerted by underlying domestic processes and forces. while we are unaware of any comprehensive review of the extent that sthms apply systems concepts, many christian relief organizations are founded on various cas principles (though it may not be explicitly communicated or even recognized), and all sthms likely apply these and other systems approaches to some degree. for example, world vision partners with communities to alleviate poverty with long-term, sustainable changes.38 christian medical & dental associations implement systems thinking by promoting awareness of issues, working at a policy level, and providing education.39 samaritan’s purse sponsors several branches of international aid including everything from disaster response to campaigns to stop human trafficking. samaritan’s purse provides holistic training, equipment, and education, thereby, allowing people to help themselves.40 while not explicitly applying systems thinking concepts to sthms, the global community health evangelism (che) network is one example of applied systems thinking concepts.41 the che network has several models which allow for strategy adaptation to suit various cultural, political, and religious environments. this evolutionary approach allows che to build relationships with local leaders and equip community members to find and implement solutions. the community is the primary driving force behind change which allows for sustainable progress. such community ownership, defined by che as people “taking responsibility for their own health and well-being,” is a principle of systems thinking that che uses to measure results.41 the che network further implements systems thinking by evaluating intervention outcomes in order to more effectively facilitate positive change in the future. while not a sthm, the experience of comprehensive rural health project in jamkhed, india could be considered an example of a learning health system. two indian physicians, raj and mabel arole, focused on population health improvement and equity while acknowledging complexity and operating within local context. newly empowered community members self-organized and, as a result, increased capacity emerged.42 health outcomes improved significantly, including decreases in infant mortality. learn more readers interested in additional systems thinking applications in global health may wish to review this list of resources: http://st4chealth.com/systems-thinking-reading-list/. the landmark publication, ‘good health at low cost’ 25 years on: what makes a successful health system?, also contains many examples of how systems thinking has improved health around the world, mostly on the country level.43 cas principles including long-term vision, history dependency, feedback loops, and operating within cultural context are shared that led to improved health in several countries and contexts. many global health systems practitioners have found two systems thinking classics helpful in their work: peter senge’s the fifth discipline and donella meadow’s systems thinking: a primer.44-45 conclusion sthms can be approached as events within complex adaptive health systems, where each action has an effect on other parts of the system. such a perspective might minimize unintended negative consequences and accomplish long-term objectives, such as increasing local capacity. for some, this may require a paradigm shift away from one-time, isolated interventions toward a learning health system, where ghas are an integrated part of the system long-term with increased local ownership, mutual engagement, and shared learning. references martiniuk a, manouchehrian m, negin ja, zwi ab. brain gains: a literature review of medical missions to low and middle-income countries. bmc health serv res [internet]. 2012 may 29 [cited 2014 may 30];12:134. available from: http://dx.doi.org/10.1186/1472-6963-12-134 maki j, qualls m, 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capacity development: between planned interventions and emergent processes. implications for development cooperation. capacity change and performance. 2009;1-8. world vision. federal way, wa; c2015 [cited 2015 feb 22]. available from: http://www.worldvision.org/ christian medical & dental associations. c2015 [cited 2015 feb 22]. available from: http://www.cmda.org samaritan’s purse. boone, nc; c2015 [cited 2015 feb 22]. available from: http://www.samaritanspurse.org/ global community health evangelism network. phoenix, az; c2014-15 [cited 2015 feb 21]. available from: http://www.chenetwork.org/ systems thinking for capacity in health [internet]. provo: st4c health; c2008-2014. equity and “health for all” at jamkhed, india’s comprehensive rural health project; 2013 sep 25 [cited 2014 oct 23]; [about 5 screens]. available from: http://st4chealth.com/2013/09/25/crhp-jamkhed-and-systems-thinking/ balabanova d, mckee m, mills a, editors. ‘good health at low cost’25 years on: what makes a successful health system? london: london school of hygiene & tropical medicine; 2011. 399 p. senge pm. the fifth discipline: the art and practice of the learning organization. new york: doubleday/currency; 1990. http://dx.doi.org/10.1002/hrdq.3920020215 meadows dh, wright d. thinking in systems: a primer paperback. vermont: chelsea green publishing; 2008. peer reviewed: competing interests: none declared. acknowledgements: formatting assistance was supported by the doris duke charitable foundation’s african health initiative grant 2012158. the funding organization did not participate in the study design, data collection and analysis, decision to publish, or preparation of manuscript. we thank talicee lindsay for her assistance in editing and formatting, as well as 3 anonymous reviewers for their insightful comments and suggestions. we also thank dr. henry mosley for his thoughtful review. correspondence: robert chad swanson, swancitos@gmail.com system thinking for capacity in health (st4c health) http://st4chealth.com/ cite this article as: swanson rc and thacker bj. systems thinking in short-term health missions: a conceptual introduction and consideration of implications for practice. christian journal for global health (may 2015), 2(1):7-22. © swanson rc and thacker bj. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ field report may 2023. christian journal for global health 10(1) a school-university collaboration to promote school health and physical education in north sulawesi, indonesia alva supit a, theo mautang b, melky pangemanan c a md, mbmsc, lecturer, department of public health, manado state university, indonesia b phd, dean, faculty of sport and health science, manado state university, indonesia c msc, head, department of sports sciences, manado state university, indonesia introduction school-university partnerships have been in existence for a very long time. universities need schools as the location for teaching internships as well as providing participants for its research activity.1 schools may have needs for an updated curriculum or teaching methods. however, individuals in schools can also face undiagnosed health-related issues, mostly unattended due to the lack of resources or knowledge. in this report, we will describe the efforts of our faculty—as the region’s educational center for graduating public health experts and physical education teachers—to contribute to school health by integrating health surveillance, research, and community service targeting the schools within our region of service. the unique ecosystem formed by our alumni network and the faculty also serves as an important strength as will be described and reflected on, in an attempt to formulate future strategies. geohistorical context formerly known as the teaching and pedagogical institute (institut keguruan dan ilmu pendidikan, ikip), the manado state university (msu) was founded in 1955 to fulfil the region’s need for school teachers. in line with this, the faculty of sport sciences held an exclusive undergraduate program to educate future physical education and health (peh) teachers. recently, in 2015, the faculty merged with the previously independent department of public health to form the current faculty of sport and health sciences (fshs), focusing on both sports and health sciences. this unique composition of the faculty has led to the combination of these two majors to conduct health-oriented research in the schools where most of our graduates are working as peh teachers. situated in tondano, minahasa, fshs is the sole faculty graduating peh teachers in north sulawesi province. nevertheless, its graduates have been diasporic, serving within and surrounding the province. the currently-enrolled students came from all over the eastern part of indonesia, thus enriching the student cohort and later strengthening the alumni network. integration of university research and school health promotion despite the covid-19 pandemic that hit the planet in recent years, on a bigger scale, the world is experiencing an epidemiological shift from the dominance of communicable to noncommunicable, degenerative, and metabolic diseases.2,3 thus, prevention from an early age is becoming more relevant within this forecasted scenario where school health is increasingly a health promotion pillar that is critical to be strengthened. the term “physical education and health” is more suitably considered as an umbrella term for various implementation points. it is critical to note that the fitness of school students acts as a strong predictor of future morbidity.4 the health of school students in our province, in particular, has been the focus of the faculty as the subject for research and community service. indonesian university lecturers are obliged to fulfil the “tri dharma perguruan tinggi” (the three duties of the university): teaching, research, and community service. in fact, a tenured lecturer must perform all three on a yearly basis to be promoted to the next academic position. on the supit, mautang & pangemanan 44 other hand, under the indonesian college curriculum, final-year undergraduate students are obliged to perform research where the research topic would be chosen by the students and their academic mentors. in our center, currently, there is no written rule about how to determine the research topic and location; interestingly, there is an unspoken desire for the students to conduct their research in their hometown (community-based) or their previous school (school-based). based on mutual agreement between the student and their academic mentor, a research project would be designed and carried out upon the passing of the proposal examination. prior to the integration of the public health department into the faculty in 2015, the schooluniversity partnership was mostly driven by the needs of the university to conduct pedagogical internships and research. more recently, following the merger of public health and sport science departments, the faculty has increasingly observed unattended health problems among school students, thanks to the praktik belajar lapangan (field study practicum) of the public health (ph) students. in this year-3 practicum-based subject, the students are asked to observe and identify health problems in their location of choice (either communityor school-based). following this, the ph students may share the initial observation result with their peers from the sports science department and initiate a collaboration between them to address the problem. to provide more quantitative insight, we recapitulated the research conducted in our center within the last three years that has been peerreviewed and accepted for publication in our inhouse journals (olympus, physical, and epidemia). between 2020-2022, the faculty has conducted hundreds of final-year research, 200 of which were accepted for publication. of these, 95 studies (47.5%) were conducted in schools, while the remaining were performed in community settings, among their peer college students, or literature reviews/meta-analyses (figure 1). among the 95 school-based studies, 41 studies were about physical education pedagogy (i.e., teaching methods), owing to the nature of the faculty to graduate pe teachers. the remaining 44 studies focused on various subjects, including physical fitness, nutritional status, hygiene, reproductive health, and several specific diseases. most of the research was descriptive, with only two being experimental. some examples of the titles were presented in table 1. figure 1. the distribution of research topics in the faculty between 2020-2022. note: most of them are school-based (47.5%), followed by community-based (26.5%) research. n=200 table 1. examples of the research titles targeting school students as the subjects 45 supit, mautang & pangemanan may 2023. christian journal for global health 10(1) scope research title ref physical education and health the relationship between nutritional status with physical fitness in tomohon junior high school 2 students 5 sport pedagogic the effect of “demonstration” teaching method on badminton short-serve ability among karegesan junior high school students 6 reproductive health knowledge and attitude of 9th-grade students in langowan high school about premarital sex 7 note: all journal articles were published in the indonesian language. english translations were provided by the authors. more importantly, in every school-based research, the student-researcher would issue a recommendation to the school teachers regarding the variables studied, which provided a useful framework for determining the school’s policies. in line with the faculty’s research focus on physical health, most studies would screen the students’ physical fitness and body mass index as baseline demographic characteristics. from this data alone, it was sufficient to identify potential health problems among the students by screening those overor underweight. following the data analysis, the headmaster or related teachers (usually the school’s pe teacher–most likely our graduates) were informed about the results and invited to the student viva/oral examination, either as an external examiner or as “field mentor” (pembimbing lapangan). the school teachers might provide insight from the school’s point of view, as well as absorb the research output and recommendations. for example, pangemanan and mioyo found that 9.9% of the students in a public school were obese or overweight, which correlated with their physical activity.8 after performing data analysis and providing concluding remarks, the authors recommended that “...the pe teachers should educate [the students] to do regular exercise . . . and take care of their nutritional intake.” this recommendation sounds normative in the paper, but what matters most–in our case–is the nonformal communication between the researchers from the faculty and pe teachers from the school (occasionally, the headmaster as well). in another study about students’ hygiene in elementary schools, the authors identified a high incidence of seasonal diarrhea and identified its correlation with hand hygiene.9 these findings were followed up by the school in ensuring the cleanliness and availability of water in the school–which could still be a problem in some remote public schools. although mostly descriptive, the research provided useful findings, feedback, and recommendation for the school regarding the topic being investigated, where the students can get the direct benefit. as mentioned above, all pe teachers in the province are our alumni, which provides a fertile ground for non-formal communication and feasible post-research follow-up monitoring. in indonesia, this non-formal communication seems to be critical in achieving a common target.10 the research findings can be followed up by the school, for example, by matching the intracurricular pe training with the recommendation, i.e., posing more aerobic exercise or providing extra feeding. in case of malnutrition (which in our region can be underweight and most likely overweight), the pe teacher may forward this information to the parents or the ministry of health as a holistic approach to overcoming the problem. reflection and hope upon the making of this report, one theme emerged regarding the distribution of the research titles: the studies were not following any established roadmap, as the research topics were as diverse as our students’ interests and our alumni distribution. shortly, we intend to generate a roadmap to make our research more systematic and continuous, at least within the province. as a beginning, a geographical mapping based on epidemiological research will be performed so that future students can be directed to conduct their final-year research following the actual needs of society and schools. this mapping can be supit, mautang & pangemanan 46 integrated into the ph curriculum to systematically map the problem in our province, starting from the nearest district to the more distant ones. more importantly, this university-school collaboration should give more space for the school teachers (and students) to provide input about their needs. and last but not least, fshs/msu is located in a christian-majority area inside the largest moslem-majority country in the world. most of the lecturers and students are christians; thus, being attentive to school health and students’ well-being carries a deeper meaning as an extension of christ’s special love for the children. we would consider the strategic position of our faculty both a blessing and a commission to elevate school health statuses, at least within our region. international collaboration from fellow researchers is very welcomed. references 1. walsh me, backe s. school–university partnerships: reflections and opportunities. peabody j educ. 2013;88(5):594-607. https://doi.org/10.1080/0161956x.2013.835158 2. gersten o, barbieri m. evaluation of the cancer transition theory in the us, select european nations, and japan by investigating mortality of infectiousand noninfectious-related cancers, 1950-2018. jama network open. 2021;4(4):e215322. https://doi.org/10.1001/jamanetworkopen.2021.532 2 3. siswati t, paramashanti ba, rialihanto mp, waris l. epidemiological transition in indonesia and its prevention: a narrative review. j compl altern med res. 2022;18(1):50-60. https://doi.org/10.9734/jocamr/2022/v18i130345 4. ortega fb, ruiz jr, castillo mj, sjöström m. physical fitness in childhood and adolescence: a powerful marker of health. int j obesity. 2002;32(1):1-11. https://doi.org/10.1038/sj.ijo.0803774 5. manopo m, mautang t, pangemanan m. hubungan status gizi dengan tingkat kebugaran jasmani pada siswa smp negeri 2 tomohon. j olympus. 2021;2(01): 53-61. https://doi.org/10.53682/jo.v2i01.2501 6. maramis c, makadada f, supit r. pengaruh metode demonstrasi terhadap kemampuan servis pendek dalam permainan bulu tangkis pada siswa smp kristen karegesan. physical jurnal ilmu kesehatan olahraga. 2022;2(1):50-7. https://doi.org/10.53682/pj.v2i1.1034 7. manitik a, langitan f, telew a. hubungan antara pengetahuan dengan sikap remaja tentang seks pranikah pada siswa kelas xi sma negeri 1 langowan. epidemia: j kesehatan masyarakat unima. 2022;3(1):17-22. https://doi.org/10.53682/ejkmu.v1i2.571 8. pengemanan m, miyoyo b. hubungan aktivitas fisik dengan status gizi di smp nasional mogoyunggung. j olympus. 2020;1(1):29-34. 9. kaunang p, pangemanan m, bokau j. faktor-faktor yang berhubungan dengan kejadian diare pada siswa sd gmim 46 sukur kecamatan airmadidi. epidemia: j kesehatan masyarakat unima. 2022;3(1):60-5. 10. poedjosudarmo s. informal indonesian and the spirit of pluralis. j lang lit. 2014;14(1):1-7. https://doi.org/10.24071/joll.v14i1.387 peer reviewed: submitted 23 march 2023, accepted 24 april 2023, published 29 may 2023 competing interests: none declared. correspondence: dr. alva supit, tondano, minahasa, indonesia alva.supit@unima.ac.id cite this article as: supit a, mautang t, pangemanan m. a school-university collaboration to promote school health and physical education in north sulawesi, indonesia. christ j global health. may 2023; 10(1):43-46. https://doi.org/10.15566/cjgh.10i1.761 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1080/0161956x.2013.835158 https://doi.org/10.1001/jamanetworkopen.2021.5322 https://doi.org/10.1001/jamanetworkopen.2021.5322 https://doi.org/10.9734/jocamr/2022/v18i130345 https://doi.org/10.1038/sj.ijo.0803774 https://doi.org/10.53682/jo.v2i01.2501 https://doi.org/10.53682/pj.v2i1.1034 https://doi.org/10.53682/ejkmu.v1i2.571 https://doi.org/10.24071/joll.v14i1.387 mailto:alva.supit@unima.ac.id https://doi.org/10.15566/cjgh.10i1.761 http://creativecommons.org/licenses/by/4.0/ introduction editorial caring in conflict, paradigms, and health systems this is issue number one of volume two of the christian journal for global health, addressing some aspects of the theme caring in conflict. mindful that conflict is a major feature of daily life for billions the world over, we invited papers that concern conflict on multiple levels: international, events in our environment, and inter-personal. it is perhaps early to hear reports from the response to the earthquakes in nepal, but maha asham tells us what it has been like for internally displaced refugees from the fighting in iraq who have been cared for by christians in kurdish areas. sangeeta nair, lois joy armstrong, and philip finny present a study on family conflict as the major underlying influence in suicide attempts in northern bihar, india. dr. sarah nageshwari describes the rigors of health care delivery amid political and religious conflict in kashmir. dr david stevens, speaking from his experience as a global health physician and chief executive officer of the christian medical and dental associations, contributes his wisdom on resolving interpersonal and institutional conflict. contributions on the theology and philosophy of missions and of global health continue to be a major interest of journal contributors and three articles in the current issue reflect this. professor raymond downing provocatively makes the case that science had replaced spirituality in medical missions in the 19th century, at least partly as a consequence of disparaging african spiritual cosmology. dr. jose miguel de angulo and luz stella losada offer an historical overview of paradigms in global health as they have evolved over the 20th century, pointing out how systems theory and the study of complexity have affected theory and practice. these provide a background for emerging paradigms in the 21st century. chad swanson and brian thacker provide an excellent introduction to systems thinking, and propose its application fruitfully to short-term health missions. gnanaraj jesudian is a surgeon in rural india and is in a position to describe the value and pitfalls of short-term medical work from the unique perspective of a host for better health care access, spiritual growth and research. his research meets a gaping need in the literature, and not all of what he has to say is congratulatory. book reviews can be effective commentary on current issues, and ronald halbrooks’ review of health, healing and the church’s mission does this well. the editors are pleased to be able, from time to time, to help disseminate practical advice on global health practice from experts in the field. dr. elvira beracochea has written a short contribution on improving the quality of child healthcare as the first part of a series. her article can be printed and used as an evaluation checklist in the field. we also intend to provide reports from conferences relevant to our readers. this issue contains summaries of the engage disability conference held in new delhi in september 2014 and the medicine and religion conference held in boston in march 2015 with hopes to remind us of the relevance of our faith to healthcare and the latest thinking in the global health community. the editors are pleased at the continued flow of submissions to the journal; there are currently a number of articles still in the review process. we hope to encourage more articles describing original research, and will continue to waive the article processing charge for 2015 and possibly beyond with the support of generous donors. we offer a strong team of reviewers to help authors less familiar with the preparation of such work. we are working on a procedure to help authors lacking access to an institutional review board. this procedure will still maintain a high standard of ethical review for the journal, and when completed, will be described clearly on the website author guidelines. beside regular submissions, we are calling for papers related to disability and rehabilitation for the next issue. we encourage comments on the disqus feature for articles of interest, feedback to the editors, and to let this resource be known among your respective circles. engage and enjoy! book review dec 2021. christian journal for global health 8(2) health-promoting churches: reflections on health and healing for churches on commemorative world health days, by mwai makoka, world council of churches publications, vol. 1, 2020; vol. 2, 2021 arnold l gorskea a md, faap. ceo, standards of excellence in healthcare missions. editor, health education program for developing communities (hepfdc.org), usa it is difficult to overemphasize the importance of these two small handbooks. other than the bible, they have more lifesaving, health and healing potential than anything else i have read in more than 50 years as a physician. the purpose of both volumes by dr. mwai makoka, wcc programme executive for health and healing, is to help reestablish the local church’s mission as a healing community. this is not a new concept; until the past two generations, the church followed the example of jesus’ holistic healing ministry, and most hospitals were established by the church. volume i gives churches starting points for conversations and action on different health topics chosen from the world health organization (who) calendar.1 for example, though the section on “world immunization week” was written before covid-19, churches could apply the principles and current who guidelines to covid-19 vaccine hesitancy and do much to prevent the tragic numbers of unnecessary deaths due to false information. volume ii is especially important as it provides comprehensive guidelines to enable every congregation to reassume its health and healing responsibilities.2 both volumes are “expected to support the healing ministry of the local congregation to ensure that: 1. the church is a place of health education. 2. the church is a place of practical action. 3. the church is a place for advocacy and care for creation, and 4. the church is a place of empowerment for public witness.” (vol. i, p. 1; vol. ii, p. ix) the volumes may be downloaded free as a service of the world council of churches (wcc). volume i is available in english, french, and spanish. volume ii is available in english with french and spanish translations pending. as ministries of health throughout the world follow who guidelines, it is important to emphasize that these handbooks are not only biblically-based but also based on who international standards and guidelines. remarkably, both volumes have even been endorsed by the director general of the who tedros adhanom ghebreyesus. this is essential for those of us working in the secular world, especially in restrictive access settings. this is not a new collaboration. it was christian missionaries who originated who’s primary care system with its health promotion and prevention back in the 1960s, and who’s declaration of alma ata was coauthored by a christian missionary.3 these same missionaries reported, “one of the most urgent needs of to-day is that christian congregations, in collaboration with christian medical workers, should again recognise and exercise the healing ministry which belongs properly to them . . .” 4 (p. 14) 37 gorske dec 2021. christian journal for global health 8(2) it is also important to recognize why these simple handbooks are potentially world changing. who’s world health report 2008: primary health care—now more than ever5 emphasizes the following as one of the most critical mistakes in both developed and developing countries: “misdirected care: resource allocation clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden.” (p. xiv) although most churches do not have the financial or physical resources to provide modern curative care services, all churches have the human and community assets to provide lifesaving evidence-based holistic education and interventions for health promotion and disease prevention (the 70%). this has also long been emphasized by who’s building from common foundations: the world health organization and faith-based organizations in primary healthcare.6 the discipline of public health provides an opportunity for churches to develop community health ministries. this remains the key to community transformation and the success of healthcare systems in both developed and developing countries. the highly respected medical journal, the lancet, reports: the missing link in the translation of the principles of alma-ata from idealism to practical, effective strategies has been the failure to integrate the perspective of personal and public health. the future of health care generally, and primary care specifically, depends on the integration of personal health care and public health at the level of the local community. 7 as reported in health-promoting churches, volume i, for those who follow the example of jesus, “the christian ministry of healing belongs primarily to the congregation as a whole, and only in that context to those who are specially trained.”(p. iii) yet health professionals who follow evidence-based guidelines are also essential. nurses, community health workers, and health educators have been especially effective in assisting congregations in their holistic health promotion and disease prevention services both locally and on the mission field.8 as has again been demonstrated with covid19, it is important to recognize that healthcare information not evidence-based can harm as many people as curative care not evidence based. through its constitution and 193 member states, the who is responsible for “setting norms and standards” and requires its guidelines be based on the best available evidnce.9 numerous biblical/who evidence-based guidelines addressing our most important healthcare problems are now available free in multiple languages to meet these requirements.10 church-based community health utilizing evidence-based guidelines is especially important for prevention of the ever-increasing deaths due to unhealthy lifestyle. the who reports at least 80% of chronic diseases, such as diabetes, heart disease, and stroke, could be prevented by simple lifestyle changes.11 these diseases are also the leading risk factors for deaths due to covid-19. however, even before covid-19, unhealthy diet had become the leading cause of early death and disability in the world.12 for example, the lancet commission reported, “unhealthy diets pose a greater risk to morbidity and mortality than does unsafe sex, and alcohol, drug, and tobacco use combined.” in addition: the commission quantitatively describes a universal healthy reference diet, based on an increase in consumption of healthy foods (such as vegetables, fruits, whole grains, legumes, and nuts), and a decrease in consumption of unhealthy foods (such as red meat, sugar, and refined grains) that would provide major health benefits and also increase the likelihood of attainment of the sustainable development goals.13 here again, who’s interventions on diet and physical activity: what works gives local church programs for health promotion and prevention its highest evidence-based rating for effectiveness.11 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 38 gorske dec 2021. christian journal for global health 8(2) the only significant weaknesses we could find were due to the brevity of the handbooks. however, additional supporting documentation is readily and abundantly available elsewhere. a few recently published examples follow. for those who wish more biblically-based evidence, all creation groans: toward a theology of disease and global health14 provides an even more comprehensive and compelling theological foundation for reestablishing the healing mission of the congregation in our modern-day world. setting up community health programmes in low and middle income settings-4th ed 15 (can be downloaded free) and beyond poverty-multiplying sustainable community development16 provide simple and effective guidelines on how best to enable communities to lift themselves out of poverty and disease and initiate “transformational movements that multiply change from village to village and sweep the countryside.” (p.ix) the health-promoting churches handbooks emphasize that even small congregations can follow the health and healing example of jesus and “let your light shine before others, so that they may see your good works and give glory to your father who is in heaven.” (matthew 5:13-16, niv). allen,17 yorgin,18 and others19 have provided additional guidelines on the importance of simple church-based health fairs in meeting these requirements. probably more than any other activity, church-based, holistic health fairs enable more congregation members (from teenagers to grandparents to healthcare professionals) to accomplish the above and do it in a fun-filled, joyful setting as well. they also provide important introductions to available community services as well as both curative care and churchbased health promotion/ prevention follow-up. numerous additional examples of churches that are following the holistic health and healing example of jesus can be found on the best practices in global health missions20 website. see especially the church & healthcare21 and health promotion & education10 for additional biblical and who international, evidence-based guidelines and resources that can be downloaded free. reestablishing jesus’ holistic healing ministry may well be the key to resolving problems related to declining church attendance as well as our lifestylerelated, declining health. churches with declining attendance will grow as they meet the needs of the people in their community. pastors are also now reporting that “engagement (of individual church members) will drive almost all future church growth.”22 as emphasized by health-promoting churches, every congregation should have a church health committee: “the hub of the health—promoting church is the church health committee (chc), which leads the health ministry. it should represent the full diversity of the local church. the main criteria for membership in the committee are passion for health issues, willingness to work as a team, and ability to organize and motivate others. church members who are trained health professionals are encouraged to participate in the committee without having to dominate it. besides the chc, all church members should be encouraged to participate and contribute with their gifts and abilities as much as possible.” dr. isabel apawo phiri, deputy general secretary for public witness and diakonia world council of churches (vol. i, p. xi) christianity is the largest religious group in the world, and in 2020 there were about 2.6 billion adherents globally23,24, and the numbers of churches are multiple times the numbers of hospitals and clinics in many countries. from a biblical and who evidence-based standpoint, the local congregation is currently the world’s most qualified and underused health and healing resource. 3,4,6,7,11,19,20,21 our prayer is that all who read this review will forward the links to these two volumes to every pastor, theologian, and health professional they know, especially those with influence in seminary, bible school, and health about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 39 gorske dec 2021. christian journal for global health 8(2) training institutions. never has the need or the opportunity been greater. references 1. makoka m. health-promoting churches. reflections on health and healing for churches on commemorative world health days [internet]. geneva:world council of churches [wcc] publications. 2020. [english, french, and spanish]. [cited 2021 sept]. available from: https://www.oikoumene.org/resources/publications/he alth-promoting-churches 2. makoka m, ed. health-promoting churches. a handbook to accompany churches in establishing and running sustainable health promotion ministries [internet]. vol. 2. geneva:wcc publications. 2021. [english, french, and spanish translations pending]. [cited 2021 sept]. available from: https://www.oikoumene.org/resources/publications/he alth-promoting-churches-volume-ii 3. gorske a. christian contributions to international standards & guidelines (is&gs) [internet]. [cited 2021 sept]. available from: https://www.bpghm.org/health_topics/christiancontributions-to-international-standards-guidelinesisgs/ 4. mcgilvray jc. the quest for health and wholeness [internet]. tubingen: german institute for medical missions. herausgeber: deutsches institut für ärztliche mission. paul-lechler-straße 24, 7400 tübingen; 1981 [cited 2021 sept]. available from: https://difaem.de/fileadmin/dokumente/publikationen /dokumente_aerztliche_mission/webthe_quest_for _health_and_wholeness.pdf 5. world health organization. world health report 2008: primary health care—now more than ever [internet]. geneva:world health organization; 2008 [cited 2021 sept]. available from: https://www.who.int/whr/2008/whr08_en.pdf 6. world health organization. building from common foundations: the world health organization and faith-based organizations in primary healthcare [internet]. geneva:who; 2008. [cited 2021 sept]. available from: http://apps.who.int/iris/bitstream/handle/10665/43884/ 9789241596626_eng.pdf;jsessionid=a15242c3bd8d 2e3e398075adcda8e9ed?sequence=1 7. van weel c, de maeseneer j, roberts r. integration of personal and community health care. lancet. 2008;372(9642). p871-2. https://doi.org/10.1016/s0140-6736(08)61376-8 8. nursing. best practices in global health missions (bpghm) [internet]. [cited 2021 sept]. available from: https://www.bpghm.org/health_topics/nursing/ 9. world health organization. who handbook for guideline development 2nd ed. [internet]. geneva:who; 2014. [cited 2021 sept]. available from: https://apps.who.int/iris/handle/10665/145714 10. health promotion & education. best practices in global health missions [internet]. [cited 2021 oct]. available from: https://www.bpghm.org/health_topics/healthpromotion-education/ 11. world health organization. interventions on diet and physical activity: what works [internet]. geneva:who publications; 2009. [cited 2021 oct]. available from: https://www.who.int/dietphysicalactivity/summaryreport-09.pdf 12. nutrition programs. health education program for developing communities (hepfdc) [internet]. [cited 2021 sept]. available from: https://hepfdc.org/nutrition-programs/ 13. the lancet commission. food in the anthropocene: the eat–lancet commission on healthy diets from sustainable food systems. lancet. 2019. available from: https://www.thelancet.com/commissions/eat 14. o’neill dw, snodderly b, editors. all creation groans: toward a theology of disease and global health. eugene, oregon: pickwick publications; 2021. available from: https://wipfandstock.com/9781725290112/allcreation-groans/ 15. lankester t, grills nj, editors. setting up community health programmes in lowand middle-income settings. 4th ed. oxford university press, 2021. available open access from: https://oxfordmedicine.com/view/10.1093/med/97801 98806653.001.0001/med-9780198806653 16. dalrymple t. beyond poverty-multiplying sustainable community development. littleton, co: william carey publishing; 2021:80129. available from: https://missionbooks.org/products/beyond-poverty about:blank about:blank about:blank https://www.oikoumene.org/resources/publications/health-promoting-churches https://www.oikoumene.org/resources/publications/health-promoting-churches about:blank about:blank about:blank https://www.oikoumene.org/resources/publications/health-promoting-churches-volume-ii https://www.oikoumene.org/resources/publications/health-promoting-churches-volume-ii https://www.bpghm.org/health_topics/christian-contributions-to-international-standards-guidelines-isgs/ https://www.bpghm.org/health_topics/christian-contributions-to-international-standards-guidelines-isgs/ https://www.bpghm.org/health_topics/christian-contributions-to-international-standards-guidelines-isgs/ https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/webthe_quest_for_health_and_wholeness.pdf https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/webthe_quest_for_health_and_wholeness.pdf https://difaem.de/fileadmin/dokumente/publikationen/dokumente_aerztliche_mission/webthe_quest_for_health_and_wholeness.pdf about:blank about:blank https://www.who.int/whr/2008/whr08_en.pdf about:blank about:blank about:blank http://apps.who.int/iris/bitstream/handle/10665/43884/9789241596626_eng.pdf;jsessionid=a15242c3bd8d2e3e398075adcda8e9ed?sequence=1 http://apps.who.int/iris/bitstream/handle/10665/43884/9789241596626_eng.pdf;jsessionid=a15242c3bd8d2e3e398075adcda8e9ed?sequence=1 http://apps.who.int/iris/bitstream/handle/10665/43884/9789241596626_eng.pdf;jsessionid=a15242c3bd8d2e3e398075adcda8e9ed?sequence=1 https://doi.org/10.1016/s0140-6736(08)61376-8 about:blank about:blank about:blank https://www.bpghm.org/health_topics/nursing/ https://apps.who.int/iris/handle/10665/145714 about:blank https://www.bpghm.org/health_topics/health-promotion-education/ https://www.bpghm.org/health_topics/health-promotion-education/ about:blank about:blank https://www.who.int/dietphysicalactivity/summary-report-09.pdf https://www.who.int/dietphysicalactivity/summary-report-09.pdf about:blank about:blank https://hepfdc.org/nutrition-programs/ about:blank about:blank about:blank https://www.thelancet.com/commissions/eat about:blank about:blank about:blank https://wipfandstock.com/9781725290112/all-creation-groans/ https://wipfandstock.com/9781725290112/all-creation-groans/ about:blank about:blank about:blank https://oxfordmedicine.com/view/10.1093/med/9780198806653.001.0001/med-9780198806653 https://oxfordmedicine.com/view/10.1093/med/9780198806653.001.0001/med-9780198806653 about:blank about:blank https://missionbooks.org/products/beyond-poverty 40 gorske dec 2021. christian journal for global health 8(2) 17. allen ea. the church for whole person healing. wholistic screening & education activities in church health fairs [internet]. [cited 2021 sept]. available from: https://faithandhealth.files.wordpress.com/2017/01/wh olistic-screening-and-education-activities-in-churchhealth-fairs1.pdf 18. yorgin p. resources. church-based health screening and education fairs around the world. [cited 2021 oct]. available from: https://www.medicalmissions.com/resources/4082/ch urch-based-health-screening-and-education-fairsaround-the-world 19. system 3: che&s. church/community health fairs. health education program for developing communities (hepfdc) [internet]. [cited 2021 oct]. available from: https://hepfdc.org/pdfviewer/system3-ches-church-community-healthfairs/#page=&zoom=&pagemode=none 20. bpghm. health topics. best practices in global health missions [internet]. [cited 2021 oct]. available from: https://www.bpghm.org/health-topics/ 21. bpghm. the church & healthcare. best practices in global health missions [internet]. cited 2021 oct. available from: https://www.bpghm.org/health_topics/church-andhealthcare/ 22. nieuwhof c. 7 ways to grow the church by increasing engagement [internet blog] 102. [cited 2021 oct]. available from: https://careynieuwhof.com/7-waysgrow-church-attendance-increasing-engagement/ 23. list of christian denominations by number of members. wikipedia, the free encyclopedia. [cited 2021 oct]. available from: https://en.wikipedia.org/wiki/list_of_christian_deno minations_by_number_of_members 24. johnson tm; grim bj, editors. “all religions [global totals].” world religion database. leiden, boston: brill, boston university; 2021 [cited 2021 oct]. available from: https://worldreligiondatabase.org/ submitted 25 oct 2021, accepted 27 oct 2021, published 27 dec 2021 competing interests: none declared. acknowledgements: i wish to thank the following for their contributions to this review: pastor mark dahle, daniel dugan phd, robert ellwood phd, nathan grills md, vicki hesterman phd, judith lasker phd, elenore lugo rn, michael mclaughlin mdiv, jason paltzer phd, john payne md, laura smelter md, grace tazelaar rn, and peter yorgin md. correspondence: arnold l gorske, standards of excellence in healthcare missions; health education program for developing countries (hepfdc.org), usa. arnoldgorske@gmail.com cite this article as: gorske al. health-promoting churches. reflections on health and healing for churches on commemorative world health days, by mwai makoka. vol. 1, 2020; vol.2, 2021. christ j global health. december 2021; 8(2):36-40. https://doi.org/10.15566/cjgh.v8i2.591 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank https://faithandhealth.files.wordpress.com/2017/01/wholistic-screening-and-education-activities-in-church-health-fairs1.pdf https://faithandhealth.files.wordpress.com/2017/01/wholistic-screening-and-education-activities-in-church-health-fairs1.pdf https://faithandhealth.files.wordpress.com/2017/01/wholistic-screening-and-education-activities-in-church-health-fairs1.pdf about:blank about:blank https://www.medicalmissions.com/resources/4082/church-based-health-screening-and-education-fairs-around-the-world https://www.medicalmissions.com/resources/4082/church-based-health-screening-and-education-fairs-around-the-world https://www.medicalmissions.com/resources/4082/church-based-health-screening-and-education-fairs-around-the-world about:blank#page=&zoom=&pagemode=none about:blank#page=&zoom=&pagemode=none about:blank#page=&zoom=&pagemode=none https://hepfdc.org/pdfviewer/system-3-ches-church-community-health-fairs/#page=&zoom=&pagemode=none https://hepfdc.org/pdfviewer/system-3-ches-church-community-health-fairs/#page=&zoom=&pagemode=none https://hepfdc.org/pdfviewer/system-3-ches-church-community-health-fairs/#page=&zoom=&pagemode=none about:blank about:blank https://www.bpghm.org/health-topics/ about:blank about:blank about:blank https://www.bpghm.org/health_topics/church-and-healthcare/ https://www.bpghm.org/health_topics/church-and-healthcare/ about:blank about:blank https://careynieuwhof.com/7-ways-grow-church-attendance-increasing-engagement/ https://careynieuwhof.com/7-ways-grow-church-attendance-increasing-engagement/ about:blank about:blank https://en.wikipedia.org/wiki/list_of_christian_denominations_by_number_of_members https://en.wikipedia.org/wiki/list_of_christian_denominations_by_number_of_members https://worldreligiondatabase.org/ mailto:arnoldgorske@gmail.com about:blank about:blank https://doi.org/10.15566/cjgh.v8i2.591 http://creativecommons.org/licenses/by/4.0/ commentary july 2021. christian journal for global health 8(1) the impact of covid-19 on church gatherings in the philippines: a policy analysis grace zurielle malolosa, joseph christian obnialb, rena mallillinc, pamela bianca pascoa, erika onga, arianne andesd, faith ann apate, emma teresa carmela aportaderab, rafael valenciaf and don eliseo iii lucero-prisnog a college of medicine, university of the philippines manila, manila, philippines b faculty of medicine and surgery, university of santo tomas, manila, philippines c ateneo de manila university school of medicine and public health, pasig city, philippines d jonelta foundation school of medicine, university of perpetual help rizal, las piñas city, philippines e matias h. aznar memorial, college of medicine, cebu city, philippines f university of the philippines diliman g department of global health and development, london school of hygiene and tropical medicine, london, united kingdom abstract the philippines is the largest christian-majority country in asia. with church gatherings playing a vital role in the nature of christianity in the filipino culture, the advent of the coronavirus disease (covid-19) pandemic in the philippines posed challenges to public religious practices amid efforts to mitigate covid-19 community transmission. various policy pronouncements from both the government-led interagency task force (iatf) on emerging diseases and the church-led catholic bishops’ conference of the philippines (cbcp) were issued. these guidelines were implemented in order to address the two-pronged problem on healthcare and religious obligations. while these guidelines were initially contributory to the mitigation of disease transmission, varied compliance by filipinos was observed through the progression of the pandemic. considering the value that church gatherings and religion play in the lives of the filipino people, further studies on covid-19 transmission in the church should be conducted in order to develop more efficient policies and guidelines on the practice of religion, particularly for religious gatherings. furthermore, a more synergistic state and church cooperation must be encouraged in order to arrive at solutions that will mutually address the concomitant problems of the covid-19 pandemic. key words: covid-19, philippines, policy analysis, state and church cooperation 54 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) introduction the first confirmed cases of the coronavirus disease (covid-19) in the philippines were in january 2020.1 in the following months, the numbers escalated, rising second only to indonesia in the southeast asian region, with 1,006,428 confirmed cases by april 26, 2021.2 the continuous rise in the number of cases and the swift escalation of the pandemic prompted the philippine government to enact sweeping measures to curtail the spread of covid-19. by march 2020, community transmission was already evident, and the government announced community quarantine, or the lockdown of the national capital region (ncr) and its surrounding provinces. the community quarantine restrictions resulted in the prohibition of many social activities, including religious gatherings. with the philippines being a largely catholic country comprising 79.5 percent of its religious and christian affiliation, restrictions on religious gatherings dealt a heavy blow to a large aspect of filipino life.3 in a survey conducted in december 2019, 83 percent of adult filipino catholics surveyed regarded religion as very important to their lives, with 45 percent of the total respondents reporting to have attended religious services weekly.4 even with an ongoing pandemic, 62 percent of respondents in a survey in may 2020 still want church gatherings to resume in areas under community quarantine.5 therefore, it is imperative to review the policies instituted by both the government and church authorities during the pandemic and examine the response of the filipino devout regarding their practice of religion amidst this global health crisis. the practice of faith in the philippines religion is central to the lives of filipinos, as the philippines ranks fifth among the most religious countries globally.6 with over 79.5 percent of its population baptized as catholics, it is the largest catholic nation in asia. a comparison of crossnational trends in religious service attendance among various countries indicated that the philippines has a high and stable religious service attendance, with attendance rates of catholic church members reaching 84 percent and 80 percent during the late 1990s and early 2000s, respectively.7 faith plays a pivotal role in the life of most filipinos, existing not only as an abstract belief system but also as a host of ceremonies, rituals, and experiences. religion provides continuity in life, cohesion in the community, and moral purpose for existence.8 it renders spiritual solace and guidance in times of crisis, more so in the midst of a global pandemic.9 even among the filipino diaspora, the church remains vital in shaping migrant populations. for them, it functions as a means of social control, a center of collective identity, and a source of empowerment.10 government guidelines and policies on religious gatherings the philippine government responded by calling together the inter-agency task force on emerging diseases (iatf), headed by the secretary of the philippine department of health. upon its recommendation, ncr was placed under “stringent social distancing measures” on march 12, 2020.11 on march 16, 2020, a state of calamity was declared throughout the philippines, and enhanced community quarantine (ecq) was imposed in luzon with only essential services allowed to operate (e.g., groceries, utilities, etc.). as far as religious activities were concerned, religious ministers were only allowed to conduct funeral rites.11 quarantine guidelines were modified and further consolidated with subsequent meetings of the iatf, summarized in table 1. on april 29, 2020, the first version of the omnibus guidelines on the implementation of community quarantine in the philippines was released to “harmonize and codify the existing policies.”12 mass gatherings, with 55 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) explicit mention of religious gatherings, were prohibited for areas under ecq and the less stringent general community quarantine (gcq).12 on may 15, 2020, the conduct of gcq was modified further, and additional guidelines were issued for two more quarantine classifications—the modified enhanced community quarantine (mecq) and modified general community quarantine (mgcq).13 for mecq, religious gatherings would be allowed but were limited to not more than five persons, and only 50 percent of the seating capacity of the church was permitted for mgcq.13 meanwhile, gcq restrictions were loosened to not more than 10 persons allowed at religious gatherings. table 1. the four levels of quarantine in the philippines, from most stringent to the least. category restrictions on religious gatherings ecq religious gatherings are prohibited only funeral rites allowed mecq may 15, 2020 not more than five persons allowed per religious gathering apr 12, 2021 until 10% seating capacity, with local government units (lgus) having the power to prohibit or increase it until 30% gcq may 1, 2020 same restrictions as ecq on religious gatherings may 15, 2020 not more than 10 persons per gathering july 2, 2020 until 10% seating capacity or 10 persons october 22, 2020 until 30% seating capacity february 15, 2021 until 50% of the venue capacity march 22, 2021 religious gatherings are prohibited weddings, baptisms, funerals are limited to 10 persons mgcq 50% of church seating capacity permitted note: *the specific guidelines under each classification may change as the government sometimes revises policy. on july 2, 2020, restrictions on religious gatherings under gcq were relaxed to allow up to 10 percent of the seating capacity (or 10 people, whichever is higher). churches were also officially allowed to reopen in july 2020 under the assumption that churches will only be used for the sole purpose of religious services. concomitantly, churches were required to observe minimum public health standards, such as social distancing protocols and the use of face masks, in conducting gatherings within their premises.14 on october 22, 2020, restrictions were further relaxed to allow up to 30 percent of the seating capacity.15 additional provisions were added to the iatf guidelines by december 2020, requiring the use of face shields when leaving residences, including going to church.16 starting february 15, 2021, the government permitted churches under gcq to operate at up to 50 percent seating capacity, just two days before ash wednesday, which signals the beginning of the lenten season.17 however, on march 22, 2021, a few days before the beginning of holy week, the government completely prohibited religious gatherings due to a surge in active covid19 cases.18-20 56 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) with mixed reactions by catholic and protestant religious leaders,21,22 the government conceded to permit religious gatherings once a day at 10 percent seating capacity by march 26, 2021.23 however, this decision was retracted the following day when metro manila, along with some of its surrounding provinces, was placed under ecq for the entirety of the holy week 2021.24 beyond the imposition of guidelines, the national government and the local government units (lgus) have also consistently worked with church officials to ensure proper maintenance of health protocols upon the resumption of regular church activity. lgus created technical working groups to coordinate plans for large religious festivities. members of the police were routinely dispatched during religious gatherings with traditionally high public turnout, such as masses during christmas season.25,26 the department of health periodically releases statements and directives to guide lgus in the conduct of religious celebrations, such as orders for attendees to fill up contact tracing forms and the performance of regular temperature checks.27 guidelines of the religious leadership on religious gatherings the catholic church largely responded by following the guidelines of the iatf, such as shifting worship to online platforms and limiting church capacity. individual dioceses were the first to take initiatives in suspending masses at the start of the pandemic before guidelines were instituted by the catholic bishops’ conference of the philippines (cbcp).28 the cbcp subsequently released their own guidelines in response to government and health regulations.29 the primary modification of live activities was through televising and online streaming of most church services.28,29 the cbcp further elaborated on guidelines upon the easing of community quarantine, such as the use of thermal scanners, foot baths, and hand sanitizers. it gave instructions on proper entrance and exit areas and social distancing with markers on pews and standing areas. attendees were required to use face masks during church services.30 mass practices were also modified, such as the omission of the offertory procession and the strict implementation of receiving the host by the hand and not directly to the mouth. some parishes offered drive-in masses to avoid public crowding in their church and developed mobile phone applications for use by its parishioners.31,32 certain catholic traditions and practices in the philippines were also modified. at the start of community quarantine in march 2020, the cbcp published instructions for holy week celebrations to be held in the same month.33 the blessing of palms on palm sunday was suspended and replaced by verbal blessings around the streets of the parish. similarly, simbang gabi or night mass, a nine-day series of masses culminating in christmas eve, usually held between 3 a.m. to 5 a.m., were permitted to be held as early as 6:00 p.m. in response to curfew hours mandated by lgus.34 in addition, church officials encouraged holding masses more frequently in order to properly distribute the number of attendees.34 along with traditional practices in the philippines, various catholic religious festivals are held in different parts of the country. numerous modifications were also instituted to conduct these festivities. for one, the philippines is celebrating 500 years of christianity in 2021, initially planned to be a large affair. however, with the pandemic stretching into 2021, the quincentennial anniversary will now be a year-long celebration, beginning april 2021, and with grand culminating activities postponed for april 2022.35 some festival events were initially allowed, but because of local spikes in active covid-19 cases, all of the festival’s physical activities, with the exception of masses, were cancelled.36-38 perhaps one of the most significant changes to religious festivities is the modification of the feast of the black nazarene held every january. 57 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) traslacion, the yearly 6-kilometer procession of the image of the black nazarene around manila, was cancelled. instead, consecutive masses were held within quiapo church, limiting each mass to only 400 participants, or 30 percent of the church’s capacity, in line with the guidelines.39,40 in addition, simultaneous novena masses were held in numerous parishes within metro manila to accommodate more distant devotees. the tradition of kissing the black nazarene image by devotees, or pahalik, was also prohibited.40 in lieu of this practice, the black nazarene was placed in front of the church for viewing by the public. sanitation efforts were also performed by church volunteers before every new batch of devotees could occupy the viewing areas.40 impacts of covid-19 on other christian denominations in the philippines other prominent christian denominations in the philippines include the evangelicals, represented by the philippine council of evangelical churches (pcec) and the iglesia ni cristo (inc), comprising 2.4 and 2.6 percent of the population, respectively. although the inc initially planned to allow their gatherings despite government guidelines,41 they now utilize online streaming in areas with sufficient internet access and conduct household worship services in areas with relatively limited connectivity.42 the evangelicals responded to the government guidelines in a similar way by conducting online streaming of their religious services and requiring the observation of minimum public health standards.43 pre-registrations were also employed for the purpose of initial health screening and ensuring seating capacity compliance.44,45 biannual prayer and fasting traditions by some evangelical churches were also moved online, with the provision of prayer and fasting guides and virtual prayer rooms to enable fellowship among their religious members.45,46 compliance and reception of filipinos to church gathering policies a survey released in september 2020 by pulse asia’s ulat ng bayan revealed that among 1200 respondents around the philippines, 51.8 percent have become more religious during the covid-19 pandemic. this provides a glimpse of the value of christian faith to the filipino in times of crisis.47 while the pandemic has limited religious gatherings in the philippines, it has transformed the christian devotion of many filipinos from being reliant on external practices to internal reflection.48 contrary to other countries, where outbreaks have happened as a result of religious activities,49 initial covid-19 outbreak reports in the philippines noted clusters resulted from social events, such as wakes or birthday parties.50 in august 2020, reports on covid-19 transmission in the philippines were primarily healthcare facility-, prison-, or workplacebased.51 the strict lockdown instituted at the start of the pandemic contributed largely to the adherence of the filipinos on policies regarding church gatherings. due to the fact that the parishes themselves were prohibited from opening their church to live masses, the public was compelled to adapt to by attending live streamed masses at their own homes. filipinos also complied with modifications of other religious traditions, especially during the lenten season, observed at the height of the community lockdown. along with online masses, videos by devotees shared ways on how to observe the season at home, such as instructions on making homemade palm crosses from palm fronds and makeshift altars.52 instead of gathering outside their homes for the blessing of the palm fronds on palm sunday, parishioners opted to set up the fronds on tables in the streets for the blessing of the priest going around the neighborhood.53 public novenas during lent, or pasyon, usually initiated by devotees in their backyards, were put on hold and were instead conducted privately within 58 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) homes. some even used powerpoint presentations to conduct certain prayers, such as the way of the cross or via crucis. however, despite guidelines prohibiting any form of public or religious gathering, holy week rituals such as self-flagellation on good friday were still initiated by devotees and were done publicly outside closed churches.54 relaxation of guidelines were eventually observed for the remainder of 2020, consequently resulting in church gatherings being permitted during the christmas season.55 multiple reports state that the public and their respective parishes were compliant with the guidelines instituted by the government and the cbcp. observations by authorities in southern metro manila showed orderly and peaceful night masses, with proper social distancing. however, mass turnouts were still high despite the pandemic,17 resulting in some parishes becoming over-crowded.18 similar to religious holiday traditions and practices, the celebration of religious festivals also posed an additional threat to the mitigation of covid-19 in the philippines. the most important of these is the feast of the black nazarene held on january 9, 2021. public turnout was still heavy, with an estimated 400,000 people attending, despite multiple warnings of the activity being a potential super-spreader event.56-58 nonetheless, this was significantly lower than annual numbers, as this procession draws in millions of devotees each year, which may signify that a large majority of filipino catholics adhere to the restrictions and are wary of the dangers of the pandemic. even among attendees, strict social distancing measures were implemented, and photos of the crowds show that devotees were largely compliant, standing at least 1-meter apart from each other.57,58 state and church cooperation in the time of the covid-19 pandemic with the advent of the covid-19 pandemic in the philippines, both the state and the church responded through the near-simultaneous implementation of iatf and cbcp guidelines on religious gatherings. in addition, both sectors appeared to be cooperative with each other, evidenced by their coordinated mitigation efforts during high-volume events. at face value, guidelines on religious gatherings were adequately complied with by filipinos. however, the philippine government’s general covid-19 response was met with the disapproval of 53.7 percent of filipino respondents of the state of southeast asia: 2021 survey,59 prompting questions on its effectiveness and in consistently mitigating the spread of covid19. despite not being primarily attributed to religious gatherings,50 covid-19 transmission in the philippines saw notable fluctuations during the christmas season and the start of the year,60,61 during which church gatherings were of heightened importance. this was observed with an increase in the reproductive number or r0, from 1.06 to 1.15 in metro manila two weeks before christmas.60,61 even at the start of the new year in 2021, upward trends were reported with increases in r0 to 1.17.61 these numbers did not significantly go down as the r0 in ncr peaked at 2.21 by march 23, 2021, just a few days before the celebration of holy week.62 given this, it can be surmised that while these guidelines appear to be contributory to covid-19 mitigation in the philippines, its impact with regards to major religious celebrations remains debatable. likewise, the effect of major religious celebrations in spreading the virus is still unknown. the lack of available data on religious gatherings during the covid-19 pandemic limits the understanding of these on conjectures and unverified correlations. hence, further studies on covid-19 transmissions in the setting of religious gatherings, as well as on the effectiveness of present guidelines must be done in order to develop evidence-based and specific guidelines on religious gatherings. what remains certain is that with the importance and the fundamental role of religion to 59 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) filipinos, a more proactive approach must be taken in order to more adequately address the impact of covid-19 on religious gatherings. through open communication and meaningful collaboration among the church, the state, and the general public, all factors can be adequately addressed. effective monitoring and evaluation can identify points of improvement and ensure a more effective response. with its aforementioned value to filipinos, and its societal, cultural, and traditional roots, future guidelines and policies must also take church gatherings and religion into major consideration. the pandemic has shown that mutual cooperation between the government and religious institutions has been beneficial to everyone in this time of emergency; since, ultimately, their constituents are one and the same, the general public.63 this is evident in other countries that were able to demonstrate it is possible for religion and the government to cooperate, such as in germany and in neighboring vietnam.63,64 while the philippine constitution states that the separation of the state and church must be inviolable, it is evident that the two must work together in mitigating the covid-19 community transmission and its concomitant problems, highlighting the importance of a multisectoral approach to healthcare. conclusion the high percentage of people expected to observe church services and religious practices despite the pandemic has demonstrated the deepseated nature of religion in filipino culture. with the importance given to consistent church attendance by filipinos, it is recommended that further studies on covid-19 transmission in the church be done to further develop more specific guidelines in line with religious practices. ultimately, a multisectoral and collaborative approach must be taken in addressing the concomitant problems of the covid-19 pandemic. references 1. edrada em, lopez eb, villarama jb, salva villarama ep, dagoc bf, smith c, et al. first covid-19 infections in the philippines: a case report. trop med health. 2020;48(1):21. http://doi.org/10.1186/s41182-020-00203-0 2. department of health. beat covid-19 today: a covid-19 philippine situationer. report no.: issue 265. [internet]. philippines: department of health. 2021 [updated 2021 apr 27] [cited 2021 apr 28]. available from: https://doh.gov.ph/2019-ncov 3. 2019 philippine statistical yearbook [internet]. 2019 oct [cited 2020 dec 29]. available from: https://psa.gov.ph/sites/default/files/2019psy_1003.pdf 4. social weather stations | fourth quarter 2019 social weather survey: record-high 83% of adult filipinos say religion is “very important.” [cited 2021 feb 2] available from: http://www.sws.org.ph/swsmain/artcldisppage/?artcsy scode=art-20200412155426 5. patinio f. more pinoys want masses resumed amid quarantine: church survey [internet]. philippine news agency. 2020 may 19 [cited 2020 dec 29]. available from: https://www.pna.gov.ph/articles/1103300 6. merez a. ph among world’s most religious countries: study [internet]. abs-cbn news. 2018 may 9 [cited 2020 dec 29]. available from: https://news.abscbn.com/news/05/09/18/ph-among-worlds-mostreligious-countries-study 7. brenner p. cross-national trends in religious service attendance. publ opin q. 2016;80(2):563-83. https://doi.org/10.1093/poq/nfw016 8. dolan r. philippines: a country study [internet]. country studies. 1991 [cited 2020 dec 29]. available from: http://countrystudies.us/philippines/ 9. yee v. in a pandemic, religion can be a balm and a risk. new york times. 2020 mar 22 [cited 2021 apr 23]. available from: https://www.nytimes.com/2020/03/22/world/middleea st/coronavirus-religion.html 10. fresnoza-flot a. the catholic church in the lives of irregular migrant filipinas in france: identity formation, empowerment and social control. asia pac j anthropol. 2010;11(3-4):345-61. http://doi.org/10.1080/14442213.2010.511628 about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 60 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) 11. resolutions relative to the management of the coronavirus diseases 2019 (covid19) situation [internet]. [resolution no. 11; series of 2020]. 2020 march 12 [cited 2020 dec 29]. available from: https://doh.gov.ph/sites/default/files/healthupdate/iatf-reso-11.pdf 12. omnibus guidelines on the implementation of community quarantine in the philippines [internet]. presidential communications operations office. 2020 apr 29 [cited 2020 dec 29]. available from: https://pcoo.gov.ph/wpcontent/uploads/2020/05/omnibus-guidelines-on-theimplementation-of-community-quarantine-in-thephilippines.pdf 13. omnibus guidelines on the implementation of community quarantine in the philippines [internet]. 2020 may 15 [cited 2020 dec 29]. available from: https://pcoo.gov.ph/wpcontent/uploads/2020/05/omnibus_guidelines.pdf 14. inter-agency task force for the management of emerging infectious disease resolution [internet]. 2020 july 2 [cited 2020 dec 19];51. available from: https://pcoo.gov.ph/wpcontent/uploads/2020/07/iatf_res.no_.51.pdf 15. inter-agency task force for the management of emerging infectious disease resolution [internet]. 2020 oct 22 [cited 2020 dec 29];80. available from: https://pcoo.gov.ph/wpcontent/uploads/2020/10/iatf-resolution-no.-80.pdf 16. inter-agency task force for the management of emerging infectious disease resolution [internet]. 2020 dec 14 [cited 2020 dec 29];88. available from: https://www.officialgazette.gov.ph/downloads/2020/1 2dec/20201214-iatf-resolution-88-rrd.pdf 17. religious gatherings under gcq relaxed, allowed up to 50% seating capacity starting february 15 – presidential communications operations office [internet]. [cited 2021 may 15]. available from: https://pcoo.gov.ph/news_releases/religiousgatherings-under-gcq-relaxed-allowed-up-to-50seating-capacity-starting-february-15/ 18. inter-agency task force for the management of emerging infectious disease resolution [internet]. 2021 oct 20 [cited 2021 may 10];104. available from: http://www.exteriores.gob.es/consulados/manila/e s/consulado/documents/iatf%20resolution%20104 .%20march%2020%202021.pdf 19. talabong r. ph restricts cross-border travel, mass gatherings in ncr, 4 provinces. rappler [internet]. 2021 mar 21 [cited 2021 apr 27]. available from: https://www.rappler.com/nation/duterte-gcq-metromanila-bulacan-cavite-laguna-rizal-march-2021 20. ranada p, tomacruz s. stricter gcq, ‘ncr plus’ bubble explained. rappler [internet]. 2021 mar 22 [cited2021 apr 27]. available from: https://www.rappler.com/nation/manila-archdiocesedefy-government-ban-holy-week-gatherings-2021 21. esmaquel er. archdiocese of manila to defy government ban on holy week gatherings. rappler [internet]. published march 23, 2021. accessed april 27, 2021. available from: https://www.rappler.com/nation/manila-archdiocesedefy-government-ban-holy-week-gatherings-2021 22. dagle rm. ‘unjust, inconsistent’: protestant churches hit ‘ncr plus’ religious gathering ban. rappler [internet]. 2021 mar 25 [cited apr 27]. available from: https://www.rappler.com/nation/protestantchurches-hit-ncr-plus-religious-gathering-ban 23. ranada p. gov’t allows ‘once a day’ religious gatherings from april 1 to 4. rappler [internet]. 2021 mar 26 [cited 2021 apr 27]. available from: https://www.rappler.com/nation/govt-allows-once-aday-religious-gatherings-from-april-1-to-4 24. cnn philippines staff. metro manila, four provinces shift to stricter ecq for one week. cnn philippines [internet]. 2021 mar 27 [cited 2021 apr 27]. available from: https://cnnphilippines.com/news/2021/3/27/ecq2021-ncr-plus-bubble.html 25. filipinos flock to churches for ‘simbang gabi’ to pray for covid-19 deliverance. inquirer.net. 2020 dec 16 [cited 2021 jan 29]. available from: https://newsinfo.inquirer.net/1372409/filipinos-flockto-churches-for-simbang-gabi-to-pray-for-covid-19deliverance 26. rita j. simbang gabi attendees fail to keep distancing rule in some cebu parishes. gma news online. 2020 dec 16 [cited 2021 jan 29]. available from: https://www.gmanetwork.com/news/news/regions/768 185/simbang-gabi-attendees-fail-to-keep-distancingrule-in-some-cebu-churches/story/ about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 61 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) 27. joint statement on preventing a post-holiday surge [internet]. department of health. 2020 dec 17 [cited 2021 feb 2]. available from: https://doh.gov.ph/press-release/joint-statement-onpreventing-a-post-holiday-surge 28. lagarde r. several dioceses suspend masses due to coronavirus [internet]. cbcp monitor. 2020 [cited 2021 feb 1].24(6). available from: https://cbcpnews.net/cbcpnews/wpcontent/uploads/2020/03/vol24-no06.pdf 29. valles r. recommendations and guidelines for the liturgical celebration in ‘new normal’ condition [internet]. cbcpnews. 2020 may 16 [cited 2020 dec29]. available from: https://cbcpnews.net/cbcpnews/liturgical-guidelinesin-new-normal-condition/ 30. del castillo fa, biana ht, joaquin jjb. churchinaction: the role of religious interventions in times of covid-19. j public health. 2020;42(3):6334. http://doi.org/10.1093/pubmed/fdaa086 31. sorote rc. leyte church offers ‘drive-in’ mass amid pandemic [internet]. cbcpnews. 2020 sept 15 [cited 2021 feb 1]. available from: https://cbcpnews.net/cbcpnews/leyte-church-offersdrive-in-mass-amid-pandemic/ 32. quiapo church goes mobile to reach out devotees [internet]. cbcpnews. 2020 oct 20 [cited 2021 feb 2]. available from: https://cbcpnews.net/cbcpnews/quiapo-church-gomobile-to-reach-out-devotees/ 33. valles r. circular no. 20-15, re: recommendations for the celebrations of the holy week during the quarantine period [internet]. 2020 mar 20 [cited 2020 dec 29]. available from: https://cbcpnews.net/cbcpnews/recommendations-forthe-celebrations-of-the-holy-week-during-thequarantine-period-2020/ 34. valles r. instructions on the celebration of aguinaldo masses, misa de gallo or simbang gabi [internet]. cbcpnews. 2020 nov 27. available from: https://cbcpnews.net/cbcpnews/instructions-on-thecelebration-of-aguinaldo-masses-misa-de-gallo-orsimbang-gabi/ 35. leslie a. covid-19 forces bishops to postpone quincentennial celebration of christianity in ph. manila bulletin. 2020 sept 24 [cited 2021 feb 1]. available from: https://mb.com.ph/2020/09/24/covid19-forces-bishops-to-postpone-quincentennialcelebration-of-christianity-in-ph/ 36. major sinulog activities in cebu cancelled over coronavirus [internet]. cbcpnews. 2020 nov 10 [cited 2021 feb 2]. available from: https://cbcpnews.net/cbcpnews/major-sinulogactivities-in-cebu-cancelled-over-coronavirus/ 37. macasero r. after cancellation of physical events, virtual sinulog postponed too [internet]. rappler. 2021 jan 9 [cited 2021 jan 29]. available from: https://www.rappler.com/nation/visayas/virtualsinulog-2021-postponed 38. national youth day postponed to 2022 [internet]. cbcpnews. 2020 dec 18 [cited 2021 feb 2]. available from: https://cbcpnews.net/cbcpnews/national-youth-daypostponed-to-2022/ 39. only 400 persons per mass allowed in quiapo church on nazarene feast. cbcpnews [internet]. 2021 jan 6 [cited 2021 feb 2]. available from: https://cbcpnews.net/cbcpnews/only-400-persons-permass-allowed-in-quiapo-church-on-nazarene-feast/ 40. ongcal a. how covid affected one of the largest catholic processions in the world [internet]. 2021 jan 11 [cited 2021 feb 2]. available from: https://www.vice.com/en/article/88avwz/blacknazarene-traslacion-2021-procession-religioncatholic-philippines-pandemic-covid-coronavirus 41. manlupig k. sara duterte warns iglesia ni cristo: violate quarantine, face suit [internet]. inquirer.net. 2020 mar [cited 2021 apr 22]. available from: https://newsinfo.inquirer.net/1243063/sara-dutertewarns-inc-violate-quarantine-face-suit 42. iglesia ni cristo overcomes pandemic threat to distance people of faith from god [internet]. accesswire. 2021 jan 5 [cited 2021 apr 22]. available from: https://www.accesswire.com/624487/iglesia-nicristo-overcomes-pandemic-threat-to-distancepeople-of-faith-from-god 43. gavilan j. list: online masses, services by religious groups amid coronavirus [internet]. rappler. 2020 apr 1 [cited 2021 apr 22]. https://www.rappler.com/nation/list-online-massesservices-religious-groups-amid-coronavirus about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 62 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) 44. we are resuming our onsite worship services in metro manila! [internet]. victory honor god. make disciples. 2020 [cited 2021 may 15]. available from: https://victory.org.ph/we-are-resuming-our-onsiteworship-services-in-metro-manila/ 45. intercede [internet]. christ’s commission fellowship. [cited 2021 may 15]. available from: https://www.ccf.org.ph/intercede/ 46. awesome god prayer & fasting [internet]. victory honor god. make disciples. [cited 2021 may 15]. available from: https://victory.org.ph/fasting2021/ 47. cornelio j. [analysis] are filipinos more religious because of covid-19 [internet]? rappler. 2020 oct 23 [cited 2021 apr 23]. available from: www.rappler.com/voices/thought-leaders/analysisare-filipinos-more-religious-because-covid-19. 48. calleja jp. filipino faith perseveres despite pandemic restrictions [internet]. ucanews. 2020 sept 30 [cited 2021 apr 23]. available from: www.ucanews.com/news/filipino-faith-perseveresdespite-pandemic-restrictions/89718# . 49. quadri s. covid-19 and religious congregations: implications for spread of novel pathogens [internet]. int j infec dis. 2020 may 7 [cited 2021 apr 23]. available from: www.sciencedirect.com/science/article/pii/s12019712 20303131. 50. haw njl, uy j, sy ktl, abrigo mrm. epidemiological profile and transmission dynamics of covid-19 in the philippines. epidemiol infect. 2020;148. http://doi.org/10.1017/s0950268820002137 51. tomacruz s. ph coronavirus cases surge past 106,000, as doh monitors 887 clusters [internet]. rappler. 2020 aug 3 [cited 2020 dec 29]. available from: https://www.rappler.com/nation/coronaviruscases-philippines-august-3-2020 52. esmaquel pi. catholics in quarantine mark first online holy week [internet]. rappler. 2020 apr 5 [cited 2021 jan 29]. available from: https://www.rappler.com/nation/catholics-quarantineonline-holy-week-2020 53. kravchuk m. covid-19 empties churches, but holy week rites continue online. onenews.ph. [cited 2021 feb 2]. https://www.onenews.ph/covid-19-emptieschurches-but-holy-week-rites-continue-online 54. nepomuceno p. unshaken faith: observing holy week amid covid-19. 2020 apr 8 [cited 2020 jan 29]. available from: https://www.pna.gov.ph/articles/1099225 55. mongaya c. christmas in the philippines in the time of duterte and covid-19 [internet]. global voices. 2020 dec 31 [cited 2020 jan 29]. available from: https://globalvoices.org/2020/12/31/christmas-in-thephilippines-in-the-time-of-duterte-and-covid-19/ 56. doh reiterates reminder to devotees and calls on igus to monitor constituents who attend traslacion [internet]. department of health. 2021 jan 9 [cited 2021 feb 1]. available from: https://doh.gov.ph/press-release/doh-reiteratesreminder-to-devotees-and-calls-onlgus-to-monitor-constituents-whoattend-traslacion 57. gregorio x. who says rise in covid-19 cases “inevitable” after holidays [internet]. traslacion. philstar.com. 2021 jan 12 [cited 2021 feb 2]. available from: https://www.philstar.com/headlines/2021/01/12/20699 21/who-says-rise-covid-19-cases-inevitable-afterholidays-traslacion 58. portugal a, lopez e. philippines’ catholics show devotion to statue amid super-spreader worries [internet]. reuters. 2021 jan 9 [cited 2021 feb 2]. available from: https://www.reuters.com/article/ushealth-coronavirus-religion-philippiniduskbn29e03b 59. seah s, ha ht, martinus m, thao pt . the state of southeast asia: 2021 [internet]. iseas-yusof ishak institute, singapore. 2021 feb 2 [cited 2021 apr 27]. available from: https://iseas.edu.sg/wpcontent/uploads/2021/01/the-state-of-sea-2021v2.pdf 60. metro manila covid-19 surge begins ahead of christmas: octa research [internet]. abs-cbn. 2020 dec 22 [cited 2021 feb 1]. available from: https://news.abs-cbn.com/news/12/22/20/metromanila-covid-19-surge-begins-ahead-of-christmasocta-research 61. galvez d. research team marks ‘clear upward trend’ of covid-19 cases in ncr [internet]. inquirer.net. 2021 jan 12 [cited 2021 feb 2]. available from: https://newsinfo.inquirer.net/1382791/research-teammarks-clear-upward-trend-of-covid-19-cases-in-ncr about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 63 malolos, obnial, mallillin, et al. july 2021. christian journal for global health 8(1) 62. hallare k. octa research: covid-19 cases ‘unlikely’ to go down in 2 weeks [internet]. inquirer. net. 2021 mar 23 [cited 2021 may 2]. available from: https://cnnphilippines.com/news/2021/3/27/ecq2021-ncr-plus-bubble.html 63. berkmann bj. the covid-19 crisis and religious freedom. j law, relig, state. 2020;8(2-3):179-200. http://doi.org/10.1163/22124810-2020013 64. phuong, nt. religion, law, state, and covid-19 in vietnam. j law, religion, state. 2020;8(2-3):284-97. peer reviewed: submitted 8 feb 2021, accepted 19 may 2021, published 30 july 2021 competing interests: none declared. correspondence: grace zurielle malolos, college of medicine, university of the philippines manila, manila, philippines. gcmalolos@up.edu.ph cite this article as: malolos gz, obnial jc, mallillin r, pasco pb, ong e, andes a, apat fa, aportadera etc, valencia r, prisno del. the impact of covid-19 on church gatherings in the philippines: a policy analysis. christian journal for global health. july 2021; 8(1):53-63. https://doi.org/10.15566/cjgh.v8i1.505 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v8i1.505 about:blank field report may 2023. christian journal for global health 10(1) strengthening very young adolescents in gender equality in bangladesh kohima daringa, nancy tenbroekb, shagota chisimc, carolyn o'briend, mona bormete, meroji sebanyf, kaitlyn slateg a ma, senior country director, world renew bangladesh b ma, senior program consultant, world renew bangladesh c mss, capacity development manager, world renew bangladesh d msph (international health), program advisor, usaid’s momentum country and global leadership, christian e mph, program director, usaid’s momentum country and global leadership, christian connections for international health f mph, adolescent and youth health specialist, usaid’s momentum country and global g m.a., director, program excellence, world renew, byron center, michigan, us key words: momentum global health, ccih, world renew, local partner faith in action, usaid introduction amena (full name withheld to protect privacy), a 15-year-old girl from a remote village in satkhira district of bangladesh, escaped a forced marriage at the age of 13 and is now continuing with her studies. she gained the confidence to say “no” to early marriage through a very young adolescent (vya) program for 10– 14-year-olds run by faith-based organizations world renew and its local partner faith in action (fia) with funding from usaid’s momentum country and global leadership project in 2021 2022. with the confidence and skills she learned through the vya program, she spoke to her parents about her concerns and dreams and garnered community support to stop her marriage. amena is among many very young adolescents who benefited from this program. satkhira district has a high prevalence of child marriage. according to the 2019 multiple indicator cluster survey (mics) in bangladesh, 42.8% of girls aged 15-19 years are married.1 the situation is similar across the country with 22% of girls getting married before the age of 15.2 bangladesh has the highest proportion of girls becoming mothers during adolescence in the world outside sub-saharan africa with 48% entering motherhood before turning 20.3 one girls’ school in the satkhira district reported 66 of 460 students were forced to marry by their parents during the covid-19 pandemic as the families lost their source of income due to lockdown imposed by the government. because of this, many of the married girls will find it difficult to return to school due to their new responsibilities. gender inequality is deeply rooted in the patriarchal social context of bangladesh where social and gender norms limit adolescent girls’ autonomy and decision making, knowledge about their reproductive health, and access to health services.4 thus, it is important to intervene early before gendered behaviors, attitudes, and norms are solidified. early adolescence is a critical window of opportunity to work with girls, families, and others who influence decision-making to shift the trajectory of the vya life course to improve gender attitudes, behaviors, and norms before firmly entrenched and improve social and emotional development and health outcomes.5 world renew living justice, loving mercy, serving christ world renew is motivated by micah 6:8 to do justice, love mercy, and walk humbly with god. this has informed their work in bangladesh since 1975 and is the motivation to work with vyas and daring, tenbroek, chisim, o'brien, bormet, sebany & slate 48 may 2023. christian journal for global health 10(1) communities to help them build capacity to experience freedom from poverty and injustices and flourish in the fullness of life. world renew bangladesh works with five local partner organizations in over 700 villages, supporting 29 people’s institutions (apex bodies of village self-help groups are the higher level leadership body above self-help groups that provide leadership at the government level) and 1,500 primary groups. world renew bangladesh works with local men, women, adolescents, and children for community engagement, leadership building, and capacity development in food security, economic opportunities, and health. world renew bangladesh helps communities develop local structures to ensure the communities can sustain gains made through the work. why strengthen the capacity of faithbased organizations? faith-based organizations (fbos) are located closest to multicultural and multireligious communities with significant access to and influence over adolescents and youth, particularly vyas. however, many fbos like world renew are not fully equipped with the knowledge, skills, and resources to promote positive health and development among vyas, their families, and their communities. world renew has ongoing projects with older adolescents but needed support with delivering tailored programming for vyas. in response to this gap, momentum country and global leadership strengthened the capacity of world renew through the network of its consortium partner, christian connections for international health (ccih) and save the children. the capacity strengthening served two strategic purposes: 1. increase the quality and reach of programming with vyas to delay pregnancy, prevent child marriage, and improve youth programing. 2. allow for the development of models and examples for how to engage the faith-based community in family-centered vya programming which can provide lessons learned and recommendations that might inform similar efforts. specific capacity building efforts include: ● increased knowledge and skill to implement evidence-based gender transformative programming with the vyas. in world renew’s former programming, older and younger adolescents are grouped together. this program helped world renew to learn how to implement separate programs with a special emphasis on vyas to bring a lasting change. ● fostered linkages with the government at all levels (local, district, and subdistrict). world renew and fia were connected with the national level adolescent health working group. ● development of gender tools and materials that can be adapted to other contexts. world renew adopted some of the choices, voices and promises (cvp) materials (e.g., domestic violence posters from promises intervention to one of its ongoing programs that addressed gender based violence (gbv)). ● learned new learning and assessment tools (l&a) that world renew is continuing to use in its ongoing programs. ● strengthened organizational capacity through the integrated technical and organizational capacity assessment (itoca) process under the technical guidance of pact which helped world renew in four areas: program planning and management, financial management, partnership and communication, and gender equitable programming. implementation of choices, voices, and promises world renew found save the children’s choices, voices, promises (cvp) approach6 49 daring, tenbroek, chisim, o'brien, bormet, sebany & slate may 2023. christian journal for global health 10(1) appropriate and adopted it with the support of momentum to promote gender equality among vyas in two unions of satkhira district. cvp is a package of interventions, which works across different groups in the community to accomplish positive social and behavior change, recognizing that behaviors and norms are influenced by both individual and social factors. the package has three distinct interventions described below including details on how each was implemented by wr: choices choices works with vya boys and girls to help them discover alternatives to conventional gender roles and behaviors. it uses a curriculum of ageand developmentally-appropriate participatory activities designed to stimulate discussion and reflection between vya girls and boys with the goal of helping them challenge restrictive norms and promote healthy behaviors. by including activities to catalyze behavior and attitude changes on dreams important to the boys and girls, choices also included specific discussions on early and forced marriage. how the intervention was implemented by world renew world renew implemented 12 choices lessons with mixed groups of vya girls and boys, reaching 301 vyas (156f/145m). world renew intentionally formed mixed groups of boys and girls so they could learn to work with the opposite gender and participate in activities together. formation of mixed groups was intentional as in the context of bangladesh bringing girls and boys together is a bit uncommon, and it takes special care and attention. for this to happen, groups were formed in close proximity where everyone knew each other and parents could oversee the activities. adult volunteers were also present along with the older adolescent facilitators. choices lessons were delivered by ten older adolescents (5m/5f) from the local community who received training and testified that their individual lives had been impacted positively by the learnings they’ve received, how it affected their status in the community and in their families by serving as teachers of the lessons. health professionals from nearby health facilities were present in the puberty session to help answer questions and also to provide linkages. the puberty lesson was conducted in sex segregated groups which were facilitated by same sex adult volunteers and health professionals to help the vyas feel more comfortable to share and ask questions. vyas learning about the benefits of working together. photo credit: shomuel sangma (september 9, 2021). voices voices works with parents/caregivers of vyas through a small group approach. audio testimonies or recorded stories from parents and community members who have adopted positive behaviors and who support gender equality in their homes are played in small groups to prompt conversation. the purpose of the voices intervention is to increase dialogue between parents/caregivers and vyas while improving gender equity within the household. how the intervention was implemented by world renew world renew used mixed groups of parents/caregivers for implementation. four local volunteers (2m/2f) facilitated six sessions that addressed: gender equitable division of household tasks, equal homework time, equal food for boys and girls, encouraging daughters as well as sons to attend school, commitment to not discuss daughters’ marriage, and equally bringing hope to girls and boys. they listened to audio testimonials, daring, tenbroek, chisim, o'brien, bormet, sebany & slate 50 may 2023. christian journal for global health 10(1) participated in discussion, and reflected on an action they can do to improve gender equity in their families. voices parents’ group listening to audio testimonials about practicing gender equitable behavior with children. photo credit: shomuel sangma (april 24, 2022). promises promises is a community-wide intervention that aims to create dialogue and shift norms around gender and social norms. in bangladesh, promises aimed to change parental behaviors regarding their vyas’ health and education. seven large posters were posted in the community to spark discussion around norms in a proactive way and included behavior change messages to encourage parents to prioritize their childrens’ health and allow their daughters to complete their education before marriage. how the intervention was implemented by world renew world renew’s program coordinator and a community facilitator (a local primary school head teacher) created a space for key community leaders to take part in a structured dialogue. parents made commitments to prioritize their adolescents’ education and health and made public pledges on a pledge board to keep their children in school through completion. promises discussion session in ramjannagar. photo credit: shomuel sangma (april 20, 2022). learning and unique role of fbos in vya gender and health interventions implementing cvp was a learning experience for world renew bangladesh and fia, and both are now equipped to expand the program with additional local partners in bangladesh. ● programming through a gender lens (in this case, boys and girls) is effective when it simultaneously impacts the individual, family, and community. cvp was designed to shift traditional gender behaviors and attitudes in all three levels which lead to the program achieving its desired goal. ● partnership with local government is key to successful implementation of a gender transformative program. their active participation and support for the intervention encouraged community members to embrace the shift in traditional gender norms and trust the changes that the program brings. ● since world renew bangladesh has long standing relationships with the community and local government entities, including health services, it was well positioned to reach a range of diverse community members and stakeholders in behavior change programming which addresses long-standing social and cultural norms. 51 daring, tenbroek, chisim, o'brien, bormet, sebany & slate may 2023. christian journal for global health 10(1) moving forward the multi-level, gender-equitable program aligns with world renew’s vision which is to change the stories of participants and renew hope. wrb is confident in the tools and is currently extending the vya work to its other partner organizations in bangladesh. learning tools are also being used in other programs, including work in gender-based violence. world renew bangladesh is grateful for the opportunity to learn and implement this evidence-based approach that reaches a vulnerable group of vyas. references 1. bangladesh bureau of statistics. statistics and informatics division (sid) ministry of planning. bangladesh statistics 2019. [internet], 2019, p. 54. available from: https://bbs.portal.gov.bd/sites/default/files/files/bb s.portal.gov.bd/page/a1d32f13_8553_44f1_92e6_ 8ff80a4ff82e/2020-05-15-09-25dccb5193f34eb8e9ed1780511e55c2cf.pdf 2. child marriage atlas. girls not brides. england and wales; c2022-2023 [internet]. [cited 2023 april 4]. available from: https://www.girlsnotbrides.org/learningresources/child-marriage-atlas/atlas/bangladesh 3. unfpa. motherhood in childhood: the untold story [internet]. 2022 june 27. available from: https://www.unfpa.org/publications/motherhoodchildhood-untold-story 4. ainul s, bajracharya a, reichenbach l, gillesk. adolescents in bangladesh: a situation analysis of programmatic approaches to sexual and reproductive health education and services [internet] [situation analysis report]. washington, dc and dhaka: population council, the evidence project; 2017 https://doi.org/10.31899/rh7.1004 available from: https://knowledgecommons.popcouncil.org/depart ments_sbsr-rh/578/ 5. woog v, kågesten a. the sexual and reproductive health needs of very young adolescents aged 10-14 in developing countries: what does the evidence show? new york: guttmacher institute; 2017 [internet]. available from: https://www.guttmacher.org/sites/default/files/rep ort_pdf/srh-needs-very-young-adolescentsreport_0.pdf 6. save the children international. choices, voices, promises program [cited 2023 april 4]. available from: https://resourcecentre.savethechildren.net/collectio n/choices-voices-promises-program/ peer reviewed: submitted 9 jan 2023, revised 6 apr 2023, accepted 19 apr 2023, published 29 may 2023 competing interests: none declared. correspondence: nancy tenbroek, bangladesh ntenbroek@worldrenew.net cite this article as: daring k, tenbroek n, chisim s, o'brien c, bormet m, sebany m, slate k. strengthening very young adolescents in gender equality in bangladesh. christ j global health. may 2023; 10(1):47-51. https://doi.org/10.15566/cjgh.v10i1.741 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/a1d32f13_8553_44f1_92e6_8ff80a4ff82e/2020-05-15-09-25-dccb5193f34eb8e9ed1780511e55c2cf.pdf https://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/a1d32f13_8553_44f1_92e6_8ff80a4ff82e/2020-05-15-09-25-dccb5193f34eb8e9ed1780511e55c2cf.pdf https://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/a1d32f13_8553_44f1_92e6_8ff80a4ff82e/2020-05-15-09-25-dccb5193f34eb8e9ed1780511e55c2cf.pdf https://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/a1d32f13_8553_44f1_92e6_8ff80a4ff82e/2020-05-15-09-25-dccb5193f34eb8e9ed1780511e55c2cf.pdf https://www.girlsnotbrides.org/learning-resources/child-marriage-atlas/atlas/bangladesh https://www.girlsnotbrides.org/learning-resources/child-marriage-atlas/atlas/bangladesh https://www.unfpa.org/publications/motherhood-childhood-untold-story https://www.unfpa.org/publications/motherhood-childhood-untold-story https://knowledgecommons.popcouncil.org/departments_sbsr-rh/578/ https://knowledgecommons.popcouncil.org/departments_sbsr-rh/578/ https://www.guttmacher.org/sites/default/files/report_pdf/srh-needs-very-young-adolescents-report_0.pdf https://www.guttmacher.org/sites/default/files/report_pdf/srh-needs-very-young-adolescents-report_0.pdf https://www.guttmacher.org/sites/default/files/report_pdf/srh-needs-very-young-adolescents-report_0.pdf https://resourcecentre.savethechildren.net/collection/choices-voices-promises-program/ https://resourcecentre.savethechildren.net/collection/choices-voices-promises-program/ mailto:ntenbroek@worldrenew.net https://doi.org/10.15566/cjgh.v10i1.741 http://creativecommons.org/licenses/by/4.0/ key words: momentum global health, ccih, world renew, local partner faith in action, usaid introduction poetry dec 2022. christian journal for global health 9(2) may we know oyebode dosunmu a a msc, pharmacist, bowden university teaching hospital, ogbomosho, nigeria oh lord, may you cause to know! to know the extent of your love for us to know the greatness of your plans for us to know the awesomeness of your deeds in us to know the supremacy of your being in us oh lord, may you cause to have! to have the patience for your promise for us to have the sweetness of your fellowship with us to have the awareness of your treasures in us to have the understanding of your faithfulness in us oh lord, may you cause us to hope! to hope for the manifestation of your glory through us to hope for the revealing of your promise to us to hope for the greatness of you through us to hope for the coming of you for us oh lord, may you cause us to see! to see the manifold of your goodness in us to see the fulfillment of your words to us to see the good things you plan for us to see the actualization of your greatness in us oh lord, may we know, have, hope, and see! for in knowing we’ll be transformed for in having we’ll be grateful for in hoping we’ll not be disappointed for in seeing we’ll be enlightened. peer reviewed: submitted 5 july 2022, accepted 15 aug 2022, published 20 dec 2022 competing interests: none declared. correspondence: oyebode dosunmu, bowen university, nigeria pharmaseyist@gmail.com cite this article as: dosunmu o. may we know. christ j glob health. dec 2022; 9(2):32. https://doi.org/10.15566/cjgh.v9i2.685 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:pharmaseyist@gmail.com https://doi.org/10.15566/cjgh.v9i2.685 about:blank editorial may 2023. christian journal for global health 10(1) getting the word out: research, reflection, and writing for global health daniel w. o’neill a and nathan grillsb a md, mth, managing editor, cjgh; assistant professor of family medicine, university of connecticut school of medicine, usa b mbbs, mph, dphil, professor, nossal institute for global health, university of melbourne, australia; senior research advisor, australia india institute introduction observing the world around us, evaluating humans and nature, measuring results, and understanding present reality are important professional activities for the people of god both locally and globally. christians have a significant footprint in responding to human need, but sometimes fail to measure their impact or assess their own practices in light of a growing base of evidence in the literature. additionally, their work and wisdom could have significant effects on global health practice if it were more discoverable in this growing body of evidence. in order to build a greater capacity for research, reflection and publishing for individuals and organizations inspired by the christian faith, we will start with the essence of evidence gathering, then assess motivations, then move to methods, then finish with a call to action. evidence & research evidence is the available body of facts or information indicating whether a belief or proposition is true or valid. it is used to support a hypothesis or assertion. research is using established methods to investigate a problem or question with the aim of generating new knowledge about it. it is observation and analysis of the knowable world. evidence from a christian perspective it is clear that god made the world knowable and gave humans a special place to test and steward the earth’s resources. “it is the glory of god to conceal a matter; to search out a matter is the glory of kings.” (prov 25:2) there is an expanding body of knowledge in all sectors, disciplines, and nations ready to be searched out and to be contributed to. though the church is designed to embody the fullness of truth, she does not have a monopoly on the truth. there was wisdom in the men of the east in solomon’s day (1 kings 4:30), the queen of sheba was thought able to judge the generation of jesus’ day (matt 12:42), and the cretan poets were true in their self-assessment of unhealthy practices in paul’s day (titus 1:12-13). the creation mandate of gen 1:28 was to have thoughtful dominion over the created order (including knowledge stewardship). god extoled king solomon for asking for wisdom and discernment over riches or long life, and he was granted both (1 kings 3:11-12). jesus was the word (logos) who became flesh and embodied the wisdom of god as the light of human beings (jn 1), and he invited his disciples to follow the evidence wherever that may have led (jn 14:11) and to test the spirits to see if they were from god (1 jn 4). the scriptures are the living word, useful for equipping for a great many things (1 tim 3:16), and the holy spirit confirms collective wisdom (acts 15:28). the disciples were called by the apostle paul to knowledge stewardship: “we demolish arguments and every pretension that sets itself up against the knowledge of god, and we take captive every thought to make it obedient to christ” (2 cor 10:4-5) we are also called to speak the truth in love in order to grow (eph 4:15), “that your love may abound more and more in knowledge and depth of insight . . . so that you may be able to discern what is best.” (phil 1:6&10). 3 o’neill & grills may 2023. christian journal for global health 10(1) evaluating what works and what doesn’t work is applying wisdom to the phenomena of life, in order to actualize best practices. it’s making the most of every opportunity, because of the pervasive problems of life (eph 5:16). the result is to promote life and godliness through knowledge stewardship (2 peter 1:3) and to avoid waste and duplication of efforts. it is to practice contemplative reflection “whatever is . . . true, noble, excellent, praiseworthy, think about such things . . .” leading to practice and peace (phil 4:8). as paul instructed his protégé timothy, “be prepared in season and out of season; correct, rebuke and encourage — with great patience and careful instruction.” (2 tim 4:2) motivations practical reasons to research and publish there are several practical and professional reasons to engage in research, reflection, and writing. it is a way to participate in collective wisdom and scholarly dialogue. it is being a good steward of one’s skills and experiences, refining and improving the quality of one’s work — and enhancing the quality of the work of others. it advocates for people that one serves, highlights one’s organization, generates further resources, and leads to professional development. it also facilitates partnership development with collaboration toward shared goals. research through observations and analysis of the knowable world accomplishes more than satisfying curiosity. it can move us from knowledge to wisdom when we apply that knowledge for a greater good. when research is applied at the community level, it can move us from information to better practices — data to development, truth to transformation. the pursuit of evidence in the world and in the word evidence can be pursued in the knowable material world (cosmos). “day after day they pour forth speech; night after night they reveal knowledge.” (ps 19:1-6) it is discerned in the science of biomedicine which assesses and cares for the biosphere. it looks at historical trends and taps into the existing body of collective knowledge — the literature. it assesses associations vs. causeand-effect and pursues testable realities across cultures and across sectors. it considers (and critiques) international standards of practice, pursuing the best practices in local contexts.1 it is utilized to understand social or spiritual determinants of health and to deal with complex systems challenges. evidence is also used in following the precepts in the word of god. “the law of the lord is perfect, refreshing the soul.” (ps 19:7-14) “come let us reason together. . .” (is 1:18). it is encouraged by an invitation to see the wounded hands and the empty tomb. it is an affirmation of life and abundance (jn 10:10) and a manifestation of god’s presence and activity (shalom). paul encouraged the ephesians to speak the truth in love (eph 4:15), eschewing fruitlessness and exposing it (eph 5:11). he regularly used reason and persuasion for a diverse audience in corinth (acts 18:4). christians are called to properly exegete scripture, the universe, and humans toward the higher purposes of god. accountability and transparency part of social responsibility and truth-telling is to give an account. it is one of the four aspects of a faith-based approach of measuring, evaluating, accountability, and learning (meal) in development,2 and a part of guided excellence in evidence for faith groups.3 christian accountability is in three directions: 1. to give an account to god. knowing the omniscient one still asks for honest reporting from the beginning — adam was asked in the garden, “where are you?” (gen 3:9). the response of the righteous leader is this: “test me, lord, and try me, examine my heart and my mind.” (ps 26:2). no one can escape the purview of god, as job realized, “that you examine them every morning and test them every moment?” (job 7:17-18) the hebrew writer reiterates this reporting responsibility: “nothing in all creation is hidden from god’s sight. everything is o’neill & grills 4 uncovered and laid bare before the eyes of him to whom we must give account.” (heb 4:13) therefore, our research must be done with integrity as god, knower of all, is the ultimate reviewer of our work. 2. to give an account to others. mutual confession and prayer for healing were hallmarks of the early church (james 5:16). paul encouraged the corinthians to “examine yourselves . . . test yourselves” (2 cor 13:5). the goal in a community of grace is to have honest appraisals and to then collaborate in order to bear each other’s burdens by forgiving shortcomings in order to improve (col 3:13). paul instructed titus to build into emerging leaders through integrity and capacity-building: “in everything set them an example by doing what is good. in your teaching show integrity, seriousness and soundness of speech that cannot be condemned, so that those who oppose you may be ashamed because they have nothing bad to say about us.” (titus 2:7-8) the goal of mutual transparency is to remain above reproach, and this principle can be applied to collaborative research pursuits in pluralistic contexts. 3. to give an account to the world. christoffer grundmann highlighted the christian call to give a credible account of the “corporeality of salvation” in their respective witness to the world, “which will be credible not in what it claims but on what it actually brings about tangibly.”4 this should be life, life in abundance (jn 10:10) — true human flourishing. actions are louder than (empty) words (james 2:14-23). the international community is asking for more evidence from faith-based organizations: more than highminded ideals, or pious speculations, but measurable life-giving outcomes. will we search out the evidence in our work and publish it in order to uncover the light that is there that others may recognize the goodness of god? (mat 5:16) displaying christian distinctions what are the marks of the christian community that might set them apart from others in research and evidence gathering for global health and professional healthcare? • the imago dei concept of human dignity at all levels of development and dependency and fostering moral responsibility instead of just claiming human rights. • real humility instead of false humility, such as learning from others and being willing to report even poor results. • prioritizing those populations in greatest need through self-sacrificial service and attention — the poor, the oppressed, the foreigner, the vulnerable (isaiah 1:17, zech 7:10). • longsuffering service in areas of deprivation in the slow progress towards community transformation. • localization of aid at the community level, ethical integrity, and mobilization of existing local resources for sustainable development.5 • whole-person care in all dimensions of life — physical, social, emotional, cognitive, spiritual, economic, and ecological. • maintaining hopefulness that a better world can be realized, with patient expectation of the fullness of transformation through an eschatological long view. research, reflection, and writing become essential elements in an authentic and persuasive global christian witness methods areas of inquiry credibility is enhanced, and authority is granted to those using the scientific method to discern truth from un-truth, real news from fake news. christians and christian agencies can contribute to health research in all areas of inquiry. however, some specific areas that christians are well positioned to research include clinical care and public health assessments amongst the marginalized, value-based leadership, the role of religion/spirituality in health, analysis of social determinants, ecological considerations, theo5 o’neill & grills may 2023. christian journal for global health 10(1) logical scholarship applied to health, and healthrelated mission studies. how to research it starts with a research question, derived from practical experience or imagination, which leads to a hypothesis. a search of the literature allows the researcher either to answer the question or to show that the question is novel, and the research will seek to fill gaps in collective knowledge. collecting a research team, procuring funding if needed, identifying the appropriate research methods to be used, and, if needed, the sample population to study. research ethics are paramount and need to be formally addressed up front, or the research risks being unethical and most likely unpublishable. data is then collected, then the results are analyzed and interpreted. claims to truth are made based on the results and not beyond the results. results are then applied to relevant contexts and conclusions synthesized based on the findings in light of the existing literature. finally, limitations of the research are then expressed followed by possible suggestions for further studies. how to publish truth claims completed through research and reflections must be communicated, and this can be done via pulpit, patient, population, or pen — speaking up and into the world’s literature and conversations. it means sharing the evidence in consultations, churches and other forums, government health systems, conferences, books, posts, and journals. taking the extra time to move these insights into concise written communication is worth every moment. the work or research and reflection can then be submitted for publication, preferably in peer-reviewed, reputable and discoverable journals to as wide and strategic an audience as possible.6 the process of publishing is an exercise in clarifying and proclaiming, like the apostle paul who meticulously wrote about that which he had observed and reflected and asked the colossians to “pray that i may proclaim it clearly, as i should.” (col 4:4). the goal is to fill gaps in knowledge, to propose keen insights, or to challenge existing paradigms. it could be an honest appraisal of your organization’s results (positive or negative), which leads others into better practices in their own contexts. it utilizes numbers and narratives, images and words, tables and figures, all to convey a single overriding communication objective (soco). it takes time, intentionality, and courage to publish in the scientific and theological literature — but it is time well spent. it is not to boast, but to be a blessing, and to reflect the light you can shed in the darkness and chaos of the world. we acknowledge that the whole research, reflecting, and writing process can be daunting. both authors are editors of the christian journal for global health, an open-access, scholarly, multi-disciplinary, international journal. cjgh is unique in that instead of rejecting research offhand, we work with the corresponding authors to guide them through the demanding and sometimes overwhelming process of telling their story clearly, using the best of evidence and making this available to researchers everywhere. conclusion and call to action we invite you to consider publishing your research in the christian journal for global health. we must not hold our experiences and the truths we embrace to ourselves, but creatively and intelligently share them in order that our collective and unique voices may be clarified and magnified. in line with the ancient texts, “we also believe, therefore we speak.” (2 cor 4:13). research, reflection, and writing is both an ancient and a modern way to derive and share truth in the knowable world. when we engage in such intelligent processes, we enhance credible witness and can more effectively persuade both our supporters and our critics. collective wisdom is enhanced and capacity is built for global health. when the divine element is included in analysis and reporting, it becomes an exercise in ascribing to the lord glory and strength for the healing of all nations (1 chron 16:28). the world is clamoring for evidence. when we are reflecting god’s o’neill & grills 6 wisdom and ways in our truth searching and evidence production, then we speak clearly into the public square and bring more substantial healing to the nations. references 1. health for all nations. best practices in global health missions [internet]. available from: https://bpghm.org/ 2. joint learning initiative for faith and local communities (jli). meal hub [internet]. available from: https://jliflc.com/meal/ 3. jli. guide to excellence in evidence for faith groups [internet]. available from: https://jliflc.com/guide-to-excellence-in-evidencefor-faith-groups/ 4. christopher h. grundmann, sent to heal! emergence and development of medical missions. (maryland: university press of america, 2005), 203, 221. 5. australian government. dept of foreign affairs and trade. localisation and the australian ngo cooperation program (ancp) 2019-20 [internet]. april 2021. available from: https://www.dfat.gov.au/sites/default/files/localisa tion-and-the-ancp-2019-20.pdf 6. o’neill, d. w. (2018). the lancet global health academic writing workshop: navigating and getting noticed in the scholarly publishing world. christ j global health. 5(2):52-6. https://doi.org/10.15566/cjgh.v5i2.237 competing interests: none declared. acknowledgements: bible quotes are from the english translation the holy bible: new international version. zondervan, 1984. some of the contents of this paper were presented by the authors at the 2018 icmda world congress, hyderabad, india; and it was co-published in luke’s journal by christian medical and dental fellowship of australia 24 jan 2023 https://lukesjournalcmdfa.com/2023/01/24/getting-the-word-out-research-reflection-and-writingfor-global-health-dr-daniel-w-oneill-prof-nathan-grills/ correspondence: nathan grills, university of melbourne, australia ngrills@unimelb.edu.au and daniel o'neill, university of connecticut, usa dwoneill@cjgh.org cite this article as: o’neill dw, grills n. getting the word out: research, reflection, and writing for global health. christ j global health. may 2023; 10(1):2-6. https://doi.org/10.15566/cjgh.v10i1.757 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://bpghm.org/ https://jliflc.com/meal/ https://jliflc.com/guide-to-excellence-in-evidence-for-faith-groups/ https://jliflc.com/guide-to-excellence-in-evidence-for-faith-groups/ https://www.dfat.gov.au/sites/default/files/localisation-and-the-ancp-2019-20.pdf https://www.dfat.gov.au/sites/default/files/localisation-and-the-ancp-2019-20.pdf https://doi.org/10.15566/cjgh.v5i2.237 https://lukesjournalcmdfa.com/2023/01/24/getting-the-word-out-research-reflection-and-writing-for-global-health-dr-daniel-w-oneill-prof-nathan-grills/ https://lukesjournalcmdfa.com/2023/01/24/getting-the-word-out-research-reflection-and-writing-for-global-health-dr-daniel-w-oneill-prof-nathan-grills/ mailto:ngrills@unimelb.edu.au mailto:dwoneill@cjgh.org https://doi.org/10.15566/cjgh.v10i1.757 http://creativecommons.org/licenses/by/4.0/ introduction motivations methods conclusion and call to action editorial july 2021. christian journal for global health 8(1) environmental concern, evidence and global health this issue addresses the close connections between the health of individuals and the health and flourishing of the planet, and our responsibility to steward the resources we’ve been given. in our first guest editorial, james hospedales offers a plea to carefully look at the evidence on the rising global health problems generated from the human neglect of maintaining the delicate balance in nature, and our god-directed responsibility to maintain that balance. stewardship of the earth also includes knowledge stewardship. professors rebecca meyer and jason paltzer introduce a nascent research collaborative to serve christian organizations by helping them measure and evaluate the results of their work in health and development – to design research and share results. the editors endorse this project which would serve an important need for fbos to produce the evidence needed for partners, donors, and the international development community. jason paltzer and keyanna taylor’s crosssectional study in this issue supports the need for such a research collaborative initiative. the covid-19 pandemic has led to new-found opportunities to measure and evaluate the results of faithbased work. emily hirata, michael peach, and sharon tobing present a case study showing the way adventist development and relief agency has met the humanitarian needs during the pandemic, highlighting the unique advantage of well-connected fbos. james pender offers an insightful commentary on the work, often-divided, between heath, social development and environmental concerns, and uses his work with the leprosy mission as an example of the need to unify these objectives. health-related work as cross-cultural christian mission has evolved over the years. several authors from the asia-pacific region present an integral paradigm of service in academia, government, or research, often in secular organizations, to build health and missional capacity in strategic areas. the pandemic has strained not only health services, but church gatherings, which serve as a source of hope and support. grace zurielle malolos, et al. analyze the effect of the social distancing restrictions in philippines on church gatherings, and the need for more research on the effect of church gatherings on transmission, as well as church-state relations. two short communications highlight the importance of nutrition and exercise as global health factors. alva supit, et al show efforts to curtail bushmeat eating through church leadership in a christian-majority region of indonesia as one approach to fostering health in an era of pandemics and ncds. physiotherapist qais gasibat from libya reviews the latest data on exercise as an adjunct to enhance the immunogenicity of sars cov2 and other vaccines, especially in at-risk populations. two surgical case reports from low-resource settings of rural india by royson dsouza, et al highlight the resourcefulness needed to provide good quality surgical services for liver abscess and breast cancer management. two poems by professor reena george round out this issue: burnout which gives resurrection hope through death filled days, and alone at christmas showing the value of the pearl of great price. in facing the complexities of global climate change, and its human health consequences, as well as global vulnerabilities highlighted by the current pandemic, we need now, more than ever, to look at the data, the trends, the causes, and the cures. we need to pray for the courage to critically self-evaluate, and to offer deeply transformational solutions to these issues in light of the renewal of all of groaning creation, awaiting the engagement of the children of god (rom 8:18-30). professor sigve tonstad proposes a “theology of ecology” to interpret scripture anew, retrieve materiality, highlight the faithfulness of god, acquire a new vision of community, pursue sabbath rest, and to https://journal.cjgh.org/index.php/cjgh/article/view/575 https://journal.cjgh.org/index.php/cjgh/article/view/503 https://journal.cjgh.org/index.php/cjgh/article/view/503 https://journal.cjgh.org/index.php/cjgh/article/view/491 https://journal.cjgh.org/index.php/cjgh/article/view/541 https://journal.cjgh.org/index.php/cjgh/article/view/541 https://journal.cjgh.org/index.php/cjgh/article/view/543 https://journal.cjgh.org/index.php/cjgh/article/view/523 https://journal.cjgh.org/index.php/cjgh/article/view/505 https://journal.cjgh.org/index.php/cjgh/article/view/537 https://journal.cjgh.org/index.php/cjgh/article/view/545 https://journal.cjgh.org/index.php/cjgh/article/view/545 https://journal.cjgh.org/index.php/cjgh/article/view/507 https://journal.cjgh.org/index.php/cjgh/article/view/539 https://journal.cjgh.org/index.php/cjgh/article/view/501 https://journal.cjgh.org/index.php/cjgh/article/view/499 2 editors july 2021. christian journal for global health 8(1) restore compassion and grace.1 may we all be found faithful in that pursuit. references 1. tonstad sk. a theology of ecology: earthcare and health. in: o'neill dw, snodderly e, editors. all creation groans: toward a theology of disease and global health. eugene, or: pickwick; 2021. p. 60-79. references commentary nov 2015. christian journal for global health, 2(2):20-22. untapped potential choose wisely catharine anna henderson a a ms, phd, associate professor, department of public and community health, liberty university, united states last november, i attended the 142nd annual meeting and expo of the american public health association in new orleans, louisiana: https://apha.confex.com/apha/142am/webprogram/ meeting.html. the theme of the conference examined the intersection of health and geography and was appropriately termed healthography: how, where you live affects your health and wellbeing. the opening speaker for the general session wove a story of the hardships faced by african americans in the post american civil war reconstruction period migration from the south. as i listened, it began to dawn on me how the circumstances she discussed applied to another oppressed population around the globe, the unborn. the opening speaker was isabel wilkerson, pulitzer prize winning author of the new york times best seller, the warmth of other suns. she laughed as she confessed that, had she known it was going to take her 15 years to complete the novel, she never would have started it. ms. wilkerson stated that her book was about freedom and how far people would go to obtain it. wilkerson described these heroic treks as attempts to flee a cast system: a place or a role in an artificial hierarchy to which people had been assigned. wilkerson had the audience spellbound as she introduced historic african americans whose lives were forever changed as a result of their family’s decision to bravely leave the south. brief biographies were shared of the families of four-time olympic gold medalist, jessie owens; novelist, editor, and professor toni morrison; record producer and songwriter, barry gordy; one of the most influential musicians of the 20th century, miles davis; american jazz saxophonist and composer, john coltrane; and american playwright, lorrain hansberry. while highlighting these individuals, wilkerson noted: on those tobacco, cotton, and rice fields were musicians, surgeons, opera singers, and playwrights. then wilkerson made a statement that brought tears to my eyes. her statement referenced the power of an individual decision. she commented how the people who made these brave decisions had no idea that their children, and yet unknown grandchildren, would bring gifts to the world: gifts that would change the world and improve it. tears began to flow down my cheeks as wilkerson continued to talk about the power of an individual decision. i knew she was talking about african americans fleeing the south, and yet my mind kept drifting to additional sources of untapped potential. she shared that this trek was a young person’s endeavor, a journey for those on the cusp of life. those on the cusp of life! there it was! her words helped me make the connection. as she continued to talk, i continued to see parallels. the world is forever grateful for the brave decisions those african americans made. their contributions to society affected every area of life from science to music, from sports and entertainment to effective leadership. the power of each individual decision to leave the south resulted in influence and inspiration that has forever shaped mankind. on the other hand, we will never know or experience the gifts, talents, and contributions of those who have been at the mercy of the powerful decision of abortion. just as one decision moved field workers from potential surgeons and playwrights to actual surgeons and playwrights, one decision can also extinguish the same reality for the unborn. https://apha.confex.com/apha/142am/webprogram/meeting.html https://apha.confex.com/apha/142am/webprogram/meeting.html 21 henderson nov 2015. christian journal for global health, 2(2):20-22. between 1922 and 2013, 938,000,000 abortions were reported globally. 1 abortion has not always been legal; therefore, the actual number of abortions is unknown and is undoubtedly higher. consequently, it is conceivable that the scientists who would have discovered the cures for cancer and alzheimer’s disease were never realized. it is also plausible that the talents of an unborn humanitarian, who would have brought peace to war zones, will never be appreciated. it is reasonable to think that others would have created a new form of music or solved current unsolvable equations. those of us who were given the gift of life will never know. on the inside wall of the american adventure in epcot center, us cartoonist and movie producer, walt disney (1901-1966), is quoted as saying, “our greatest national resource is the minds of our children.” we will never know how the world would have been made better by those who were never able to share their gifts because of, as ms. wilkerson stated, the power of one individual decision. it is a social virtue for us as a society to reconsider our future that is in the hands of individual choices. we need to help educate women around the globe to understand that abortions not only destroy the lives of individuals, but they also rob all humanity of the many potential benefits these individuals could contribute to society. the decision for abortion is powerful and irrevocable, and in addition to depriving gifts from society as a whole, it has multiple negative repercussions for the health of the mother, including suicide, early death, post-abortion syndrome, relationship break-ups, and future relationship problems. 2,3,4,5,6,7,8,9 all of these consequences negatively impact the health and strength of families, communities, and nations. the devastating effects of abortions globally do not create a foundation for thriving, healthy, or productive communities or nations. “civilized societies do not kill children as a solution to any problem, no matter how grave.” 10 we need to support women facing crisis pregnancies with understanding, material assistance, and lots of love so they will not feel that their only choice is abortion. deuteronomy 30:19 states, today i have given you the choice between life and death, between blessings and curses. now i call on heaven and earth to witness the choice you make. oh, that you would choose life, so that you and your descendants might live! while this passage literally reflects the exhortation for israel to follow god’s law, the passage also echoes god’s will for us, his beloved children. the bible is our guide book. for starters, it teaches us how to manage time, interact with one another, view money, develop character, build our faith, and respond to difficulties. it is filled with hope, guidance, and direction for godly living. in every situation, regardless of how difficult, god’s response to us is always to reflect his character that includes choosing love and life. references 1. johnston r. summary of registered abortions worldwide, through december 2013. johnston’s archive website. http://www.johnstonsarchive.net/policy/abortion/wrjp331 2.html. published 2013. accessed may 7, 2015. 2. abortion grief counseling association, inc. post abortion syndrome: the silent suffering. abortion grief australia website; 2011. available from: http://www.abortiongrief.asn.au/documents/pas-thesilent-suffering.pdf 3. suliman s, ericksen t, labucshgne p, dewit r, stein dj, seedat s. comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anesthesia versus intravenous sedation. bmc psychiatry. 2007;7:1-9. http://dx.doi.org/10.1186/1471-244x-7-24 http://www.johnstonsarchive.net/policy/abortion/wrjp3312.html http://www.johnstonsarchive.net/policy/abortion/wrjp3312.html http://www.abortiongrief.asn.au/documents/pas-the-silent-suffering.pdf http://www.abortiongrief.asn.au/documents/pas-the-silent-suffering.pdf http://dx.doi.org/10.1186/1471-244x-7-24 22 henderson nov 2015. christian journal for global health, 2(2):20-22. 4. somers r. risk of admission to psychiatric institutions among danish women who experienced induced abortion: an analysis based on national report linkage [dissertation]. los angeles: university of california. 1979. [disseration abstracts international, public health 2621-b, order no. 7926066] 5. gissler m, hemminki e, lonnqvist j. suicides after pregnancy in finland, 1987 to 94: register linkage study. british medical journal. 1996 december 7; 313(7070):1431-4. http://dx.doi.org/10.1136/bmj.313.7070.1431 6. gissler m. injury deaths, suicides, and homicides associated with pregnancy, finland 1987-2000. european j public health. 2005;15(5):459-63. http://dx.doi.org/10.1093/eurpub/cki042 7. garfinkel g et al. stress, depression, and suicide: a study of adolescents in minnesota. responding to high risk youth. university of minnesota: minnesota extension service; 1986. 8. reardon dc et al. deaths associated with pregnancy outcome: a record linkage study of low income women. southern med j. 2002;95(8):834-41. http://www.afterabortion.org/research/deathsassociated withabortion.pdf 9. the life resources charitable trust. a new zealand resource: for life related issues. published 2011. accessed may 6, 2015. http://www.life.org.nz/abortion/abortionkeyissues/impact -on-society-abortion/ 10. santo m. our society needs to find a solution other than abortion. the baltimore sun. january 22, 2013. peer reviewed competing interests: none declared. correspondence: catharine anna henderson, liberty university, united states. cahenderson2@liberty.edu cite this article as: henderson ca. untapped potential – choose wisely. christian journal for global health (nov 2015), 2(2): 20-22. © henderson ca this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.1136/bmj.313.7070.1431 http://dx.doi.org/10.1093/eurpub/cki042 http://www.afterabortion.org/research/deathsassociatedwithabortion.pdf http://www.afterabortion.org/research/deathsassociatedwithabortion.pdf http://www.life.org.nz/abortion/abortionkeyissues/impact-on-society-abortion/ http://www.life.org.nz/abortion/abortionkeyissues/impact-on-society-abortion/ mailto:cahenderson2@liberty.edu http://creativecommons.org/licenses/by/3.0/ guest editorial dec 2020. christian journal for global health 7(5) cura personalis, cura communitas: loving our neighbor in covid-19 times jonathan d. quick a a md, mph, managing director, pandemic preparedness and prevention, the rockefeller foundation adjunct professor of global health, duke global health institute author, the end of epidemics (2018, 2020) the months of november and december have given chilling notice that the pandemic is far from over. worldwide the global case rates continued steadily upward, with daily new cases exceeding 700,000 for the first time, total confirmed cases surpassing 75 million, and deaths exceeding 1.6 million.1 after pushing back or being spared by the april-may covid-19 onslaught france, italy, germany, russia, the united kingdom, and other countries experienced record daily highs for new cases and a steady increase in the cumulative death toll. in the u.s., nearly every state experienced new daily highs for confirmed cases.2 by mid-december deaths were occurring at the rate of more than 75,000 per month. nationwide nearly 17 million cases and more than 300,000 deaths had been reported. parts of latin america, north africa, and the middle east were also seeing new surges. with the exception of new outbreaks in india, kenya, south africa, australia and a few other countries, asia and subsaharan africa maintained a relatively low incidence of covd-19. pandemic misinformation, fatigue, denial, and resistance – along with cooler weather – have created a perfect storm for regional and national surges.3 pandemic fatigue occurred among the many who understood the reality of covid-19 but were tiring of the efforts needed to keep themselves and their loved ones safe.4,5 pandemic denial continued among those convinced reports of a pandemic were untrue and that masking, distancing, and other preventive measures were an unnecessary infringement on their liberty. finally, resistance against stringent restrictions resulted in sometimes violent protests.6 in stark contrast, the last weeks of 2020 also brought the most encouraging – some would say miraculous – news since the pandemic began: in rapid succession the world learned that the pfizer and moderna vaccines both had achieved over 90% efficacy in preventing covid-19 illness, the oxford/astra-zeneca vaccine had achieved at least 70% efficacy, and several other vaccines were showing promising results. combined production capacity of at least three billion doses added further cause for optimism.7 what should be the christian response in the face of an out-of-control pandemic in large parts of the world, continuing vulnerabilities in other parts of the world, and the potential to immunize the world with safe, effective vaccines? as always, we turn to jesus, who taught with carefully crafted words and inspiring deeds. since its earliest days the church has responded to pandemics through jesus’ great commandment to, “love your neighbor as yourself.” he made clear the practical meaning of these words thought his miracles, two-thirds of which were healings. the apostle paul, building upon this, added “the only thing that counts [for jesus] is faith expressing itself through love.” (galatians 5:6) drawing on the new testament’s framework of action motived by faith, the catholic jesuit 4 quick dec 2020. christian journal for global health 7(5) concept of cura personalis, “care of the whole person,” emphasizes dedication to the physical, psychological, and spiritual well-being of the individual.8,9 one of the most visible ways the early church exemplified this spirit was through its response to pandemics. in 260 a.d. during the height of the cyprian plague, the bishop dionysius of corinth in his easter sunday message noted that, most of our brother christians showed unbounded love and loyalty, never sparing themselves, and thinking only of one another. heedless of danger, they took charge of the sick, attending to their every need and ministering to them in christ, and with them departed this life serenely happy.10 in response to the deadliest pandemic in one hundred years, the christian medical community around the world has responded to the current pandemic with same cura personalis, providing care for the sickest and most vulnerable, even at the cost of their own lives. jesus’ admonition to his followers referred not only to acts of love toward individuals but also to loving our neighbors collectively through acts of cura communitas – what one might call dedication to the “care of the whole community”. martin luther reflects this obligation in this 1527 letter, whether one may flee from a deadly plague. he writes that not only health providers, but pastors, mayors, and others in public service, “must remain steadfast before the peril of death.”11 the christian medical commission leadership in the 1978 alma ata declaration and primary health care and health for all movement that followed12 are examples of the spirit of cura communitas in action. in their dialogue on a christian response to the current pandemic13 noted british theologian nt wright, author of god and the pandemic14 and u.s. national institutes of health director, dr. francis collins, author of the language of god15 reflect the spirit of cura communitas. what should cura communitas look like in the time of covid-19? first, it requires knowing, applying, and publicly encouraging masking, distancing, and other safe living practices that have enabled entire communities and countries to bend their pandemic curve of new cases. science that increases well-being and saves lives is one of god’s greatest gifts to humanity. yet religious leaders have been some of the most influential opponents to proven pandemic control measures.16 religious services, weddings, and funerals around the globe have been associated with covid-19 outbreaks, with tens to thousands of resulting infections and some deaths.17,18 the most notable, which occurred in the early days of the pandemic, was the february 9 service at the shincheonji church of jesus service in south korea that ultimately was associated with 5006 covid-19 cases and numerous deaths.19 speaking as both a scientist and devout christian, francis collins advises, the church, in this time of confusion, ought to be a beacon, a light on the hill, an entity that believes in truth. this is a great moment for the church to say, no matter how well intentioned someone’s opinions may be, if they’re not based upon fact, the church should not endorse them.20 drawing from decades of experience in health, development and natural disasters, religious communities across the faith spectrum have actively worked to mobilize, educate, and support community responses. 21,22 christian connections for international health, with more than 120 organizational members from five continents, compiled covid-19 resources for faith-based organizations23 including country work from nigeria24 to nicaragua.25 second, with the prospect of large-scale availability sars-cov-2 vaccines, cura communitas commits us to support global and national commitments to action that ensures both equity of access to vaccines and widespread acceptance of vaccination. coordinated by the 5 quick dec 2020. christian journal for global health 7(5) who, gavi, and cepi, covax has brought together more than 180 countries with the goal of providing at least 2 billion doses of proven covid19 vaccines to immunize the most vulnerable 20 per cent of people in 91 low and middle-income countries, mostly in africa, asia and latin america.26 at the same time, inadequate funding and actions by high income countries competing for vaccine access threaten to delay access to the rest of the world.27 it is incumbent on all of us to join religious leaders in supporting to access to pandemic vaccines for the most vulnerable.28,29 vaccine availability must be followed by vaccine confidence and vaccination acceptance. building on the persistent vaccine-autism myth30, a steady campaign of misinformation, and isolated examples of genuine vaccine safety issues, vaccine skeptics have mounted an aggressive campaign against sars-cov-2 vaccines. some communities decline vaccination for “religious reasons”, even though no major faith tradition opposes vaccination.31 in a june, 2020 global survey, the percent of respondents saying they would take a covid-19 vaccine if “proven safe and effective and is available” varied from more than 80% in brazil, china, south africa and south korea to less than 60% in france, poland, and russia.32 a late november survey in the u.s. found that just over 60% of whites and latinos would be vaccinated when given the opportunity, but just 42% of black americans, who have been hardest-hit by the pandemic, would trust the vaccine.33 personal healthcare providers and pastors remain highly trusted sources of information and advice.33,34 this makes it incumbent on the faithbased global health community to empathetically explore reasons for vaccine hesitation, to become fully informed on the safety and efficacy of new vaccines,35 and to champion vaccine acceptance – especially for the most vulnerable individuals and communities.36 drawing on the historical roots of this distrust, dr. rueben warren of tuskegee university describes steps clinicians, researchers, and others must take to earn and rebuild trustworthiness among black americans.37 a recent multi-faith exploration on bridging religious divides and mobilizing religious support concluded, theologians, scientists, and public health specialists need to join with political and community leaders in a thoughtful conversation that builds the needed trust and respect in carefully vetted vaccines. 28 finally, in the spirit of cura communitas, even as we fight to end covid-19 we must learn from it and take all necessary action to make the world safer from future pandemics. through god’s grace humanity has created a world with far more comforts and opportunities to flourish than our forebears enjoyed. with these benefits has come greater complexity, inter-connectedness, and vulnerability. without vigorous preventive action we face innumerable future pandemics from an accelerating web of risk factors: urbanization, healthcare inequities, lifestyle diseases, international travel, encroachment on animal habitats, and more.38 as covid-19 has vividly reminded us, the human and economic cost of complacent inaction is far, far greater than the cost of prevention.39,40 scientists, public health officials, behavioral scientists, and economists know what is needed.41 it remains with leaders at all levels, committed professionals and engaged citizens to press forward. how will the christian global health community be remembered? surely it will be remembered for loving our neighbor through the selfless cura personalis response of christian health workers, hospitals, and caregivers. we must strive also to be remembered for loving our neighbor through a spirit of cura communitas that helped to contain the spread of the virus, ended the pandemic through worldwide immunization, and after the crisis worked even more vigorously to make the world safer from future devastating pandemics. 6 quick dec 2020. christian journal for global health 7(5) references 1. johns hopkins university & medicine, coronavirus resource centers. johns hopkins coronavirus resource center [internet]. [cited 2020 nov 8]. available from: https://coronavirus.jhu.edu/ 2. gillet k, magdziarz a, pronczuk m, novak b, kramer ae. u.s. hits new coronavirus case record for third straight day. the new york times [internet]. 2020 nov 9. [cited 2020 nov 8]. available from: https://www.nytimes.com/live/2020/11/06/world/cov id-19-coronavirus-updates 3. quick j. coronavirus crisis update: transcending pandemic denial, fatigue and anger [audio podcast]. [cited 2020 dec14]. available from: https://www.csis.org/podcasts/take-directedcoronavirus-crisis-update/coronavirus-crisis-updatedr-jonathan-jono-quick-%e2%80%93 4. meichtry s, sugden j, barnett a. pandemic fatigue is real—and it’s spreading. wall street journal [internet]. 2020 oct 26. [cited 2020 dec 14]. available from: https://www.wsj.com/articles/pandemic-fatigue-isrealand-its-spreading-11603704601 5. aboagye d, hamill s. it’s time to fight covid fatigue in africa. the mail & guardian [internet]. 2020 dec 8]. [cited 2020 dec 14]. available from: https://mg.co.za/africa/2020-12-08-its-time-to-fightcovid-fatigue-in-africa/ 6. carothers t, press b. amid the covid-19 pandemic, protest movements challenge lockdowns worldwide. world polit rev [internet] 2020 oct 15. [cited 2020 dec 14]. available from: https://www.worldpoliticsreview.com/articles/29137/ amid-the-covid-19-pandemic-protest-movementschallenge-lockdowns-worldwide 7. zimmer c, corum j, wee s-l. coronavirus vaccine tracker. the new york times [internet]. 2020 jun 10. [cited dec 14]. available from: https://www.nytimes.com/interactive/2020/science/c oronavirus-vaccine-tracker.html. 8. otto a. cura personalis. ignatian spirituality [internet]. 2013 aug 15. [cited 2020 nov 8]. available from: https://www.ignatianspirituality.com/cura-personalis/ 9. georgetown university school of medicine [internet]. about cura personalis. [citied 2020 nov 8]. available from: https://som.georgetown.edu/mission-andculture/cura-personalis/ 10. stark r. the rise of christianity: how the obscure, marginal jesus movement became the dominant religious force in the western world in a few centuries. princeton university press; 1997. 11. luther m. whether one may flee from a deadly plague [internet]. 1527. [cited 2020 dec 17]. available from: https://www.christianitytoday.com/ct/2020/mayweb-only/martin-luther-plague-pandemiccoronavirus-covid-flee-letter.html. 12. flessa s. christian milestones in global health: the declarations of tübingen. christ j glob health. 2016;3(1):11-24. https://doi.org/10.15566/cjgh.v3i1.96 13. biologos resources [internet]. a christian response to coronavirus: a virtual event with n.t. wright and francis collins. 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[cited 2020 dec 14]. available from: https://www.npr.org/2020/11/19/936490226/somefaith-leaders-defiant-others-transparent-over-covid19-outbreaks 17. james a, eagle l, phillips c, hedges ds, bodenhamer c, brown r, wheeler jg, kirking h. high covid-19 attack rate among attendees at events at a church — arkansas, march 2020. mmwr morb mortal wkly rep. 2020 may 22;69(20):632–635. https://doi.org/10.15585/mmwr.mm6920e2 18. mahale p, rothfuss c, bly s, et al. multiple covid-19 outbreaks linked to a wedding reception in rural maine august 7-september 14, 2020. mmwr morb mortal wkly rep. 2020;69(45):16861690. https://doi.org/10.15585/mmwr.mm6945a5 https://coronavirus.jhu.edu/ https://www.nytimes.com/live/2020/11/06/world/covid-19-coronavirus-updates https://www.nytimes.com/live/2020/11/06/world/covid-19-coronavirus-updates https://www.csis.org/podcasts/take-directed-coronavirus-crisis-update/coronavirus-crisis-update-dr-jonathan-jono-quick-%e2%80%93 https://www.csis.org/podcasts/take-directed-coronavirus-crisis-update/coronavirus-crisis-update-dr-jonathan-jono-quick-%e2%80%93 https://www.csis.org/podcasts/take-directed-coronavirus-crisis-update/coronavirus-crisis-update-dr-jonathan-jono-quick-%e2%80%93 https://www.wsj.com/articles/pandemic-fatigue-is-realand-its-spreading-11603704601 https://www.wsj.com/articles/pandemic-fatigue-is-realand-its-spreading-11603704601 https://mg.co.za/africa/2020-12-08-its-time-to-fight-covid-fatigue-in-africa/ https://mg.co.za/africa/2020-12-08-its-time-to-fight-covid-fatigue-in-africa/ https://www.worldpoliticsreview.com/articles/29137/amid-the-covid-19-pandemic-protest-movements-challenge-lockdowns-worldwide https://www.worldpoliticsreview.com/articles/29137/amid-the-covid-19-pandemic-protest-movements-challenge-lockdowns-worldwide https://www.worldpoliticsreview.com/articles/29137/amid-the-covid-19-pandemic-protest-movements-challenge-lockdowns-worldwide https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html https://www.ignatianspirituality.com/cura-personalis/ https://som.georgetown.edu/mission-and-culture/cura-personalis/ https://som.georgetown.edu/mission-and-culture/cura-personalis/ https://www.christianitytoday.com/ct/2020/may-web-only/martin-luther-plague-pandemic-coronavirus-covid-flee-letter.html https://www.christianitytoday.com/ct/2020/may-web-only/martin-luther-plague-pandemic-coronavirus-covid-flee-letter.html https://www.christianitytoday.com/ct/2020/may-web-only/martin-luther-plague-pandemic-coronavirus-covid-flee-letter.html https://doi.org/10.15566/cjgh.v3i1.96 https://biologos.org/resources/a-christian-response-to-coronavirus-a-podcast-recording-with-n-t-wright-and-francis-collins/ https://biologos.org/resources/a-christian-response-to-coronavirus-a-podcast-recording-with-n-t-wright-and-francis-collins/ https://biologos.org/resources/a-christian-response-to-coronavirus-a-podcast-recording-with-n-t-wright-and-francis-collins/ https://www.npr.org/2020/11/19/936490226/some-faith-leaders-defiant-others-transparent-over-covid-19-outbreaks https://www.npr.org/2020/11/19/936490226/some-faith-leaders-defiant-others-transparent-over-covid-19-outbreaks https://www.npr.org/2020/11/19/936490226/some-faith-leaders-defiant-others-transparent-over-covid-19-outbreaks https://doi.org/10.15585/mmwr.mm6920e2 https://doi.org/10.15585/mmwr.mm6945a5 7 quick dec 2020. christian journal for global health 7(5) 19. kim s, jeong yd, byun jh, et al. evaluation of covid-19 epidemic outbreak caused by temporal contact-increase in south korea. int j infect dis ijid off publ int soc infect dis. 2020;96:454-457. https://doi.org/10.1016/j.ijid.2020.05.036 20. bailey sp. what nih chief francis collins wants religious leaders to know about the coronavirus vaccines. washington post [internet]. 2020 dec 12. [cited 2020 dec 14]. available from: https://www.washingtonpost.com/religion/2020/12/1 2/coronavirus-vaccine-nih-francis-collins-faithleaders/ 21. lieberman a. ties between un, faith-based groups poised to grow during pandemic. devex [internet]. 2020 oct 28. [cited 2020 dec 17]. available from: https://www.devex.com/news/sponsored/tiesbetween-un-faith-based-groups-poised-to-growduring-pandemic-98357 22. xiong j (jane), isgandarova n, panton ae. covid19 demands theological reflection: buddhist, muslim, and christian perspectives on the present pandemic. int j pract theol. 2020;24(1):5-28. https://doi.org/10.1515/ijpt-2020-0039 23. christian connections for international health [internet]. faith-based organizations and covid-19. accessed december 16, 2020. available from: https://www.ccih.org/cpt_resources/covid-19/ 24. scott s. adapting to covid-19 reality to continue other health services. ccih [internet]. 2020 nov 20. [cited 2020 dec 16. available from: https://www.ccih.org/adapting-to-covid-19-realityto-continue-other-health-services/ 25. carty t. navigating one crisis helped prepare for another: amos health & hope responds to covid19 in nicaragua. ccih [internet]. 2020 july 17. [cited dec 17]. available from: https://www.ccih.org/navigating-one-crisis-helpedprepare-for-another-amos-health-hope-responds-tocovid-19-in-nicaragua/ 26. gavi [internet]. covax explained. [cited 2020 dec 17]. available from: https://www.gavi.org/vaccineswork/covax-explained 27. lancet editorial. global governance for covid-19 vaccines. the lancet. 2020;395(10241):1883. https://doi.org/10.1016/s0140-6736(20)31405-7 28. marshall k, seifman r. covid-19 vaccines: bridging religious divides, engaging religious support. impakter [internet]. 2020 dec 10. [cited 2020 dec 15]. available from: https://impakter.com/covid-vaccines-engagingreligious-support/ 29. us news & world report [internet].poor should get covid-19 vaccine first, pope francis says. 2020 sept 25. [cited 2020 dec 14]. available from: https://www.usnews.com/news/world/articles/202009-25/poor-should-get-covid-19-vaccine-first-popefrancis-says 30. quick jd, larson h. the vaccine-autism myth started 20 years ago. here’s why it endures today. time. 28 feb 2018. available from: https://time.com/5175704/andrew-wakefieldvaccine-autism/ 31. grabenstein jd. what the world’s religions teach, applied to vaccines and immune globulins. vaccine. 2013;31(16):2011-2023. https://doi.org/10.1016/j.vaccine.2013.02.026 32. lazarus jv, ratzan sc, palayew a, et al. a global survey of potential acceptance of a covid-19 vaccine. nat med. 2020 oct 20:1-4. https://doi.org/10.1038/s41591-020-1124-9 33. funk c, tyson a. intent to get a covid-19 vaccine rises to 60% as confidence in research and development process increases. 2020 dec 3. [cited dec 14]. available from: https://www.pewresearch.org/science/2020/12/03/int ent-to-get-a-covid-19-vaccine-rises-to-60-asconfidence-in-research-and-development-processincreases/ 34. funk c, gramlich j. amid coronavirus threat, americans generally have a high level of trust in medical doctors. pew research center. 2020 mar 13. [cited 2020 dec 15]. available from: https://www.pewresearch.org/facttank/2020/03/13/amid-coronavirus-threat-americansgenerally-have-a-high-level-of-trust-in-medicaldoctors/ 35. johns hopkins coronavirus resource center [internet]. international vaccine access center. vaccines faq. [cited 2020 dec 15]. available from: https://coronavirus.jhu.edu/ 36. sokolow a. with science and scripture, a pastor fights covid-19 vaccine skepticism. stat. 2020 aug 31. [cited 2020 dec 14]. available from: https://www.statnews.com/2020/08/31/with-scienceand-scripture-a-baltimore-pastor-is-fighting-covid19-vaccine-skepticism/ https://doi.org/10.1016/j.ijid.2020.05.036 https://www.washingtonpost.com/religion/2020/12/12/coronavirus-vaccine-nih-francis-collins-faith-leaders/ https://www.washingtonpost.com/religion/2020/12/12/coronavirus-vaccine-nih-francis-collins-faith-leaders/ https://www.washingtonpost.com/religion/2020/12/12/coronavirus-vaccine-nih-francis-collins-faith-leaders/ https://www.devex.com/news/sponsored/ties-between-un-faith-based-groups-poised-to-grow-during-pandemic-98357 https://www.devex.com/news/sponsored/ties-between-un-faith-based-groups-poised-to-grow-during-pandemic-98357 https://www.devex.com/news/sponsored/ties-between-un-faith-based-groups-poised-to-grow-during-pandemic-98357 https://doi.org/10.1515/ijpt-2020-0039 https://www.ccih.org/cpt_resources/covid-19/ https://www.ccih.org/adapting-to-covid-19-reality-to-continue-other-health-services/ https://www.ccih.org/adapting-to-covid-19-reality-to-continue-other-health-services/ https://www.ccih.org/navigating-one-crisis-helped-prepare-for-another-amos-health-hope-responds-to-covid-19-in-nicaragua/ https://www.ccih.org/navigating-one-crisis-helped-prepare-for-another-amos-health-hope-responds-to-covid-19-in-nicaragua/ https://www.ccih.org/navigating-one-crisis-helped-prepare-for-another-amos-health-hope-responds-to-covid-19-in-nicaragua/ https://www.gavi.org/vaccineswork/covax-explained https://doi.org/10.1016/s0140-6736(20)31405-7 https://impakter.com/covid-vaccines-engaging-religious-support/ https://impakter.com/covid-vaccines-engaging-religious-support/ https://www.usnews.com/news/world/articles/2020-09-25/poor-should-get-covid-19-vaccine-first-pope-francis-says https://www.usnews.com/news/world/articles/2020-09-25/poor-should-get-covid-19-vaccine-first-pope-francis-says https://www.usnews.com/news/world/articles/2020-09-25/poor-should-get-covid-19-vaccine-first-pope-francis-says https://time.com/5175704/andrew-wakefield-vaccine-autism/ https://time.com/5175704/andrew-wakefield-vaccine-autism/ https://doi.org/10.1016/j.vaccine.2013.02.026 https://doi.org/10.1038/s41591-020-1124-9 https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/ https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/ https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/ https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/ https://www.pewresearch.org/fact-tank/2020/03/13/amid-coronavirus-threat-americans-generally-have-a-high-level-of-trust-in-medical-doctors/ https://www.pewresearch.org/fact-tank/2020/03/13/amid-coronavirus-threat-americans-generally-have-a-high-level-of-trust-in-medical-doctors/ https://www.pewresearch.org/fact-tank/2020/03/13/amid-coronavirus-threat-americans-generally-have-a-high-level-of-trust-in-medical-doctors/ https://www.pewresearch.org/fact-tank/2020/03/13/amid-coronavirus-threat-americans-generally-have-a-high-level-of-trust-in-medical-doctors/ https://coronavirus.jhu.edu/ https://www.statnews.com/2020/08/31/with-science-and-scripture-a-baltimore-pastor-is-fighting-covid-19-vaccine-skepticism/ https://www.statnews.com/2020/08/31/with-science-and-scripture-a-baltimore-pastor-is-fighting-covid-19-vaccine-skepticism/ https://www.statnews.com/2020/08/31/with-science-and-scripture-a-baltimore-pastor-is-fighting-covid-19-vaccine-skepticism/ 8 quick dec 2020. christian journal for global health 7(5) 37. warren rc, forrow l, hodge da, truog rd. trustworthiness before trust — covid-19 vaccine trials and the black community. n engl j med. 2020;383(22):e121. https://doi.org/10.1056/nejmp2030033 38. quick jd, fryer b. the end of epidemics: the looming threat to humanity and how to stop it. st. martin’s press/macmillan; 2018. 39. dobson ap, pimm sl, hannah l, et al. ecology and economics for pandemic prevention. science. 2020;369(6502):379-381. https://doi.org/10.1126/science.abc3189 40. quick jd. our collective flu complacency is killing us. time. 2018 jan 19. [cited 2019 sept 17]. available from: https://time.com/5107964/flu-2018epidemic/ 41. quick jd, heymann d. the end of epidemics: how to stop viruses and save humanity now. scribe; 2020. submitted: 27 nov 2020, accepted 15 dec 2020, published 21 dec 2020 competing interests: none declared. correspondence: dr. jonathan quick, jonoquick7@gmail.com cite this article as: quick jd. cura personalis, cura communitas: loving our neighbor in covid-19 times. christ j global health. aug 2020; 7(3):3-8. https://doi.org/10.15566/cjgh.v7i3.495 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1056/nejmp2030033 https://doi.org/10.1126/science.abc3189 https://time.com/5107964/flu-2018-epidemic/ https://time.com/5107964/flu-2018-epidemic/ mailto:jonoquick7@gmail.com https://doi.org/10.15566/cjgh.v7i3.495 about:blank references poetry december 2021. christian journal for global health 8(2) i will never see a full moon the same estelle viaud-murata a md(c), wright state university, boonshoft school of medicine, dayton, oh, usa. i will never see a full moon the same since the night i stepped out in the dark, looked up to the moon and heard the cries of a mother who just lost her son. the african moon, so full and so proud, seemed too bright for such a somber night. and my empty hands, which this son once held, sought to grasp the thought of a young, lifeless body left lying on that hospital bed. swaddled by the night’s rich darkness, full of chants, cries, and pains, i am reminded that only what’s done for christ remains. tonight, as my gaze meets again this african moon, from half a world away, i remember the cries, the lost, this life, the strange peace and the hope that we will meet again. what an oddly beautiful night it was to die. so, take courage, dear heart don’t fear the night, don’t fear the pain, rest in his unchanging grace. go, and be the hands of the only son who saves. peer reviewed: submitted 4 sept 2021, accepted 19 sept 2021, published 24 dec 2021 competing interests: none declared. 46 viaud-murat december 2021. christian journal for global health 8(2) acknowledgements: i wrote this poem after a five-week medical mission trip in the democratic republic of congo summer 2021, between my first and second year of medical school. in this poem, i reflect on the death of a patient who accepted christ on the operating table, just two days before his death. in this poem, i write about the process of accepting the patient’s death and the hope that i found in the gospel. i pray this poem will inspire the reader to not shy away from the hardships that can come with medical missions but to fully embrace god’s calling to be his hands and feet to bring the gospel to the ends of the earth. i also hope and pray that this poem will allow the reader to reflect on the gift of eternal life, and inspire him or her to use medicine as an avenue to share the gospel with others. this poem was written so that the reader will reflect on the beauty, the urgency and the power of the gospel. correspondence: estelle viaud-murat. estellemvm@gmail.com cite this article as: viaud-murat e. i will never see a full moon the same. christ j global health. december 2021; 8(2):45-46. https://doi.org/10.15566/cjgh.v8i2.581 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:estellemvm@gmail.com https://doi.org/10.15566/cjgh.v8i2.581 about:blank original article may 2023. christian journal for global health 10(1) prevalence of poor sleep quality and associated factors among the elderly in amirkola, iran seyed reza hosseinia, mostafa dezhalonb, reza ghadimic, ali bijanid, ali zabihie a md, social determinants of health research center, health research institute, babol university of medical sciences, babol, iran b gp, student research committee, babol university of medical sciences, babol, iran c md, social determinants of health research center, health research institute, babol university of medical sciences, babol, iran d md, amirkola children's non-communicable disease research center, health research center, babol university of medical sciences, babol, iran e phd, nursing care research center, health research institute, babol university of medical sciences, babol, iran abstract background & aims: sleep problems have become the most common complaint among the elderly. various factors are involved in the prevalence of poor sleep quality in this age group. due to the lack of community-based data, this study was conducted to determine the prevalence of poor sleep quality among the elderly in amirkola, northern iran. methods: this cross-sectional study is part of the second phase of the amirkola health and ageing project (ahap), a cohort study conducted on all elderly aged 60 and over in amirkola, northern iran, since 2011. the sleep quality and related factors were assessed through pittsburgh sleep quality index (psqi-p) and interviews, respectively. results: of the 1675 older people, 914 (54.6%) were male, and 761 (45.4%) were female, of whom 714 (42.6%) had poor sleep quality. the prevalence of poor sleep quality in women and men was 56.9% and 30.7%, respectively (p <0.001). poor sleep quality was significantly more frequent among unmarried elderly (50.4%) (p = 0.004), those with lower education level (p<0.001), individuals who were living alone (51.3%) (p<0.001), and those with more chronic disease (p<0.001), compared to other groups. older men with diabetes had more poor sleep quality (p=0.048). also, poor sleep quality was significantly related to depression and the number of chronic diseases in both men and women (p<0.001). logistic regression analysis revealed that the female sex (or=2.34, 95% ci (2.85-95.95)) and chronic diseases (or=4.48, 95% ci (2.02-9.93)) had the most important roles in poor sleep quality. conclusion: this study showed a relatively high prevalence of poor sleep quality in older people, particularly among females. therefore, sleep quality inquiry of the elderly seems pivotal in routine public health assessments by physicians and health care providers. keywords: aging, sleep quality, prevalence, sleep 15 hosseini, dezhalon, ghadimi, bijani & zabihi may 2023. christian journal for global health 10(1) introduction as a major public health challenge, the progressive increase in the elderly population highlights the importance of aging studies for health professionals and government officials. physiological aging is concurrent with alterations in quantity, quality, and architecture of sleep, leading to a variety of diseases and causing significant social and economic problems for the elderly. treatment involves psychotherapy, counseling, cognitive behavioral therapy, such as sleep regulation training, sleep hygiene training, and relaxation therapy.1,2 according to the definition, good quality sleep has four characteristics: 1. sleeping at least 85% of the time in bed, 2. falling asleep in less than 30 minutes, 3. waking up more than once, and 4. being awake for a maximum of 20 minutes after first falling asleep. poor sleep quality includes delay in the onset of sleep, short duration of sleep, fragmented sleep, increased time of insomnia in bed, and decreased time of deep sleep.4 sleep is a vital physiological process with important restorative functions.5 as with physical changes in aging, alterations in sleep patterns are also part of the normal aging process.6 however, data from the us national social life, health, and aging project have shown that older adults with greater social participation sleep better; nevertheless, increasing social participation does not improve sleep.7 sleep disorders rank third after headache and gastrointestinal disorders as problems affecting the elderly's quality of life.8 the quality of sleep is a physical and mental health determinant factor that affects not only the daily performance but also the physical capacity of individuals.9 it is also one of the five factors that are considered in evaluating individuals’ physical and mental health.10 sleep is a basic human need, and there is strong evidence that sleep disorders have extensive adverse effects on health.11 sleep disorders are common among the elderly for three reasons: disease, the natural aging process, and psychosocial and economic factors, with negative health-related consequences, including increased complications and mortality.12 along with many physiological alterations in normal aging, sleep patterns change with aging, independent of other factors, such as medical comorbidity and medications. age-related changes in the sleep pattern include advanced sleep timing, shortened nocturnal sleep duration, increased frequency of daytime naps, increased number of nocturnal awakenings and time spent awake during the night, decreased slow wave sleep, and other changes.13 studies have shown that poor sleep quality is common in the elderly and various factors play a role in its occurrence.6,14 a study showed that 33.8% of the elderly had poor sleep quality, which was more common in women (39.2%) than in men (26.3%). the most common abnormal sleep domains were prolonged sleep latency (39.7%), decreased sleep duration (31%), and reduced habitual sleep efficiency (28.8%). furthermore, poor sleep quality was associated with hypertension, coronary artery disease, and chronic obstructive pulmonary diseases.15 according to zhu et. al., the prevalence of poor sleep quality among the elderly in nursing homes was 67.3% and related to aging, the number of chronic diseases, depression symptoms, anxiety symptoms, and social support.16 the elderly population of iran is growing, and this age group is more susceptible to poor sleep quality than other groups.17 although there have been several studies regarding the quality of sleep in different countries and elderly societies, few studies have been conducted in iran with respect to the elderly’s quality of sleep and related factors, most of which have been either on nursing home populations18,19 or on small populations. they have not been based on a general population.20 the aim of this study was to determine the prevalence of poor sleep quality among a general population of elderly in amirkola. materials and methods this descriptive-analytical, cross-sectional study is a part of the second phase (2016-17) of the amirkola health and ageing project (ahap), a cohort study conducted on all older people aged 60 and over in amirkola in the northern part of iran.21 hosseini, dezhalon, ghadimi, bijani & zabihi 16 there are 2135 older people in amirkola, where there are two health care centers. the list of all older people and their addresses are available. all older people were invited to participate in the study through phone calls and home visits while providing the necessary information about the plan. although there are nursing homes under the supervision of the country's welfare organization, in small cities such as amirkola, the elderly still live with their families. older people's place of reference was the social determinants of health research center of the university in amirkola. the necessary information was collected by a trained nurse or midwife using standard questionnaires and examinations. inclusion criteria included age 60 or over and residence in amirkola. exclusion criteria were cognitive impairment, inability to answer questions, reluctance to participate in the study, and incomplete records. this study was conducted after being approved by the ethics committee of babol university of medical sciences with the code ir.mubabol.hri.rec.1398.044. after initial explanation and consent acquisition, individuals were enrolled in this study. data collection tools included a demographic questionnaire (age, sex, education level, living status, and occupation), questions about chronic diseases, and questions about the elderly’s sleep status. the pittsburgh sleep quality index questionnaire (psqi-p) was used to investigate sleep quality. the questionnaire consists of 19 questions scored on a 4-point likert scale ranging from 0 to 3. this questionnaire has seven subscales: subjective sleep efficiency, sleep latency, sleep duration, sleep quality, sleep disturbance, sleep medication use, and daytime dysfunction due to sleepiness. on each scale, scores are defined as zero = no sleep problem, 1 = average sleep problem, 2 = serious sleep problems, 3 = very serious sleep problems. a score above 5 on the whole questionnaire means poor sleep quality. the internal consistency of this questionnaire was assessed by bovis et al. with cronbach's alpha of 0.83.22 the validity and reliability of the persian version of this questionnaire were determined in a study by farahi moghaddam et al. with cronbach's alpha of 0.77, the sensitivity of 94%, and specificity of 72% at cut off 6.23 chronic diseases in this study included diabetes, hypertension, hyperthyroidism, hypothyroidism, stroke, parkinson's disease, dementia, depression, epilepsy, myocardial infarction, angina, heart failure, asthma, emphysema, liver disease, kidney disease, kidney stones, gastric ulcer, urinary incontinence, stool incontinence, any cancer type, headache, arthritis, immune disorders, hearing loss, fractures and consumption of stimulants and antidepressants, the measurement method of which was through documented self-reports. at first, descriptive analysis was conducted to compute all variables' percentages, means, and standard deviations. the t-test was used to identify the significant differences between men and women. a chi-square test was used to identify univariate relationships between the family and social variables and poor sleep quality. multiple logistic regression was used to obtain odds ratios (ors), and 95% cis was employed to examine the associations between factors analyzed in the study and poor sleep quality. all tests were two-sided, and a p-value ≤ 0.05 was considered significant. all analyses were performed using spss software version 18. results of all the 2135 older people under investigation in the second phase of the amirkola cohort, 1675 were eligible for inclusion, of whom 914 (54.6%) were male, and 764 (45.4%) were female. the mean age of the participants was 69.74 ± 7.36 (range 60-96), and the largest cohort (30.7%) belonged to the age group of 65-69 years (table 1). table 1. frequency of distribution and percentage of demographic characteristics in the elderly of amirkola. total male female variable frequency (%) frequency (%) frequency (%) age 440 (26.3) 211 (23.1) 229 (30.1) 64 -60 515 (30.7) 277 (30.3) 238 (31.3) 69 -65 310 (18.5) 169 (18.5) 141 (18.5) 74 -70 17 hosseini, dezhalon, ghadimi, bijani & zabihi may 2023. christian journal for global health 10(1) 212 (12.7) 124 (13.6) 88 (11.6) 79 -75 131 (7.8) 86 (9.4) 45 (5.9) 84 -80 67 (4) 47 (5.1) 20 (2.6) +85 marital status 280 (16.7) 71 (7.8) 209 (27.5) non-married 1395 (83.3) 843 (92.2) 552 (72.5) married level of education 970 (57.9) 453 (49.6) 517 (67.9) illiterate 593 (35/4) 363 (39/7) 230 (30/2) diploma and below 593 (35.4) 363 (39.7) 230 (30.2) university degree living condition 158 (9.4) 44 (4.8) 114 (15) alone 1517 (90.6) 870 (95.2) 647 (85) with family the number of chronic diseases 38 (2.3) 28 (3.1) 10 (1.3) 0 508 (30.3) 369 (40.4) 139 (18.3) 1-2 746 (44.5) 405 (44.3) 341 (44.8) 3-5 383 (22.9) 112 (12.3) 271 (35.6) >5 poor sleep quality 961 (57.4) 633 (69.3) 328 (43.1) no 714 (42.6) 281 (30.7) 433 (56.9) yes in this study, 714 (42.6%) of almirola’s elderly suffered from poor sleep quality. the prevalence of poor sleep quality in women (56.9%) was higher than in men (30.7%) (p<0.001). poor sleep quality was prevalent in unmarried elderly (p=0.004), those with lower education levels (p<0.001), and those who lived alone (p=0.021). totally, 65.8% of the elderly with more than five chronic diseases had significantly more poor sleep quality (p<0.001) (table 2). the present study showed that elderly men with diabetes had more poor sleep quality (p=0.048). poor sleep quality was significantly related to depression and the number of chronic diseases in both men and women (p<0.001). in this research, poor sleep quality was not significantly associated with living alone and marital status in both men and women (table 3). moreover, there was a significant positive correlation between the number of chronic diseases and the score of poor sleep quality (r = 0.241, p <0.001) (figure1). after entering all variables in the logistic regression model, gender (or= 2.34, ci 95% (1.85-2.95)) and chronic diseases (more than five diseases) (or = 4.48, ci 95% (2.02-9.93)) contributed the most to poor sleep quality. table 2. odds ratios and confidence interval of effective variables on poor sleep quality in raw and adjusted models based on the logistic regression in the elderly of amirkola. p-value adjusted or (95% ci) p-value crude or* (95% ci**) poor sleep quality variables no yes frequency (%) frequency (%) gender 1 1 633 (69.3) 281 (30.7) male >0.001 2.34 (1.85-2.95) >0.001 2.97 (2.43-3.64) 328 (43.1) 433 (56.9) female age 0.339 1 0.620 1 264 (60) 176 (40) 60-64 0.632 1.07 (0.81-1.42) 0.363 1.13 (0.87-1.46) 294 (57.1) 221 (42.9) 65-69 0.529 0.90 (o.65-1.25) 0.723 1.06 (0.79-1.42) 182 (58.7) 128 (41.3) 70-74 0.362 1.19 (0.82-1.73) 0.163 1.27 (0.91-1.76) 115 (542) 97 (45.8) 75-79 0.135 1.40 (0.90-2.18) 0.181 1.31 (0.88-1.94) 70 (53.4) 61 (46.6) 80-84 0.233 1.42 (0.80-2.54) 0.332 1.29 (0.77-2.17) 36 (53.7) 31 (46.3) 84-99 marital status 1 1 139 (49.6) 141 (50.5) non-married 0.377 1.18 (0.82-1.68) 0.004 0.69 (0.53-0.89) 822 (58.9) 573 (41.1) married level of education 1 1 515 (53.1) 455 (46.9) illiterate 0.623 0.94 (0.75-1.19) 0.001 0.71 (0.58-0.88) 364 (61.4) 229 (38.6) diploma & below 0.133 0.70 (0.43-1.12) <0.001 0.41 (0.27-0.64) 82 (73.2) 30 (26.8) university degree hosseini, dezhalon, ghadimi, bijani & zabihi 18 table 2. (continued) living condition 1 1 884 (58.3) 633 (41.7) with family 0.694 1.09 (0.70-1.70) 0.021 1.47 (1.o6-2.04) 77 (48.7) 81 (51.3) alone the number of chronic diseases 1 1 29 (76.3) 9 (23.7) 0 0.585 1.25 (0.57-2.73) 0.57 1.25 (0.58-2.71) 366 (72) 142 (28) 1-2 0.083 1.99 (0.92-4.33) 0.032 2.30 (1.08-4.94) 435 (58.3) 311 (41.7) 3-5 <0.001 4.48 (2.02-9.93) <0.001 6.20 (2.85-13.48) 131 (34.2) 252 (65.8) >5 note. **ci: confidence interval * or: odds ratio table 3. poor sleep quality in elderly women and men according to clinical and demographic characteristics p-value no frequency (%) male poor sleep quality yes frequency (%) p-value female poor sleep quality variables no yes frequency (%) frequency (%) living condition 601 (69.1) 269 (30.9) 0.396 283 (43.7) 364 (56.3) with family 0.609 32 (72.7) 12 (27.3) 45 (39.5) 69 (60.5) alone marital status 50 (70.4) 21 (29.6) 0.859 89 (42.6) 120 (57.4) non-married 0.824 583 (69.2) 260 (30.8) 239 (43.3) 313 (56.7) married diabetes 150 (64.1) 84 (35.9) 0.984 124 (43.1) 164 (56.9) yes 0.048 483 (71) 197 (29) 269 (56.9) 204 (43.1) no depression 135 (54.4) 113 (45.6) < 0.001 192 (52.6) 173 (47.4) yes < 0.001 498 (74.8) 168 (25.2) 136 (34.3) 260 (65.7) no the number of chronic diseases < 0.001 21 (75) 7 (25) < 0.001 8 (80) 2 (20) 0 287 (77.8) 82 (22.2) 79 (56.8) 60 (43.2) 1-2 270 (66.7) 135 (33.3) 165 (48.4) 176 (51.6) 3-5 55 (49.1) 57 (50.9) 76 (28) 195 (72) >5 figure 1. the relationship between pittsburgh sleep quality index and the number of chronic diseases by sex in the elderly of amirkola 19 hosseini, dezhalon, ghadimi, bijani & zabihi may 2023. christian journal for global health 10(1) discussion the findings of this study revealed that 42.6% of the elderly suffered from poor sleep quality. this result coincides with the results of studies by luo et al. in china,24 weerakorn et al. in thailand,25 and razali et al. in malaysia,26 in which 41.5%, 44%, and 47.2% of the elderly, respectively, had poor sleep quality. however, in studies by gouthaman et al. in india,27 gulseren et al. in turkey,28 and berhanu et al. in ethiopia,29 65.2%, 63.3%, and 65.4% of the elderly, respectively, were afflicted with poor sleep quality, which is relatively higher than the results of this study. in addition, wang et al. in china30 and aliabadi et al. in iran 31 reported that 33.8% and 31% of the elderly, respectively, had poor sleep quality, which was demonstrated to be less than that of our study. the variations among studies might be due to socioeconomic status, cultural habits, and different lifestyles across countries. moreover, the prevalence of poor sleep quality varies according to the cut-off point in the psqi score. for instance, in wang's study, the psqi score was assigned to be more than 730; in other studies, this score was more than 5.20,24,25 in the present study, a score greater than 5 was considered poor sleep quality. in the present study, the prevalence of poor sleep quality among women was significantly higher than that of men, which is consistent with other studies, such as wu et al. in china,32 dehghankar et al. in iran,33 kara et al. in turkey,34 and lue et al. in china.24 various reasons have been proposed by dong et al. and leblanc et al. regarding this increase among women, including the lower level of education and individual income and higher frequency of chronic diseases compared to men. furthermore, women are more prone to depression and anxiety.35,36 there is evidence that supports the effect of sex hormones on rapid and slow movements of the eyes during sleep as well as circadian rhythm through its effects on estrogen and progesterone receptors in the brain.37 hence, older women suffer from sleep complications, including long sleep latency, frequent awakening during the night, and shorter sleep.38 in the present study, the frequency of poor sleep quality increased with age, although this difference was not statistically significant, which is consistent with the results of the berhanu et al.29 and razali et al. studies. 26 however, wu et al. and luo et al.24 reported an elevation in poor sleep quality with age. growth hormone (gh) or somatotropin secretion has been proven to decrease with age.39 deep sleep also decreases markedly with age. in addition, a decrease in nighttime gh secretion and sleep disorders become a significant clinical problem in old age.40 in fact, between the ages of 20-59, the level of gh in the body decreases by about 14% per decade, and at age 60, gh secretion is reduced to a greater extent.41 in addition, with aging, melatonin levels decrease in comparison to younger individuals, which may lead to poor sleep quality.42 other causes include a decrease in testosterone levels by approximately 1% per year in men, which can lead to sleep consolidation aggravation and an increase in the frequency of awakening in the elderly.43 in this study, poor sleep quality in married elderly was significantly lower in comparison to unmarried individuals, which was consistent with the results of studies by wu et al.32 and luo et al.24 nevertheless, no correlation between marital status and sleep quality in the elderly was reported in studies by dehghankar et al.33 and razali et al.26 married people are supported by their family members; however, single people are deprived of this type of support, which can lead to stress and sleep problems. in this research, there was a significant relationship between education level and sleep quality; individuals with higher education suffered from fewer sleep problems, which is concurrent with other studies conducted in this field.24,32 however, in the study by weerakorn et al. in thailand, higher levels of education were associated with an increase in sleep disorder, which was considered to be related to job stress.25 in the study by dehghankar et al.33 and gouthman et al.,27 no significant correlation was found. lower education level is accompanied by manual occupations and long working hours, which may contribute to an increase in the occurrence of poor hosseini, dezhalon, ghadimi, bijani & zabihi 20 sleep quality. in addition, individuals with higher education are associated with health-promoting activities that prevent activities leading to poor sleep quality. moreover, lower literacy levels are associated with choosing an unhealthy lifestyle, which leads to lower sleep quality. in addition, higher literacy levels are associated with more prestigious jobs and, subsequently, higher income levels.44 in this study, the prevalence of poor sleep quality was significantly elevated with an increasing number of chronic diseases in the elderly, which fully coincides with the studies by wang et al.30, luo et al.24, kumari et al.45 and razali et al.26 the effect of any chronic illness on sleep disturbance may not be substantial enough; however, some synergistic and cumulative effects of pain and mental and physical disorders may result in poor sleep quality. in some diseases, such as hypertension, insomnia is caused by side effects of medications such as diuretics, which cause night awakening, or beta-blocker side effects on the central nervous system leading to insomnia, nightmares, and depression.46 the results of the present study showed that the poor sleep quality of the elderly is related to a number of factors relating to gender; poor sleep quality is more likely in diabetic men. also, poor sleep quality in both elderly women and men has a significant relationship with depression and the number of chronic diseases. in the study of hsu et al., depression and the number of chronic diseases were reported as the main risk factors for sleep disorders in the elderly.47 suffering from most chronic diseases through causing physical discomfort or biological mechanisms leads to movement problems, adl limitation, chronic pain, depression, economic burden, and negative emotions, and finally, poor sleep quality in the elderly. the mutual relationship between poor sleep, chronic diseases, as well as depression, is a loop, and they influence each other.48 therefore, with an ever-increasing elderly population, public health attention and effective interventions for depression are necessary. this may be achieved by improving daily activities in the elderly with chronic diseases. one of the strengths of the present study was its implementation as a cohort study with high participation of the elderly in amirkola. of 2135 older people under investigation in the second phase of the amirkola cohort, 1675 were eligible to enter the study. this study suffered from some limitations. the first constraint was its crosssectional entity, making it challenging to establish cause-and-effect relationships. second, the diagnosis of some chronic diseases, such as heart and lung diseases, was based on self-report, which may or may not be biased, although the diagnosis of many, including hypertension and diabetes, was based on standard methods. third, adjustments have been implemented for some variables; however, other factors, such as body mass index, physical activity, anxiety, and diet, have not been adjusted. forth, the psqi questionnaire employed in the present study had a sensitivity of 98% and a specificity of 55% in the diagnosis of primary poor sleep quality and its low specificity implies a risk of misclassifying normal individuals as poor sleepers and, therefore, leading to an overestimation of reported prevalence in this study. fifth, self-reporting was employed instead of a more accurate methodology, i.e., polysomnography, to determine sleep quality in this study, although the latter was not feasible in a study of this extent. conclusion this study demonstrated that two out of every five older people in amirkola, especially older women, suffered from poor sleep quality. poor sleep quality was more common among the elderly with lower education, living alone, suffering from chronic diseases, and being single. hence, comprehension of these factors can aid nurses and other treatment team members in planning to enhance sleep quality in the elderly. another point worthy of consideration is the acquaintances and families of elderly suffering from poor sleep quality. by providing the necessary training to the family members (spouse and children) about the elderly’s sleeping pattern, their illness and treatment, caring for them, treating and supporting them, and accompanying and 21 hosseini, dezhalon, ghadimi, bijani & zabihi may 2023. christian journal for global health 10(1) regularly referring them to health centers for examination, investigation, and disease control, positive measures can be taken to resolve or reduce this situation. moreover, considering the impact of poor sleep quality on health, healthcare providers should regularly monitor sleep quality and provide interventions for sleep health education and behavior change. educational messages should include advising the elderly to go to bed 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bl. the influence of sex and gonadal hormones on sleep disorders [internet]. chrono physiol ther. 2014;4:15-25. https://doi.org/10.2147/cpt.s44667 38. suzuki k, miyamoto m, hirata k. sleep disorders in the elderly: diagnosis and management. j gen fam med. 2017;18:61-71. https://doi.org/10.1002/jgf2.27 39. garcia jm, merriam gr, kargi ay. growth hormone in aging [internet]. endotext, 2019 oct 7. available from: https://pubmed.ncbi.nlm.nih.gov/25905386/ 40. sattler fr. growth hormone in the aging male. best practice & research. clin endocrin metabol. 2013 aug 1;27(4):541-55. https://doi.org/10.1016/j.beem.2013.05.003 41. blackman mr. age-related alterations in sleep quality and neuroendocrine function: interrelationships and implications. jama. 2000;284:879-81. https://doi.org/10.1001/jama.284.7.879. 42. hassan na, gunaid aa, el-khally fm, murray-lyon im. the effect of chewing khat leaves on human mood. saudi med j. 2002;23:850-3. 43. jackson c, gaston s, liu r, mukamal k, rimm e. the relationship between alcohol drinking patterns and sleep duration among black and white men and women in the united states. int j env res public health. 2018;15:557. https://doi.org/10.3390/ijerph15030557 44. galobardes b, shaw m, lawlor da, lynch jw, smith gd. indicators of socioeconomic position (part 1). j epidemiol commun health. 2006;60:7-12. https://doi.org/10.1136/jech.2004.023531 45. kumari r, gupta rk, langer b, singh p, akhtar n. insomnia and its associated factors: a cross-sectional study in rural adults of north india. int j med sci public health. 2018;7:8005. https://doi.org/10.5455/ijmsph.2018.061801506 2018001 46. pandi-perumal s, verster j, monti j, langer s. sleep disorders: diagnosis and therapeutics: taylor & francis us; 2008. https://doi.org/10.3109/9780203091715 47. hsu mf, lee ky, lin tc, liu wt, ho sc. subjective sleep quality and association with depression syndrome, chronic diseases and health-related physical fitness in the middleaged and elderly. bmc public health. 2021 dec;21:1-9. https://doi.org/10.1186/s12889021-10206-z 48. jiang ch, zhu f, qin tt. relationships between chronic diseases and depression among middle-aged and elderly people in china: a prospective study from charls. curr med sci. 2020 oct;40(5):858-70. https://doi.org/10.1007/s11596-020-2270-5 peer reviewed: submitted 15 may 2022, accepted 21 march 2023, published 29 may 2023 competing interests: none declared. acknowledgements: we hereby thank the honorable vice-president of research and technology of the babol university of medical sciences for providing the funding for this project, no. 5125, colleagues in health centers no. 1 and 2 in amirkola for their assistance in this project, and the venerable elderlies of amirkola for participating in this study. correspondence: dr. ali zabihi, babol, iran. zabihi_alii@yahoo.com cite this article as: hosseini sr, dezhalon m, ghadimi r, bijani a & zabihi a. prevalence of poor sleep quality and associated factors among the elderly in amirkola, iran. christ j global health. may 2023; 10(1):14-23. https://doi.org/10.15566/cjgh.10i1.659 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.2147/cpt.s44667 https://doi.org/10.1002/jgf2.27 https://pubmed.ncbi.nlm.nih.gov/25905386/ https://doi.org/10.1016/j.beem.2013.05.003 https://doi.org/10.1001/jama.284.7.879 https://doi.org/10.3390/ijerph15030557 https://doi.org/10.1136/jech.2004.023531 https://doi.org/10.5455/ijmsph.2018.0618015062018001 https://doi.org/10.5455/ijmsph.2018.0618015062018001 https://doi.org/10.3109/9780203091715 https://doi.org/10.1186/s12889-021-10206-z https://doi.org/10.1186/s12889-021-10206-z https://doi.org/10.1007/s11596-020-2270-5 mailto:zabihi_alii@yahoo.com https://doi.org/10.15566/cjgh.10i1.659 http://creativecommons.org/licenses/by/4.0/ abstract keywords: aging, sleep quality, prevalence, sleep introduction discussion conclusion field report nov 2015. christian journal for global health, 2(2):72-75. making distribution of wheelchairs sustainable: a wheels for the world program in north india, october 2015 jubin varghese a , nicole hughes b , nathan grills c , mukesh kumar d , lawrence singh e , raj kumar f a ma, deputy director of community health and disability program manager, emmanuel hospital association, india b ba (physiotherapy), nossal institute for global health, melbourne, australia c mbbs, mph, dphil, nossal institute of global health, university of melbourne, australia d ba, b.th, project officer, herbertpur christian hospital, emmanuel hospital association, india e b.sc, project coordinator, agnes-kunze society f ma, msw, project manager, landour community hospital, emmanuel hospital association, india the wheels for the world program is a program of joni and friends (jaf) wherein they make wheelchairs available to different parts of the world, and a team of volunteers travel to assess, modify, and fit wheelchairs for people with disabilities. they do all this in the love of jesus and demonstrate the same mind as jesus through their presence and service. in october 2015, the first wheels for the world program in north india took place. this program went ahead, despite concerns expressed by local north indian partner organisations who asked about the sustainability and appropriateness of a foreign group coming in, charitably providing wheelchairs, and then leaving. concerns about wheelchair distributions has been well documented elsewhere. 1 however, the north indian partners decided to be intentional about assuring that this event was sustainable, improved local knowledge, and linked with existing programs before and after the event. in this report, we outline the aspects that ensured this was the case. to ensure the smooth running, contextualization, and sustainability of the 2015 north india wheelchair distribution (wcd), the two main event partners, community health global network, uttarakhand chapter (chgn-ukc), and the engage disability regional hub came together to plan and strategize. a working committee was formed with members of each organization, as well as international partners, and they were given the responsibility for the logistics of the event. herbertpur christian hospital was chosen as the venue as it was near dehradun, north india, central to access, and had the appropriate facilities. the first action towards sustainability was ensuring the involvement of multiple local partners and health organizations from north india. this enabled the wcd to be contextualized and ensured an ongoing impact. operation equip india is the indian partner of jaf, and they helped with logistic planning and provided orthotists, physiotherapists, occupational therapists, etc. to support the foreign team. the chgn-ukc is a group of faith-based organizations involved with health programs throughout uttarakhand and have been focusing their work on disability inclusive programs. chgn-ukc led the local development of the wcd and linked their 50-member programs into the event for referrals, fundraising, and support. the final key partner was engage disability regional hub, a group formed following the engage disability conference in 2013 that focused on the church being central. practical steps that ngos could take to help support the ministry of the church alongside those affected by disabilities were suggested. the engage disability regional hub involvement en73 varghese, hughes, grills, kumar, singh, rajkumar nov 2015. christian journal for global health, 2(2):72-75. sured that local churches were incorporated in the program and provided assurance of long term local follow-up for participants of the wcd. the engage disability regional hub has been training pastors in the different local areas on disability for the last few years, and involvement in the wcd was seen as a practical follow-up of the training. the wcd was seen as an additional step in a series of activities to sensitize and to help the church engage with the community of those affected by disabilities. therefore, the organizers decided that the event would be conducted through the local churches and pastors. this was done by means of the following:  information dissemination in the churches to raise prayer support, funds, volunteers, and referrals.  training for pastors on identifying needs of people affected by disability and completing referral forms. pastors are linked locally and well placed to identify people with disabilities in their villages.  the forms were screened on submission and dates were set for local herbertpur physiotherapists and occupational therapists to meet with the people and do an initial assessment of the individual, home situation, and appropriateness for wheelchairs/aids.  plans were made to transport people to herbertpur for the wcd and back with their wheelchairs and other aids.  training was conducted for volunteers assisting with the wcd, including those who would be providing counseling. in securing the involvement of church leaders, the following key actions were found to be important: enlist: key church leaders were enlisted in planning and organizing for their particular regions. envisage: they were then helped to see the vision of the event and the future directions through workshops and meetings. communicate: regular communication was maintained through phone and church visits to keep the idea on the radar. act: church leaders developed specific plans of action for various churches. consolidate: process of consolidation has been taken up following the event. the engagement with the chgn-ukc members promoted sustainability in a number of ways. this engagement meant that local therapists and program staff who were present and assisting in wheelchair fitting already knew the recipients that had been referred. because the wcd team was well informed about the recipients and advice provided for follow-up, further fittings and reviews could often be given directly to their local therapist. the presence of the local therapists also meant that the foreign team could work closely with the local therapists for the wheelchair fittings. many of the local therapists commented that they learnt more about fitting wheelchairs and mobility aids than they had in their entire training secondary to the expertise and experience of the international therapists and their capacity-building approach. the therapists were also taught how to modify and maintain the wheelchairs and other mobility aids. finally, the therapists also became part of a fellowship of therapists from various local programs and from overseas. these linkages helped ensure long term sustainability and local empowerment. the outcomes can be summarized as:  the dehradun city churches were involved through prayer support and raising funds to cover the costs of transportation from the camp site to their homes and other local costs and referrals.  seventeen house churches and 30 church volunteers were involved in conducting 74 varghese, hughes, grills, kumar, singh, rajkumar nov 2015. christian journal for global health, 2(2):72-75. surveys in their communities, supporting the submission of the application forms, arranging the transportation, and staying with those who had come for aids during their assessments. during the application submission process, a number of people learned for the first time about disability certificates given by the government and their uses.  local pastors identified 310 persons with disability who required aids, and local therapists conducted 310 initial assessments to evaluate individual needs prior to the detailed assessment during the wcd. selection was based on need alone and no preference was given on basis of gender, caste, age, or faith.  overall, 210 wheelchairs, 46 crutches, 42 walkers, and 32 canes were distributed, and each person was counseled and connected with the local pastor. the pastors have been given the responsibility of following up with the families with whom they have developed relationships through the last three months of survey, assessments, and wcd. the local pastors are able to work with families to help improve access to health services, community support/engagement, and access to governmental supports.  eight local therapists were trained and developed links and relationships with each other and with expertise from america. additionally, staff and volunteers from the local programs developed closer friendships with families and pastors which should facilitate closer cooperation between ngo and churches in the future. follow-up visits with pastors have revealed stories of improved relationships with the community due to their stepping alongside those often neglected and by people with disability experiencing “love in action.” in one of the regions, the pastors and second line leaders of house churches have committed to further disability training, beginning in november. the city churches are moving them towards a joint action to promote disability inclusion before the end of the year. in conclusion, although wheelchair distributions have been criticized for being charity, for disempowering local programs, for unsustainability and inappropriateness, we believe this model avoids these pitfalls. by means of working through and with local disability programs, engaging with recipients before and after the event, recruiting religious leaders and training local therapists, this approach is more empowering, builds community, and benefits individuals in a way that accounts for their life context. references 1. krizack m. international wheelchair standards organizing committee formed [internet]. disability world. 2007;27. available from: http://www.disabilityworld.org/1201_06/wheelchairstandards.shtml competing interests: none declared. correspondence: jubin varghese, emmanuel hospital association, india. jubin@eha-health.org nicole hughes, nossal institute for global health and the university of melbourne, australia. nicolehughes4@gmail.com nathan grills, nossal institute for global health and the university of melbourne, australia. ngrills@unimelb.edu.au http://www.disabilityworld.org/12-01_06/wheelchairstandards.shtml http://www.disabilityworld.org/12-01_06/wheelchairstandards.shtml mailto:jubin@eha-health.org mailto:nicolehughes4@gmail.com mailto:ngrills@unimelb.edu.au 83 varghese, hughes, grills, kumar, singh, rajkumar nov 2015. christian journal for global health, 2(2):72-75. cite this article as: varghese j, hughes n, grills n, kumar m, singh l, kumar r. making distribution of wheelchairs sustainable: a wheels for the world program in north india, october 2015. christian journal for global health (nov 2015), 2(2): 72-75. © varghese j, hughes n, grills n, kumar m, singh l, rajkumar this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://creativecommons.org/licenses/by/3.0/ short communication june 2022. christian journal for global health 9(1) why are medsend grant recipients leaving the mission field? an internal review james v ritchiea, patricia woodsb a md, former medical missionary and emergency physician, longevity project for medsend, usa b vice president of grant management, medsend, usa introduction attrition of healthcare missionaries is a significant issue. the global health workers needs assessment survey (ghwna) of current and former medsend1 grant recipients found that the average length of service was 4.77 years.2 ending service after five years of experience has been described as particularly disappointing, because at this stage missionaries tend to be perceived as culturally competent and are able to pursue tasks more in line with their skills and interests.3 in the last few years, medsend has noted that the rate of departures from the field has been increasing. some have estimated that the cost of supporting an american missionary family of five for five years is $395,000 usd.3 a large portion of that cost is incurred in preparation and set-up. the personal cost to the missionaries, their families, their teams, their supporters, their patients and their hosts in an earlier-than-anticipated departure is impossible to estimate but is substantial. the experience of healthcare missionaries is different from that of other types of missionaries, such as church planters or bible translators. healthcare missionaries tend to be exposed to much more death, suffering, and life-and-death ethical dilemmas, which are compounded in a cross-cultural setting. the reasons for healthcare missionaries’ departure from the mission field can be expected to have some differences from other types of missionaries. previous studies have sought to understand the reasons for departure specifically for healthcare missionaries, usually using survey instruments.4,2 those studies have proven to be very useful in guiding retention and support efforts. medsend has a relatively unique window into this issue because we work with missionaries from many different sending agencies, serving in many different geographic and professional fields. medsend has initiated a longevity project, which is committed to support healthcare missionaries in thriving on the mission field and prevent avoidable attrition. when a medsend grant recipient leaves the field, we conduct an exit interview and, therefore, have a corpus of potentially useful information to help guide efforts to lessen healthcare missionary attrition. this internal review of those exit interviews was conducted to guide the efforts of the longevity project and to assess whether previouslyreported issues remained problematic and whether additional issues deserved attention. though the information from our exit interviews is relatively unstructured and, therefore, its interpretation is subject to significant limitations, we chose to use this available information while preparing for a more structured prospective study. further, many of our interviews have been conducted within the last two years, and so, we had opportunity to consider the contribution of covid19-related issues. we believe that the information in aggregate has the potential to be helpful in guiding efforts toward healthcare missionary longevity. methods medsend conducted an internal review of the exit interviews of all medsend grant recipients who ritchie & woods 118 left the mission field between january 2018 and october 2021. the reviewers used notes from exit interviews and recollections of personal conversations with these missionaries. all available pertinent issues regarding the reason for departure from the field were identified and categorized. the authors worked together in identifying issues and categorizing them. no attempt was made to verify the missionaries’ reports with any other source, and reports were accepted as they were presented. when themes were tallied, we noted a clear grouping of major themes. three themes were reported by 9–12 individuals, and no other theme was reported by more than five individuals. therefore, themes were categorized as “major” if they were reported by 9–12 grant recipients, and “minor” if they were reported by 2–5 grant recipients. themes that were reported only once were considered to be “isolated.” results records of 53 missionary “units” were reviewed. “units” may be defined as a single missionary, a married healthcare missionary and his or her family, or two married healthcare missionaries and their family. ten records did not include data regarding reasons for departure and were not considered further. forty-three records described at least one reason for departure. because of the limitations of this data, it would be inappropriate to report percentages or overall importance of contribution to the reason for departure from the field. but there was a preponderance in reporting of certain themes. major themes (9–12 responses) included: • overwork associated with burnout • inability to obtain licensure or visas, or inability to work in one’s field • change in personal situation (such as new marriage, marital problems, children’s educational needs) • change in role (such as change in vocation, transition to headquarters leadership) minor themes (2–5 responses) included: • isolation and lack of support • issues with leadership or management • personal safety • covid-associated issues • team issues / interpersonal conflict • medical problem or need for ongoing counseling • cultural adjustment problem isolated themes (1 response each) included: • called by god to return • financial hardship • frustrations working with national staff in this report, we choose not to expound on themes such as change in personal situation or change in role, as they may be unavoidable. surely, some of those changes were associated with other issues. for instance, marital problems may be associated with overwork or isolation, but we did not have enough information to confidently make such connections. comments by category major themes overwork associated with burnout: this category was the most commonly reported avoidable issue. several missionaries reported that overwork was well known as a problem at their station, but it was accepted by leadership as part of medical mission work. some reported that attempts to establish boundaries to prevent burnout were not appreciated by others on the team and led to team conflict. some reported that they had no idea there could be ethical boundaries to limit work. in contrast, some missionaries who had left the field for other reasons reported strong support from their team toward personal and team boundaries which allowed a healthy and balanced work schedule. inability to obtain visas or licensure or inability to work in one’s field: some felt that their host countries were deliberately seeking to deport missionaries and were using visas and licensure as means to remove them without direct confrontation. 119 ritchie & woods june 2022. christian journal for global health 9(1) however, a significant number of missionaries reported that they went to their station without adequate administrative preparation. for instance, some reported that their country of service required that they have work permits prior to arrival, and when they arrived without work permits, this prevented them from ever being approved for work permits. some reported that they were not able to work for years due to an administrative oversight. minor themes isolation and lack of support: several reported that they served as the only missionary or only westerner or only medical person at their station, and the lack of community or acceptance or support was intolerable. some reported that they were not accepted by their host community or team, which rendered their service fruitless in some ways. issues with leadership or management: this category included issues with both expatriate and national leadership, and the themes were similar in both groups. some missionaries reported that they felt powerless in an authoritarian structure. some noted that work was overprioritized above personal needs. personal safety: significant safety issues were reported with varying ability to cope by different members of families. a few missionaries reported that they had received no significant preparation to function in their high-threat place of service. covid-associated: the problems associated with covid-19 were diverse, including difficulty in travel, lockdowns preventing their work, team conflicts, family conflicts, hostility among hospital staff and among people in the community, and concern about a family member’s ability to be treated after acquiring covid. team issues / interpersonal conflict: issues with teammates did contribute to the decision to depart in a significant number of our missionaries. however, we did not find this to be a major contributor unless it was paired with leadership issues. medical problem or need for ongoing counseling: from information available in these interviews, it seemed that most of the individuals who needed more extensive counseling were receiving counseling due to experiences on the field which led to moral injury or trauma. most of the medical problems (such as cancer or diabetes) did not seem to have been specifically related to the location of service, though this was impossible to ascertain with certainty. cultural adjustment problem: a few missionaries or their spouses or children were not able to adequately adjust to the new culture. specific issues included being seen as only providers of money, a perception of disregard for the truth among colleagues, untrustworthy behavior in patient care among colleagues, and inability to have personal boundaries. discussion previous studies have reported on healthcare missionary attrition statistics.5,2 these studies usually are structured as written surveys using predetermined likert scales. our report instead used information from relatively unstructured exit interviews. though the unstructured nature of these interviews led to significant limitations in interpretation, this unstructured nature also provided an opportunity for the participant to introduce issues which might not have been included in a likert-scale survey. for instance, in the prism study, the issue of overwork with burnout was not provided as an option in the survey, and we found that this issue was our single most commonly-reported reason leading to departure. our two major preventable issues, burnout associated with overwork and inability to obtain licensure or permits or inability to work in one’s field, deserve further comment. overwork with concomitant burnout was our most commonly-reported serious issue. burnout and overwork are not identical, but for the purposes of our coding, the two concepts were consistently related. the prism study did not assess overwork as a cause of attrition in its survey.4 the ghwna study did note burnout as a cause of attrition, but it ritchie & woods 120 was reported as a “contributing” factor, rather than a “top” factor, and the category of overwork was not reported.2 we believe this issue to be far more important currently than has been previously recognized. this opinion is shared by gail gambill, director of the post-residency program at samaritan’s purse/world medical mission (personal communication, mar 2022). she states confidently that overwork is the most common reason for departure from their program. difficulty in obtaining licensure or work permits and inability to work in one’s field have been recognized as significant problems before.2,4,6 nonetheless, several of our grant recipients reported that they arrived at their mission stations without adequate preparation for licensure or permits or without ensuring that they would be able to work in their fields. some said they were advised that such preparations were not critical and that they could manage the arrangements after arrival. however, in some cases, arrangements were impossible after arrival. some governments will not consider license or work applications after the individual has arrived in the country. this issue must be recognized by missionaries and sending organizations as a vital prefield preparation. comments regarding some “minor themes” we were impressed by the need of support for healthcare missionaries who serve alone. some missionaries who seemed particularly well-suited and otherwise well-prepared for healthcare missions service described isolation and lack of support as the primary reason for their departure. the emotionally and spiritually challenging nature of healthcare missions may cause a greater need for supportive community. covid-related issues were identified as factors contributing to departure in four of our 43 interviews. we were surprised that this issue was so rarely reported. we are aware of some missionaries who were required to depart their stations of service and have been waiting in the us for an opportunity to return. such missionaries were not included in this analysis. recommendations from this body of information, some recommendations are warranted to combat attrition of healthcare missionaries. • agencies, and especially stations, should embrace and actively develop teamsupported boundaries to prevent overwork and burnout. • agencies should ensure that all requirements for licensure and immigration status are known and reasonably satisfied prior to sending missionaries to the field, especially if it may impact their ability to commence work upon their arrival. • agencies should avoid sending missionaries to isolated duty unless they have been carefully vetted and found able to set and maintain personal boundaries, are especially able to integrate into a supportive community, and have an intentional group of supporters to maintain regular contact. • stations should prioritize strong community and mentorship to support all on the team, to include dealing with trauma and moral injury as well as building team relationships. the information in this brief report is subject to several important limitations. the information was provided by the missionaries themselves to representatives of our organization and no effort was made to verify the information’s accuracy or completeness. such efforts may not have added to accuracy. according to previous reports of reasons for missionary attrition, correlation between the missionaries and their sending organizations tends to be low.2,6 the information in our report was not obtained in a structured, prospective fashion but was instead gleaned from unstructured notes. however, the information in this report is consistent with our experience obtained in other venues. we hope that this information may be used to help healthcare missionaries thrive in their vital and strategic service and strengthen the overall impact and successful utilization of healthcare missions in the sharing of the gospel. 121 ritchie & woods june 2022. christian journal for global health 9(1) references 1. medsend assists healthcare missionaries with grants to cover their monthly educational debt payments. these missionaries, or “grant recipients,” all serve with mission agencies which have relationships with medsend. 2. strand ma, wood a. that healthcare missionaries might flourish: global healthcare workers needs assessment report. medsend; 2015. 3. strand ma, chen, ai, pinkston lm. developing cross-cultural healthcare workers: content, process and mentoring. christ j global health. 2016;3(1):57– 72. https://doi.org/10.15566/cjgh.v3i1.102 4. strand ma. medical missions in transition: taking to heart the results of the prism survey. christian medical and dental association. 2011. 5. missio nexus. field attrition study research report. 2019. available from: https://missionexus.org/2019attrition-study-research-report/ 6. strand ma, paulson e, myrick t. characterizing the global context for cross-cultural healthcare work by regions of the world. christ j global health. 2015;2(2):23–38. https://doi.org/10.15566/cjgh.v2i2.78 submitted 3 nov 2021, accepted 30 mar 2022, published 20 jun 2022 competing interests: none declared. correspondence: james v ritchie, longevity project, medsend, usa. jim@medsend.org cite this article as: ritchie jv, woods p. why are medsend grant recipients leaving the mission field? an internal review. christian journal for global health. june 2022; 9(1):117-121. https://doi.org/10.15566/cjgh.v9i1.603 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank about:blank about:blank about:blank about:blank https://doi.org/10.15566/cjgh.v9i1.603 about:blank introduction methods results comments by category discussion references editorial december 2021. christian journal for global health 8(2) evidence of church unity for global health this issue completes eight years of publishing the christian journal for global health. at the beginning hardly anyone would have predicted that global health would become first in the minds of the majority of the earth’s population or that an infectious calamity would become the focus of global attention. in fact, health in a global sense is testimony to the unity of the human race at a time when fractionation is a strategy for political hegemony. the christian understanding of humans, made in the image of god and called to steward the creation, is a fundamental basis for this unity. the editors see the journal as a way to join this understanding with a vision of health for all nations. the journal editors have issued a call for papers on vaccinations and christian social responsibility which we anticipate publishing early in 2022. as a foretaste of that, this end-of-year issue has a commentary by professor steffen flessa on vaccination against covid-19 as a christian duty? a risk-analytic approach he analyzes the decision-making process for getting vaccinated, a process that involves probabilities and risk-analysis, as well as consideration of the greater good. two original research articles are included in this issue. jorge de andres-sanchez with his colleagues from universitat rovira i virgili in catalonia, spain, find that belonging to a religious community together with an intact family structure afford protection against unhealthy tobacco and cannabis use. syeda saniya zehra and elizabeth schwaiger from forman christian college in lahore, pakistan, provide evidence of a unique advantages of attachment to god and a collectivist family culture on reducing perceived stress, among christians who are a minority of the country’s population. personal travel gives me opportunity for access to wi-fi networks in homes of family and friends and thus acquaintance with creative ssid labels. one of the more meaningful ones was “readmorebooks”. in pursuance of that advice, this issue has two book reviews that we think deserve the attention of readers. the first is a review by arnold gorske of a two-volume handbook entitled health promoting churches, published by the world council of churches and authored and edited by dr. mwai makoka. as dr. gorske comments, these books, “have more lifesaving, health and healing potential than anything else i have read,” except the bible. the second is dr. william newbrander’s review of all creation groans: toward a theology of disease and global health, edited by daniel o’neill and beth snodderly. the essays included in this book create a comprehensive multidisciplinary survey of the theological grounds for church involvement in global health and the spiritual and behavioral aspects of disease origins. dr. newbrander’s review provides a helpful introduction to these important and often unexplored issues. the editors are pleased to receive poetry submissions from time to time and we are grateful for our poetry reviewer to help us evaluate them. i will never see a full moon the same is a moving reflection on the death of a young patient, but death with a perspective of hope. as of the middle of this december, the coronavirus pandemic is still very much with us with surges in case numbers in a variety of countries, and with several variant strains. the deployment of vaccines, their future development and the means to expedite their uptake around the world continue to be fertile subjects for research, policy, ethics and theology. we urge and look forward to publishing other submissions in response to this call for papers and other subject early in the new year. the glory the angels revealed to the shepherds at the birth of christ, he has given to his people, whom he desires to be unified to reflect that glory (john 17:22). for those strengthened by beholding each other’s work and faith, may your communities experience a very merry christmas and peaceful new year. https://journal.cjgh.org/index.php/cjgh/cfp/vaccines https://journal.cjgh.org/index.php/cjgh/article/view/611 https://journal.cjgh.org/index.php/cjgh/article/view/611 https://journal.cjgh.org/index.php/cjgh/article/view/579 https://journal.cjgh.org/index.php/cjgh/article/view/531 https://journal.cjgh.org/index.php/cjgh/article/view/531 https://journal.cjgh.org/index.php/cjgh/article/view/591 https://journal.cjgh.org/index.php/cjgh/article/view/589 https://journal.cjgh.org/index.php/cjgh/article/view/589 https://journal.cjgh.org/index.php/cjgh/article/view/589 https://journal.cjgh.org/index.php/cjgh/article/view/581 https://journal.cjgh.org/index.php/cjgh/article/view/581 book review dec 2022. christian journal for global health 9(2) a just mission by m. haddis. intervarsity press, 2022 william edward cayley a a md, mdiv, professor, university of wisconsin department of family medicine, usa in a just mission, mekdes haddis offers a bicultural perspective on western missions based on insights from her own journey as an ethiopian christian moving to the usa. raised in ethiopia by an evangelical christian mother and an orthodox christian father, she moved from addis ababa to the usa for college. she describes the shocks of encountering religious bias (“were you a christian before coming to the united states?”, p16), racist microaggressions (“do you feel like you have an easier time being accepted in white circles as a black woman because you are light-skinned?”, p13), and societal racism (including police shootings of black men, p17). following college, her work for over a decade in church ministry brought encounters with ministry paradoxes such as efforts to “reach black people in a faraway land” (p21) through short-term missions while ignoring local poverty at home, and the discrepancy between deliberate and meticulous efforts at local discipleship training contrasted with relatively minimal training of leaders in the cultural complexities inherent in short-term missions (p23). this brief cross-cultural autobiography frames her discussion of missions and ministry through the remainder of the book. while christian global mission work has historically been predicated on concepts traced to matthew 28:19 (“therefore go and make disciples of all nations”, niv) and romans 10:14 (“how can they hear without someone preaching to them”, niv), ms haddis suggests that western missionary work has historically been characterized by too much emphasis on cultural propagation, and too often failed to recognize the global scope and the cultural and ethnic diversity of the church. after a discussion of the “doctrine of discovery” whereby european cultures in the 15th and 16th centuries cast indigenous peoples in colonized lands as “savage” and justified “violence, genocide and slavery in the name of christian evangelization” (p50), she explores the ways this set of ideas continues to affect churches both in the usa (undermining the witness and authentic community) and the nature of international mission (by reducing mission to patronizing pity and casting christians as either victims or rescuers). fundamentally, she argues, “white saviorism” (p3) harms all participants in mission by creating barriers to genuine christian community. the way forward she proposes includes “decolonizing” short-term missions by shifting the focus away from “slum tourism” (p91) and the emotional needs of the “go-er” (p97), and instead emphasizing mission based on a laying down of power and embracing mutuality (p109). alluding to prior work by lesslie newbigin who proposed mission as “service learning”1 and the celtic model of evangelism described by george hunter, which “shared the gospel without dampening the beauty of the culture” (p170),2 she argues for “learning from marginalized communities here at home before going around the world” (p109) and for working to ensure true partnership and collaboration between western mission leaders and black and brown church leaders in order to develop truly reconciling ministry. the critique of western missions history in a just mission might seem to ignore evidence for a beneficial effect of protestant religious influence on developments such as education, printing, civil institutions, and economics.3 other authors, however, have previously explored in more depth the cayley 36 dec 2022. christian journal for global health 9(2) mixed legacy of missions in which contributions to health care and education must be seen in contrast to the abuses of coercive conversions and inattention to social justice issues including the african trade in enslaved humans.4 for the reader who may return to the romans 10 question of “how can they hear”, ms haddis makes three points that are both simple yet profound. first and perhaps most importantly for those whose missiology emphasizes a “go”, she points out that the gospel has already “gone.” she calls for a recognition that the church truly is global, and in many parts of the world older and more rooted than in the west in general and the usa in particular. “theology that is not of the west is deemed as lessthan, and many mission organizations won’t even consider forming partnerships with local pastors who don’t ascribe to western theology.” (p83) here again the challenge is to a view that sees western evangelical christianity as the primary manifestation of the christian faith. her argument for western christians to take seriously the historic global identity and witness of the church alludes to themes addressed in more depth by other writers. thomas oden’s how africa shaped the christian mind argues that much more of early christian intellectual and spiritual development was formed in africa than is appreciated (and that part of this under-recognition is due to european intellectual prejudice in the 1800s-1900s).5 this history is explored in more detail by mark shaw and wanjiru gitau in the kingdom of god in africa, a comprehensive survey of african believers’ efforts through the centuries to embody the kingdom of god in uniquely african christianity.6 most recently, vince bantu’s work in a multitude of all peoples provides an in-depth exploration of the historical roots of a western “cultural captivity” of the church which has led the modern western church to overlook, downplay, or ignore the historical developments and witness of non-western christianity.7 second, she points to the work of the holy spirit in spreading christianity in muslim countries through visions and dreams, reminiscent of paul’s conversion experience in acts 9. while this phenomenon is not explored in detail in a just mission, other writers describe the role that dreams may play for those of muslim background as a preliminary or initial step in a multi-year journey of faith8 and suggest that a western approach to crosscultural evangelism overly steeped in a “scientific” worldview may inordinately downplay the role of spiritual realities in the spread of faith.9 third, she argues for a more robust appreciation of the role of general revelation (romans 1:20) both in preparing the hearts of those to whom we may minister (p42) and in building unity across faiths and denominations for efforts in common to promote justice, topics addressed in more systematic detail by thomas johnson (whose the first step in missions training argues that for paul wrestling and conflict with god was the central theme of all human existence)10 and robert johnson (whose work god’s wider presence systematically and theologically explores the connection between common experiences of the transcendent or numinous, and god’s wider general revelation)11. simply put, she reminds readers that we should not think of gospel spread as primarily depending on human effort, rather it is fundamentally due to the work of the spirit whether human witness is present or not. as ms haddis notes, the term “mission” is a post-biblical latin term that simply refers to being sent, and when “god sends his people, he sends them to do his work in his name and not to make a name for themselves” (p30). bantu points out in a multitude of all peoples that the greek “go” (πορευθέντες) in matthew 28:19 is a past participle which could also be translated as a subordinate clause providing the context of “having gone” for jesus’ primary directive of making disciples.7 in other words, the discipling would be read as primary and the “going” as secondary. ms haddis takes this a step further in her discussion of the scriptural call from jesus to his followers is to “be my witnesses” (ἔσεσθέ μου μάρτυρες) (acts 1:8 niv & sblgnt) locally, nearby, and perhaps far away. the 37 cayley dec 2022. christian journal for global health 9(2) fundamental vocation is not necessarily to go, but to faithfully bear witness. a just mission gives a clear and challenging call to faithful witness and, at the same time, provides a shift in paradigm that reminds us the work is god’s and not ours. other writers and scholars have explored many of her themes in more exhaustive detail, but in a just mission ms haddis provides the uniquely first-person perspective of a bicultural christian with first-hand experience of life in both africa and the usa. much of her writing is in response to experiences with short-term mission efforts, but as demonstrated above the challenges she raises apply to considerations of both shortand long-term cross-cultural missions. the way forward she proposes invokes a new vision of mutuality, collaboration, humility, and openness to the work of the holy spirit. references 1. newbigin l. proper confidence: faith, doubt, and certainty in christian discipleship. grand rapids, mi: wm. b. eerdmans publishing; 1995. 2. hunter g. the celtic way of evangelism: how christianity can reach the west . . . again. nashville: abingdon press; 2000. 3. woodberry r. religion and the spread of human capital and political institutions: christian missions as a quasi-natural experiment. in the oxford handbook of the economics of religion. ed mccleary r. oxford: oxford university press; 2011. 4. okyere-manu b. colonial mission and the great commission in africa. in teaching all nations: interrogating the matthean great commission. ed. smith m & jayachitra l. minneapolis, mn: augsburg fortress press; 2014. 5. oden t. how africa shaped the christian mind: rediscovering the african seedbed of western christianity. downers grove, il: intervarsity press; 2010. 6. shaw m & gitau w. the kingdom of god in africa. carlisle, cumbria, uk; langham global library; 2020. 7. bantu v. a multitude of all peoples: engaging ancient christianity’s global identity. downers grove, ill: intervarsity press; 2020. 8. martin g. the god who reveals mysteries: dreams and world evangelization. southern baptist journal of theology. 2004; 8(1): 60-72. 9. peters b. the role of dreams and visions in the apostolate to muslims and its application in crosscultural ministry. st francis magazine. 2006;2(1):114. 10. johnson t. the first step in missions training: how our neighbors are wrestling with god’s general revelation. eugene, or: wipf and stock publishers; 2014. 11. johnson r. god’s wider presence: reconsidering general revelation. grand rapids, mi: baker academic; 2014. note: scripture passages are quoted from the new international version (niv) and the sbl greek new testament (sblgnt) submitted 13 oct 2022, revised 19 dec 2022, accepted 20 dec 2022, published 20 dec 2022 competing interests: none declared. correspondence: dr. william edward cayley, augusta, wisconsin, usa bcayley@yahoo.com cite this article as: cayley we. a just mission by m. haddis. intervarsity press, 2022. christ j glob health. dec 2022; 9(2):35-7. https://doi.org/10.15566/cjgh.v9i2.709 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:bcayley@yahoo.com https://doi.org/10.15566/cjgh.v9i2.709 about:blank references original article december 2021. christian journal for global health 8(2) attachment to god in a collectivistic context and its impact on perceived stress syeda saniya zehraa, elizabeth schwaigerb a ms(c), clinical psychology, forman christian college, lahore, pakistan b psyd, assistant professor, department of psychology, forman christian college, lahore, pakistan abstract introduction: research indicates that attachment to god is correlated with parental attachment and perceived stress. however, these relationships have not been studied outside the western context. the present research evaluated the relationship between attachment to god and attachment to parents within different family systems and the impact of these attachments on perceived stress. methods: a sample of 284 christian undergraduate students in pakistan was surveyed. the data were collected from the participants through convenience sampling. relationships between attachment to parents, attachment to god, religiosity, and perceived stress were studied. results: a significant positive relationship between attachment to parents and to god was found for the nuclear family system on the anxiety subscale. for the avoidance subscale, both nuclear and joint family systems had significant positive relationships between parental attachment and attachment to god; however, it was stronger for joint family systems. the multiple regression analysis showed parental avoidance (β = .256, p <.001) and god anxiety (β = .281, p <.001) as the strongest predictors of stress. discussion: the findings highlight the impact of collectivistic cultural values, particularly the importance of relationships. the implications include the significance of the impact of culture on attachment relationships and the finding that attachment correlates with lower levels of perceived stress. the research also shows the difference in attachment styles depending upon the family system the participant belongs to which can again be attributed to cultural norms and values. key words: attachment, family system, perceived stress, collectivistic culture, religiosity, pakistan introduction hofstede described the dimension of collectivism and individualism as “the degree to which people in a society are integrated into a group.”1 a greater focus on individual goals leads to bonds between extended family members becoming weaker whereas a greater focus on group goals and relational harmony strengthens those bonds. in 25 zehra & schwaiger december 2021. christian journal for global health 8(2) many individualistic cultures, the nuclear family is preferred and in collectivistic nations such as pakistan, the extended or joint family system is the family structure of choice. however, in an increasingly globalized world, there have been changes in family structures that are adapted to increase personal mobility.2,4 families which have been based on collectivistic cultures1, such as pakistan, are now being influenced by globalization and becoming more individualistic; small nuclear families are emerging as popular. the nuclear family system, which is more common in individualistic cultures such as the united states, can be explained as a structure where two generations, that is parents and their children, are living together. in a joint family system, husband, wife, and children are living with parents of either. in pakistan, this is usually with the husband’s parents.1 nuclear family structures allow for the independence to move with changing global trends. on the other hand, these smaller structures have led to increased stress, loneliness, and economic hardships.1,4 adoption of the nuclear family system and its alleged pertinence for economic growth has led to the disintegration of traditional extended/joint family systems in asian countries.3 this is evidenced by research that has shown rates of joint family system membership as low as 50%.5 this shift in family structure may also signal a shift from the traditional focus on relational harmony and group membership to more individual goals and identity.2 nevertheless, relationships or interpersonal attachments will no doubt continue to be important. attachment relationship, even in western contexts, is known to impact many facets of life, including religiosity, the way a person views god, and even the amount of perceived stress a person experiences.6,8,9 the rationale of the current research is to analyze how a religion, which is usually viewed through the westernized lens, is experienced by nonwestern citizens. in pakistan, christians constitute a minority population, and research has shown how religion and ethnicity can become identity markers for these groups.7 the current research examines how attachment relationships might be affected by non-western, collectivistic, cultural values in a minority group. attachment to god and family relationships bowlby6,8 and ainsworth9 defined attachment as an emotional and psychological bond with a significant other. attachment is a way to describe a relationship. in the context of family and parental attachment, attachment can be operationalized as the lasting bond, closeness, and security that children may or may not feel towards their parents. similarly, attachment to god can be used as a way to define a person’s relationship to god which is an excellent framework for the way christians would describe their faith.10 attachment theory proposes two broad categories of attachment styles, secure and insecure.6,8,9 ainsworth9 explained the different styles of attachment in respect to the “strange situation” experiment. the purpose was to observe the behavior of children upon being separated from their primary caregiver. ainsworth9 observed patterns of secure attachment and insecure attachment in terms of separation anxiety and avoidance. avoidant and anxious attachment are categorized as insecure attachment styles. fraley et al.24 operationalized anxious/anxiety attachment as one where the absence of the attachment figure inculcates worry in an individual. this is derived from the concept of “separation anxiety” proposed by bowlby6,8 whereupon being separated from their mothers, infants experienced distress and became anxious as the attachment figure was absent. whereas avoidance attachment style is whereupon re-emergence of the attachment figure, the individual does not exhibit any clinging behavior resulting from the separation;9 instead, the behavior can be described as turning away. research has shown how the attachment relationship to parents is directly related to the attachment relationship to god through two main 26 zehra & schwaiger december 2021. christian journal for global health 8(2) hypotheses, correspondence and compensation. according to the correspondence hypothesis, earlier attachment relationships form the basis for the dynamics of future relationships, such as that with god. the assumptions of the correspondence hypothesis can be linked to bowlby’s internal working models concept.6,8 the compensation hypothesis is based upon ainsworth’s substitute figures, where individuals may seek out attachment to god through an inverse relationship.9 that is, in cases where individuals experienced insecure attachment in childhood with their parents, they later have an experience of secure attachment with god.11,12,13 attachment relationship to god, therefore, serves as a “secure base” for individuals, allowing them to explore the environment.12,13,14 moreover, in cases where children face insecure attachment relationships during their childhood with their caregivers, they are likely to develop a more secure attachment to god, as god becomes the substitutionary caregiver.12 this relationship between parental attachment and attachment to god has been explored in individualistic cultures. however, little is known about the impact of joint family systems on attachment to god. the predictive validity of parental attachment, attachment to god, religiosity, and family system on perceived stress it has been proposed that the bond that a child has with his/her caregiver impacts not only the development of different aspects of the individual’s life,6,8,10 but also levels of stress.15 this theory of attachment can explain how attachment to god helps to mitigate stress and provides for emotional stability in one’s life. a secure attachment to significant figures such as parents and god can help to buffer stress as this attachment relationship acts as a shield that helps in stressful situations.15,16 it has been observed that factors such as attachment to god and religiosity are significant predictors of perceived stress, both with regard to attachment style and level of religiosity. depending upon these two factors, how individuals manage stress or perceived stress can be analyzed.17,18 research on attachment styles and attachment to god has shown that avoidant attachment relationship to god is one of the strongest predictors of perceived stress. attachment to god has also been demonstrated as an adequate predictor of psychological well-being in comparison to other measures such as that of image of god.19 religiosity is one of the factors that help individuals cope with stressful situations. religiousness can be regarded as pertinent to predicting growth of individuals when they face stressful situations.20 religiosity holds the power to cultivate the negative and positive outcomes of stress, thus, helping to improve the functionality of an individual. anger can be a negative outcome related to stress, due to lack of control of the situation; religiosity minimized this anger. positive outcomes like having confidence in solving one’s problems are maximized in times of stress if one has higher levels of religiosity.21 there is a dearth of research on the predictive value of nuclear and joint family systems on levels of perceived stress; however, higher levels of resilience, positive emotion, and social adjustment have been observed in adolescents from joint family systems22 as well as lower levels of family dysfunction and higher social competence.23 moreover, levels of life satisfaction have been found to be higher in pakistanis from joint family systems.5 given these findings and their relationship to perceived stress, it is possible that the family system will also be a predictor of perceived stress. hypotheses 1. the relationship between attachment to parents and attachment to god will be different in joint versus nuclear family systems. 2. after controlling for other demographic variables, attachment to parents, attachment to god, religiosity, and family system will predict levels of perceived stress. 27 zehra & schwaiger december 2021. christian journal for global health 8(2) methods for this study, secondary analysis was performed on a dataset taken from an undergraduate research thesis. the initial study used a crosssectional research design to measure and evaluate the relationships between attachment to parents, attachment to god, religiosity, and perceived stress. the current study analyzed the correspondence hypothesis of attachment in the context of joint versus nuclear family systems, and the impact of attachment to parents, attachment to god, religiosity, and family system on perceived stress. participants the participants in this study were 300 christian students enrolled in various undergraduate study programs at a university in lahore, pakistan. participation in the study was voluntary and no incentives were given. the participants had to sign the informed consent before proceeding with the questionnaire. of the 300 students who voluntarily participated, 13 did not complete all the questions in the booklet and were, therefore, excluded, while 3 more were excluded due to outliers (mahalanobis distances < .001; i.e., scores greater than 3.5 standard deviations from the mean). descriptive statistics of the demographics of the remaining 284 participants can be found in table 1. table 1. descriptive statistics of the demographics of the sample variables frequency (n) percentage m (sd) sex male female 163 121 57.4% 42.6% age 20.81 (1.68) year of education freshman sophomore junior senior 103 72 55 54 36.3% 25.4% 19.4% 19% family system nuclear family joint family 191 93 67.3% 32.7% measurement tools attachment to parents (experiences in close relationships; ecr-rs) the experiences in close relationships— relationship structures questionnaire (ecrrs)24 was used to measure the participants’ attachment relationships to parents which measures the two attachment styles, avoidance and anxious attachment. two subscales of the instrument were employed, that is mother and father subscales, with 10 items each. the internal consistency reported for the subscales is desirable, mother anxiety (α = .88)24, mother avoidance (α = .92)24, father anxiety (α = .90)24, and father avoidance (α = .90).24the responses were recorded on a 7-point likert-type scale. for the present study the reliability was adequate as well, mother anxiety (α = .78), mother avoidance (α = .74), father anxiety (α = .77), and father avoidance (α = .72). attachment to god (attachment to god inventory; agi) the attachment to god inventory (agi)10 was used to measure the individuals’ attachment relationship towards god in terms of avoidance and anxiety. the scale consisted of 28 items, with an equal number of questions measuring avoidance (α = .84)10 and anxiety (α = .80)10 on a 7-point likert-type scale. both the subscales agi avoidance (α = .79) and agi anxiety (α = .77) had good reliability values in the present study. religiosity (the centrality of religiosity scale) to measure the variable of religiosity, the 10-item version of “the centrality of religiosity scale” (crs-10) was used.25 the scale measures religiosity on five dimensions, “intellect, ideology, public practice, private 28 zehra & schwaiger december 2021. christian journal for global health 8(2) practice, and religious experience” where two questions evaluate each dimension. the responses are recorded on 5-, 6-, and 8-point likert-type scales. the scale has good reliability (α = 0.89 to 0.94).25 for the current study, the reliability of the scale was good as well (α = .77). perceived stress (perceived stress scale) for measuring perceived stress, the 4-item version of the perceived stress scale (pss) was employed.26 the scale records responses on 5point likert-type scale. the reliability of the scale was desirable in reference to previous research (α = .72).26 however, when there are four or fewer items on a scale, cronbach’s alpha has not been considered as a satisfactory indicator of reliability as it does not depict the scale’s “internal structure.” hence, substitute measures should be considered.26 an alternate method for measuring reliability in this case was using the mean inter-item correlations. the mean inter-item correlations value was .24 which was in accordance with the desired value.28 procedure and ethical considerations this study was approved by the institutional review board of fc college (irb219/02-2020). all participation in the study was voluntary and informed consent was obtained from the participants containing the details about participants’ rights and purpose of the study. the data collected was confidential and only the principle and secondary author had access to it. participants’ anonymity was maintained as no identifying data was collected. there were no ethical breaches during the course of data collection. given the sensitive nature of the topic of religion in pakistan, convenience sampling was utilized as only christians could be approached to participate. the primary researcher recruited the participants through visiting christian classes and groups on campus prior to the advent of the pandemic (over 3 weeks from 24th february, 2020 to 13th march, 2020). each participant was asked to participate given their status as a christian, and, though no incentives were offered, most of the students approached, agreed to participate. data analysis spss version 25 was used to analyze the data. for hypothesis 1, correlations were converted to z-scores to compare students from joint and nuclear family systems on the relationship between attachment to parents and attachment to god. for hypothesis 2, multiple regression was used to evaluate the impact of attachment to parents, attachment to god, religiosity, and family system on perceived stress. results descriptive statistics descriptive statistics of the study variables are displayed in table 2. table 2:.descriptive statistics of the study variables variables n (%) mean (sd) family system joint 93 (32.7) nuclear 191 (67.3) attachment ecr-rs anxiety 12.31 (7.50) ecr-rs avoidance 38.61 (10.50) agi anxiety 50.87 (13.60) agi avoidance 36.27 (12.70) religiosity 41.37 (6.38) perceived stress 7.72 (3.00) note. ecr-rs = the experiences in close relationships— relationship structures questionnaire; agi = attachment to god inventory. 29 zehra & schwaiger december 2021. christian journal for global health 8(2) inferential statistics table 3. correlation coefficients among study variables variable 1 2 3 4 5 6 7 1. ecr-rs anxiety (log 10) 2. ecr-rs avoidance .491** 3. agi anxiety .232** .064 4. agi avoidance .317** .323** .117 5. crs (log 10) .181** .189** .109 .452** 6. family system .027 .077 -.153** -.002 -.018 7. pss .174** .265** .301** .128* .072 -.073 note. * ecr-rs = the experiences in close relationships – relationship structures questionnaire; agi = attachment to god inventory; crs = centrality of religiosity scale; pss = perceived stress scale. *significant at the p < .05 level. **significant at the p < .01 level. the bivariate correlations showed that ecrrs anxiety and avoidance subscale have a significant positive relationship (r =.491, p < .01; see table 3), this can be attributed to the fact that both avoidance and anxiety attachment stem from insecure attachment with primary caregivers. furthermore, the relationship between god anxiety and parental anxiety is positive (r = .232, p < .01), and so is the correlation between god avoidance and parental avoidance (r = .323, p < .01), which can be attributed to correspondence hypothesis. religiosity on the other hand has an insignificant positive relationship with parental anxiety, parental avoidance, god anxiety, and god avoidance. on the other hand, the family system to which a participant belongs has a negative relationship with god anxiety (r = -.153, p < .01). this finding has been further been discussed in table 4. the variable of perceived stress also has a positive relationship with parental anxiety, parental avoidance, god anxiety, and god avoidance. this finding suggests a positive relationship between perceived stress and attachment to parents and god, which is further explored in a regression analysis (see table 5). hypothesis 1 to test the first hypothesis, the file was split into two groups (joint and nuclear family systems), and then correlations were computed (see table 4), transformed to z-scores, and compared between joint and nuclear family systems. table 4. correlation coefficients between attachment to god and attachment to parents across joint and nuclear family systems. variable nuclear joint ecr-rs anxiety ecr-rs avoid ecr-rs anxiety ecr-rs avoid agi anxiety .329** .094 agi avoid .282** .430** note. ecr-rs = the experiences in close relationships – relationship structures questionnaire; agi = attachment to god inventory; avoid = avoidance. **significant at the p < .01 level. the difference between joint and nuclear family systems on the anxiety subscale was significant (z = 1.95; p = .05), thereby showing that, for participants from nuclear family systems there was a moderate positive relationship (r = .329) between attachment to parents and attachment to god, while this relationship vanished for joint family system (r = .094). however, for the avoidance subscale, the difference between joint and nuclear family systems was not statistically significant (z = 1.35; p > .05). 30 zehra & schwaiger december 2021. christian journal for global health 8(2) hypothesis 2 for the second hypothesis, a simple regression analysis was computed to analyze the predictive value of the study variables (parental attachment, god attachment, religiosity, family system) on perceived stress. pre-analysis screening indicated no violations of the assumptions of multicollinearity or singularity (see table 4 for correlation values). three cases were excluded due to outliers, and two scales were transformed to improve normality (parental anxiety [log10] and religiosity [inverselog10]). table 5.results of regression analysis: impact of study variables on perceived stress unstandardized coefficients standardized coefficients variables b β p t r r2 adj. r2 semi partial correlations 1. (constant) 2.771 .189 1.31 7 .39 3 .15 4 .136 ecr-rs avoidance .073 .256 <.001 3.91 0 .230 ecr-rs anx (log10) -.277 -.021 .747 -.322 -.019 agi avoidance .006 .026 .688 .402 .024 agi anxiety .062 .281 <.001 4.82 5 .280 crs (log10) -.404 -.016 .800 -.254 -.015 family system -.314 -.049 .383 -.873 -.053 note. ecr-rs = the experiences in close relationships – relationship structures questionnaire; agi = attachment to god inventory; anx = anxiety; crs = centrality of religiosity scale.t. the results of the multiple regression were significant [f (6, 274) = 8.341, p > .001] with an r2 of .136. the strongest predictors being parental avoidance (β = .256, p <.001) and god anxiety (β = .281, p <.001; see table 5). discussion the current study sought to investigate the correspondence hypothesis in light of joint versus nuclear family systems. additionally, the study evaluated the impact that attachment to parents, attachment to god, religiosity, and family system have on perceived stress. it was found that the relationship between anxious attachment to god and anxious attachment to parents was strongest for nuclear family systems and followed the correspondence hypothesis, but not for joint family systems. avoidant attachment to god was weakly related to avoidant attachment to parents in nuclear family system, but not in joint family system. no difference was found between parental avoidance and god avoidance attachment, for both the family systems. thus, the assumptions of correspondence hypothesis appear to be applicable to both family systems. however, the correlation between parental avoidance attachment and god avoidance is greater for joint family system in comparison to nuclear family system. this is supported by the response of people in a collectivist culture to conflict. leung et al.,29 demonstrated how countries practicing collectivist culture opt for ways that promote harmony and social cohesion and not confrontation. this implicitly promotes avoidance in important attachments.29 it may be that the cultural imperative to avoid conflict is stronger than the influence of adapting to a more westernized nuclear family system. for the anxiety attachment subscale, the attachment relationship between parents and god vanishes for the joint family system. the correspondence theory can, thus, be held for nuclear 31 zehra & schwaiger december 2021. christian journal for global health 8(2) family system participants but not for joint family system. this can possibly be due to the presence of caregivers other than parents, for instance grandparents. an important relationship with a nonparent caretaker might well alter attachment relationships with parents.30,31 this possibility in a joint family system can thus account for such findings. another attachment relationship may take precedence and be correspondent with attachment to god. it is also possible that in a joint family system, with the presence of many different possible caregivers, the view of an individual about the world of attachment relationships may be more fluid. when one attachment figure is not available, there are others to take his/her place. the compensatory hypothesis was not tested here, and this can be considered as a guideline for future research studies. one reason for these findings may be the way in which the information about primary caregivers was associated with parents only, where the attachment relationship with god might have correspondence with other caregivers/relations, for instance: grandparents, uncles, or aunts. on the other hand, in nuclear family systems the correspondence hypothesis11 can help explain the relationship between parental attachment and god attachment on the basis of anxiety subscale due to a clear identification of caregivers, that is, parents as blueprint for authority figures such as god. in the current study, anxious attachment to god was the stronger predictor of perceived stress, which is inconsistent with the findings of the previous research which showed avoidant attachment to god as the stronger predictor of perceived stress or mental health.18,32 however, the previous research did show anxious attachment to god as having a negative relationship with mental health, which is consistent with the findings of the current study. this variation in results can be attributed to cultural or religious factors like the image of god, as suggested by leman et al.;18 the wrathful god image had a weak but a positive correlation with mental health. paul and nadiruzzaman’s33 analysis of research on the 2004 indian ocean tsunami showed how the two religious groups, muslims and christians, mainly regarded the natural disaster as a punishment sent from god. such interpretations of events can be helpful in explaining the anxious attachment to god as the predictor of stress. another predictor of stress was parental avoidance. as discussed earlier, avoidance-related behavior is a key component of collectivist cultures.1 cultural customs almost shun the idea of confronting individuals if any issue arises, especially with those in authority such as parents. this is consistent with supporting how avoidance attachment in a parental context can be regarded as a predictor of perceived stress amongst the pakistani population. this study did not find any predictive relationship between religiosity or family system and perceived stress. the fact that levels of religiosity do not predict perceived stress in this group may be related to the religious context of pakistan where christians are a minority. it may be that this minority status somehow mitigates the relationship between religiosity and perceived stress. research projects on levels of religiosity and perceived stress are generally conducted on majority groups whose religious affiliations have few repercussions in their lives. the finding that family system is not a significant predictor of perceived stress was also unexpected. previous research in pakistan suggests that family system has a significant impact on levels of resilience, positive emotion, social adjustment,21 family functioning, social competence,22 and life satisfaction.5 it is possible that family system is not a significant predictor because of the population under study or that the individual-collective dimension may not be the best way to characterize it. stress that is mediated by the family system when an individual is in university may be different than in other populations. moreover, it is possible that there are many other variables that impact stress in the life 32 zehra & schwaiger december 2021. christian journal for global health 8(2) of a university student, thereby reducing the mediating effect of family system on levels of stress. implications the finding that the correspondence hypothesis did not appear to explain anxious attachment to parents and anxious attachment to god for the joint family system provides a strong indication for the importance of joint family systems in mitigating anxious attachment. this can be seen as a strength of collectivistic cultures. perhaps in a joint family system, the presence of increased number of family members allows for substitute attachment figures such as grandparents.30,31 the joint family system may provide an opportunity for multiple attachment relationships and, therefore, greater fluidity in future attachments, particularly the attachment to god. the idea of parental attachment as a blueprint6,8,9 for other attachment relationships may not hold true in collectivistic cultures where there are multiple close caregivers. the finding that parental avoidance is a significant predictor of stress can provide clarity in planning therapeutic interventions. this finding further elaborates the importance of relational harmony and group membership in collectivistic cultures.1 strategies to improve and provide for mental health facilities for young adults, especially those who identify with minority groups, should consider the nature of family relationships and impact of avoidance as a tool for reducing relational tension within collectivistic cultures. anxious attachment to god was found to be one of the most significant predictors of stress. these findings help to explain how attachment to god serves as an important factor for mitigating stress when the study population belongs to the minority group living in a collectivist society. this also provides evidence for the need to train pastors and laypeople in assisting their congregants to build a less anxious relationship with god. the nature of this relationship provides either a buffer against or an impetus for greater stress. limitations and future directions a factor that might account for these findings is the level of parental religiosity. since level of parental religiosity can correspond to children’s level of religiosity, it can, therefore, influence how strong or weak the attachment relationship to god is. this variable should be evaluated in future research studies. the birth order of the participants was not taken into account. this might have contributed to the correlations between parental and god attachment relationships. for instance, the difference in attention and closeness with parents that the participants might have experienced starting from their childhood, as a result of birth order.34,35 in relation to this factor, the number of siblings the individuals of this study have might have also been a factor contributing towards the correlations. it can be explained in terms of how parents with fewer children are able to give them time, attentions, and the proximity they require. this might not be possible in cases in which there is a greater number of children in a family, and this might lead to less parental proximity and closeness, thereby, explaining the parental attachment relationship correlations. similarly, the gender of the siblings might also contribute towards their parental attachment to either of the parents.34,36 the compensatory hypothesis should also be studied in reference to variables of the current research. the compensatory hypothesis describes the inverse relationship between attachment to parents and attachment to god. for example, if the attachment relationship with parents is avoidant and anxious, such as in the case of abuse, the attachment relationship with god often shows a compensatory shift, such that god becomes a substitutionary figure. the attachment with god is therefore surprisingly healthy or “secure.” future researchers should consider examining the relationship more closely. 33 zehra & schwaiger december 2021. christian journal for global health 8(2) finally, the findings of this research suggest that further research is needed to ascertain whether minority status, religion, or the collectivistic culture play a role in determining the course of attachment. for example, a comparative analysis between muslims and christians can be 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purposes and authors were additionally contacted to confirm permission for the use of the scales for the attachment to god inventory (agi).10 correspondence: syeda saniya zehra, lahore, pakistan. saniyazehra1707@gmail.com cite this article as: zehra ss, schwaiger e. attachment to god in a collectivistic context and its impact on perceived stress. christ j global health. dec 2021;8(2):24-35. https://doi.org/10.15566/cjgh.v8i2.531 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org mailto:saniyazehra1707@gmail.com https://doi.org/10.15566/cjgh.v8i2.531 http://creativecommons.org/licenses/by/4.0/ abstract introduction methods results discussion finally, the findings of this research suggest that further research is needed to ascertain whether minority status, religion, or the collectivistic culture play a role in determining the course of attachment. for example, a comparative analysis betw... references original article nov 2015. christian journal for global health, 2(2):84-88. lancet series on the contribution of faith-based health providers: a call for greater accountability alison morgan a a nossal institute for global health, melbourne school of population and global health, university of melbourne, australia introduction in july 2015, the lancet published a series of articles examining the role of faith based health providers (fbhps). 1,2,3 the three papers examined the scope of fbhp work (focused on africa where more research has been undertaken), described the controversies associated with fbhps, and outlined how to better strengthen partnerships between fbhps and the public sector. this commentary gives a summary of the series and suggests three areas that faith based groups can consider to better describe, document, and integrate their work within national health systems. paper 1: understanding the roles of faith-based health care providers in africa the first paper begins with a rationale for the series, namely that fbhps deliver a significant proportion of services; have significant reach, particularly in settings where government services are weakest; and yet are often treated with distrust due to many past and present controversies, particularly around proselytising agendas or constrained care due to religious prohibitions on particular services. the paper then focuses on africa, where more documentation is available, to try and measure the magnitude of service delivery, how these services are financed, their reach, particularly to the poor, and the quality of services provided by faith-based groups. two limitations are recognised: most of the available literature is drawn from the hiv sector, and the focus is primarily on christian fbhps. the authors, many of whom have led significant previous systematic reviews in the area, articulate the challenges well:  defining fbhps is difficult as they can extend from small congregational efforts to large national coalitions of multiple fbhps.  the magnitude of the contribution by fbhps is variably reported as between 30-70% of all health services in africa, and the basis for these estimates is vague and maybe overstated. yet fbhps do provide a greater contribution where government systems are weakest.  in the move towards universal health coverage and an increasing proportion of health services funded by governments, fphps, who usually need to manage cost recovery through user fees, are becoming more expensive for households, even where subsidies are provided for the very poor.  evidence of increased quality of care is mixed. provider satisfaction is greater for fbhps and is attributed to more compassionate care as result of the values of faith-based institutions, but this requires further substantiation. yet fbhps may also provide poorer quality care than public providers in contexts where hiring policies prioritise the religious character of an employee over their health care competency. 85 morgan nov 2015. christian journal for global health, 2(2):84-88. paper 2: controversies in faith and health care the second paper summarised 11 issues where religious positioning has meant that health services delivered by faith-based organizations (fbos) have differed from those of the public sector or advocated by global best practice. these issues include family planning; abortion and artificial reproductive technology; child marriage; female genital mutilation (fgm); immunisation; stigma and sexuality; harm reduction and hiv; violence against women; gender; faith healing; and end of life issues. the articles begin with the recognition that 80% of the world’s population report having a religious faith. the authors outline the four principles of humanist ethics: autonomy of the individual who has intrinsic value and dignity; the obligation to assist those in need; the do-no-harm principle; and the principle of distributive justice or equitable access to services and posited that faith-based ethics are not dissimilar but may give differing weights to these principles. for example, the right or autonomy of an individual may give way to beliefs about the sanctity of life in end of life issues or in abortion service delivery. a striking factor in the article was the varying responses between and within faiths to particular issues and the reflection that these were not static positions. for many of the issues, including fgm or child marriage, attribution to religious belief distinct from cultural traditions is not possible. this is reflected in the article’s emphasis on pragmatism, i.e., what each faith is seen to be doing rather than trying to summarise doctrinal positions on each issue, which was beyond the scope of the series. important conclusions included the acceleration of change when religious leaders support a particular issue (e.g., eliminating fgm or care for people affected with hiv) and the call for greater collaboration between health professionals, faith leaders, and policy makers to overcome some of the entrenched suspicion and distrust that is largely based on assumption or hearsay. paper 3: strengthening of partnerships between the public sector and faithbased groups the final paper in the series is a call for closer partnerships between faith-based organisations and government groups. the paper begins by outlining four development trends that should foster engagement with fbhps: common goals to end extreme poverty that are increasingly supported by economic investment; a focus on ending preventable child and maternal deaths, an area that fbhps have traditionally emphasised; donors, governments, and multilateral agencies explicitly seeking to increase their own faith literacy; and increasing investment in health in low and middle income countries to provide opportunities for more formal engagement with fbhps, particularly as fbhps play an important part in providing care to remote and hard to reach areas. increasing collaboration is not without challenges. the authors describe some successful national models of cooperation, and examples where this has led to significant increases in coverage of health interventions. however, there are important complexities in government-fbhp cooperation, and the onus is on the fbhp community to work together to provide a mechanism (e.g., forming a coalition such as the africa christian health association) for meaningful engagement. the underinvestment in fbhps by large multilateral donors is disappointing, particularly considering the proportion of care they cover. the example given of the u.s. president's emergency plan for aids relief (pepfar) funding, which sought to prioritise fbhps) in kenya, demonstrated disproportionately low disbursements to fbhps, and the proportion invested by the global fund and world bank is lower again. however, when all development assistance is 86 morgan nov 2015. christian journal for global health, 2(2):84-88. measured, fbhps continue to receive substantial investment, although much is from the faith based donor pool. 4 the authors conclude that increasing engagement between fbhps and the public sector requires attention to five areas: 1. better documentation and accountability, including scope of services and evidence generation, to identify areas where fbhps constrain care, improve care, and what, if any, distinctive qualities they contribute. 2. consultation between fbhps and secular providers to develop mutual respect and greater understanding of each other’s strengths. greater transparency is critical for fbhps who wish to partner with the public sector, and more research funding is required to better understand the role of fbhps. 3. investment in fbhps. the authors call for greater representation by fbhps in health planning and policy processes, but this requires fbhps to work together and to provide a platform for meaningful participation through developing coalitions or coordinating mechanisms. these coalitions themselves will require funding to create and sustain. 4. building core competencies and developing the health literacy of religious leaders. examples of successful change as a result of advocacy and leadership development were instructive (e.g., 390,000 local faith leaders reached through world vision’s channels of hope) and demonstrate the potential of supporting fbhps to mobilise religious leaders. 5. commitment for both fbhps and secular groups to base health care on public health evidence rather than ideology. considering the controversies outlined in paper two, this last point is the most challenging, but at the very least the onus is on fbhps to be very explicit about what services they can and cannot provide and commit to ongoing re-evaluation of these parameters. the authors conclude that not all fbhps will want to collaborate with the public sector, and, conversely, many fbhps are too small, too ideological, or too fragmented to be suitable partners for the public sector. but the size of the fbhp sector means that excluding them from public sector health planning overlooks an important resource in the drive to universal health coverage. discussion the lancet series provides a welcome focus on a significant dimension of health care provision in low and middle income countries. the authors recognise that despite the significant contribution by fbhps, they have often been excluded from research and policy forums and that, ultimately, this limits the potential for engagement and entrenches the mutual mistrust that has largely defined the relationship between fbhps and the public sector to date. the quote from president james wolfensohn of the world bank (2002) that was cited in the first paper “half of the work in education and health in sub-saharan africa is done by the church. . . but they don’t talk to each other and they don’t talk to us” is a clear call for both greater accountability and greater collaboration. the challenges for those working as fbhps can be summarised as follows: greater accountability fbhps need to invest in the resources required to document the services they provide and to evaluate them. assumptions regarding the quality of care provided need to be tested. fbhps are explicit about the 87 morgan nov 2015. christian journal for global health, 2(2):84-88. values that underpin their work, yet need to document if and how those values affect the quality of care and the health outcomes of those they serve. increased integration into government systems fbhps can no longer work in silos serving their local communities’ health needs. there is the responsibility to keep informed about national health policy and to explore integration with government services, and, where appropriate, consider moving from a direct health provision role (in settings where government services are in a position to provide that care) to being an advocate for quality services that reach everyone. the series focused on africa, where the roles of fbhps are more widely accepted. the challenge for places where the fbhps come from minority religions in their settings is problematic and not really addressed in the three articles. yet these same services should be open to scrutiny and be able to stand on the care they give. there is the risk that without better integration with the public sector and the potential to receive public sector financing, fbhps will be unable to sustain care for the very poor. modelling faith in action fbhps continue to play a significant role, particularly in fragile states and in reaching the very poor or the very remote. for most major faiths, the care of the sick and the poor is a natural outworking of the basis of belief and will continue. this is very different from using health services as a means for proselytising. the challenge is in being prepared to review and consider changes to the scope of services, particularly in the more sensitive areas of sexual and reproductive health. fbhps need to critically examine where practice guidelines are constrained more by culture or indeed culturally influenced interpretation of religious texts. this calls for real dialogue between fbhps and theologians, an area that has been under-researched and underresourced. conclusion the lancet series is a valuable contribution and provides an avenue to open the discussion between fbhps and the public sector. i congratulate the authors and look forward to fbhps taking up the challenge to better monitor, measure, and engage with the wider health systems of the populations they serve. references 1. duff jf, buckingham ww. strengthening of partnerships between the public sector and faithbased groups. lancet. 2015. http://dx.doi.org/10.1016/s0140-6736(15)60250-1 2. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock f, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015. http://dx.doi.org/10.1016/s0140-6736(15)60251-3 3. tomkins a, duff j, fitzgibbon a, karam a, mills ej, munnings, k, et al. controversies in faith and health care. lancet. 2015. http://dx.doi.org/10.1016/s0140-6736(15)60252-5 4. haakenstad a, johnson e, graves c, olivier j, duff j, dieleman jl. estimating the development assistance for health provided to faith-based organizations, 1990-2013. plos one. 2015;10(6). http://dx.doi.org/10.1371/journal.pone.0128389 peer reviewed http://dx.doi.org/10.1016/s0140-6736(15)60250-1 http://dx.doi.org/10.1016/s0140-6736(15)60250-1 http://dx.doi.org/10.1016/s0140-6736(15)60251-3 http://dx.doi.org/10.1016/s0140-6736(15)60252-5 http://dx.doi.org/10.1371/journal.pone.0128389 88 morgan nov 2015. christian journal for global health, 2(2):84-88. competing interests: none declared. correspondence: alison morgan, university of melbourne, australia. apmorgan@unimelb.edu.au cite this article as: morgan a. lancet series on the contribution of faith-based health providers: a call for greater accountability. christian journal for global health (nov 2015), 2(2): 84-88. © morgan a this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:apmorgan@unimelb.edu.au http://creativecommons.org/licenses/by/3.0/ commentary nov 2015. christian journal for global health, 2(2):10-15. disability and human supports jeff mcnair a a phd, director policy center, joni and friends, christian institute on disability; professor of special education, california baptist university, california, usa abstract this article provides a brief overview of models of disability growing out of the field of disability studies and leading to a call for interventions going beyond a simply medical model approach. a brief discussion of human supports/services is provided such that readers engaged in the development of services/supports can base them on best principles. the profession that individuals with disabilities and their families perhaps look to more than any other is the medical profession. physicians are seen as those who have the power to cure, to take away or alleviate the impact of someone’s disability. in many cases, medical treatments do have the power to change the lives of those served. yet, probably far more people with disabilities are not cured of their impairments, in spite of professional help. this is a fact that is critical for both physicians and people affected by disability to recognize. however, there is a great deal that doctors can do. they have influence over patients, families and the community. the goal of this article is to help medical doctors understand the topic of disability and through this understanding, have a greater positive impact on those with disabilities. they may or may not be able to help in the strict medical sense, but as members of the human services community they can influence professionals and local communities for the benefit of people who are affected by disability. models of disability arguably, there are three basic models of disability with many nuanced versions growing out of them which provide a way for us to understand disability. 1 these models have largely come out of the field of disability studies. the answer to the question, “what is disability?” on its face may seem to be simply answered. for example, the americans with disabilities act, which became law in the united states in 1990, defines a person with a disability as someone who has physical or mental impairment that substantially limits one or more major life activity. 2 however, the world health organization states “disability is not an attribute of an individual, but rather a complex collection of conditions, many of which are created by the social environment”. 3 so in reality it is a question with complex answers. the so called models of disability help us to begin to get our minds around what disability actually is. let’s consider each of these briefly. 11 mcnair nov 2015. christian journal for global health, 2(2):10-15. the moral model the moral model says that disability is the result of the individual affected by impairment or his family’s wrong behavior or sin. 4 i personally can also do something wrong and as a result i am afflicted with some form of impairment. or one’s parents did something wrong and as a result, one receives punishment in the form of a disability. there are those who think this model is on the wane. 5 however, the author has seen evidences of this model during work in africa, europe, central america and asia. in uganda, the author was often told by nationals that from a cultural perspective disability is seen as a direct result of someone being cursed in some way. in ukraine, he was informed that disability was due to the “sins of the fathers” (reference to exodus 34:7). even in america, when a child with a disability is born to a family, as part of the grieving process a response can be, “what did i do to deserve this?” followed by intense selfexamination. 6 but let’s consider a christian response to the moral model. in john 9 jesus and his disciples come upon a man born blind. the disciples ask, “rabbi, who sinned, this man or his parents, that he was born blind?” this perspective was not just that of the disciples but of the larger jewish culture. we see this at the end of the passage, when the pharisees say to the once blind man, “you were steeped in sin at birth…” an allusion to the fact that he was born blind and that sin was the cause of the disability. jesus’ response, however, is, “neither this man nor his parents sinned but this happened that the works of god might be displayed in him.” so we see from this passage that sin is not the cause of disability. ostensibly, the blindness occurred according to god’s purpose which is that “the works of god might be displayed in him.” however, just for the sake of our discussion, let’s assume that sin is the cause of disability. if we truly understood our sinful state as described in the bible (romans 3:10 & 3:23 & 5:12, psalm 143:2 among other passages), and sin were the cause of disability, then we would expect all of our children to be disabled. that any child is born without disabilities means that sin is not the cause of disability. this however, does not diminish the cultural reality of what people think and believe. the term “social construction” is sometimes used to understand cultural perspectives on an issue. 7 so independent of a biblical reality, if the socially constructed notion of disability in a particular culture is that it is the result of bad behavior, that will be the reality within that culture. medical professionals have the ability to refute such claims and can attempt to replace them with a different narrative about what disability is. yet, these perspectives are deeply ingrained in people. in another situation, the author was providing training about a biblical perspective on disability at a university outside of kampala, uganda. one of the students was a very bright man, who was physically disabled because of polio. he confided to the author, “i know that i am disabled because i contracted polio as a child. intellectually, i know that. however, because of my enculturation, i cannot get out of my mind that i have been cursed. my culture tells me i have been cursed and it is very difficult to believe anything else.” even though his christian faith told him otherwise, his enculturation and ongoing experience with culture was constantly at battle with both his scientific and biblical understanding of why he was as he was. now, could someone do something of a sinful nature to cause another person or themselves to have a disability? of course that is possible. someone could inflict violence on another and disability could be the result. one could also engage in other behaviors leading to disability. however, the point here is that because one is a liar or a thief or has committed other personal sins, does not mean that the individual or his child will develop a disability. the medical model the term “medical model” should not be construed to be exclusively related to the medical profession. anyone who seeks to improve people 12 mcnair nov 2015. christian journal for global health, 2(2):10-15. with impairments is employing the medical model. 8 wolf wolfensberger the great american/canadian disability theorist distinguished between bodily impairments (body, brain or sense organs) and resulting functional impairments (seeing, hearing, speaking, mobility, or self-care). 9 special education teachers, rehabilitation specialists, physicians, and even those who pray for healing for someone may be basing their understanding of impairment on the notion that the individual with the disability owns the disability, and interventions need to be aimed at fixing the individual. the idea is that impairment is not normal so our efforts seek to assist the person to become as normal as possible. this will hopefully not only attenuate the impact of one’s impairment, but will also assist the person in becoming more socially accepted. you are repaired, and then reintegrated into society. it may be that although the perceptions of disability are truly based upon it being considered atypical socially, in reality it is likely that it is relatively common but simply not accepted. estimates range from 15-20% of population includes individuals with disabilities themselves. 10 so the number of people actually impacted would be much larger. the social model of disability helps us to see there may be more to disability than an individual’s personal characteristics. the social model the social model of disability basically states that disability is discrimination. 11 michael oliver the british disability reformer has stated, “disability is a social state and not a medical condition.” 12 this notion is taken to the point of those with disabilities saying about themselves, “there is nothing at all wrong with me. the entire problem is society.” intuitively, there is a lot of truth in this perspective. individuals with disabilities will often state that the most difficult part of having a disability is not the disability itself, but the manner in which you are treated if you have a disability. clearly, there are impairments which are extremely difficult causing pain, etc. but largely, most disabilities are mild and people become acclimated to their impairment and learn to live on in spite of them. oliver thus concludes, “in our view, it is society which disables physically impaired people. disability is something imposed on top of our impairments by the way we are unnecessarily isolated and excluded from full participation in society.” 13 as mentioned above, societal discrimination may largely be determined by how disability has been socially constructed within a culture. if it has been constructed negatively, there will be negative implications to people having a particular characteristic. if it is constructed as simply typical, or within the normal range of being human, different societal responses will be experienced by those with disabilities. a biblical narrative a biblical narrative has the potential to confront discriminatory, socially constructed narratives of disability. this narrative might include the following characteristics which would guide both the understanding of disability and the development of human supports. all people are created in the image of god (genesis 1:26). god will use people to accomplish hs purposes, so in order to do so, he might create people with disabilities (exodus 4:11). there is an intimacy described in the creation of people which implies purpose (psalm 139:13). god desires people with disabilities to be in the church (luke 14:12-14). disability is not the cause of sin as stated above (john 9:3-4). there is purpose in “weaker” members in that they are indispensible to the body of christ (1 corinthians 12:22-23). faith and disability are not formulaic in that you may be a person of great faith like paul and yet not be cured of a disability when you ask god to be healed (2 corinthians 12:7). in summary, people with disabilities are created in the image of god for a purpose because they are indispensible to the body of christ. disability is not caused by personal sin or 13 mcnair nov 2015. christian journal for global health, 2(2):10-15. a lack of faith, but rather is part of god’s purpose for humanity and his church. this biblical narrative is very different from the societal narrative most often purveyed by societies. through faith, we believe in god’s sovereignty which implies purpose in disability. what is disability? so what is disability? it is likely a combination of the medical and social models. “disability should not be reduced to a medical condition… neither should it be reduced to an outcome of social barriers alone.” 14 from a christian perspective one also sees god’s sovereignty and purpose in disability. yes, people do have characteristics called impairments, so there is a personal impairment aspect of disability. but there is concomitantly a social aspect of disability in that people really do experience discrimination because of their disability. however, it is an error to see disability as discrimination exclusively. as shakespeare & watson (2002) point out, “if someone has an impairment that causes constant pain, how can the social environment be implicated?” 14 their point is that disability is both a personal and societal characteristic. it is personal impairment and it is societal discrimination. therefore, if one wanted to intervene in the lives of persons with disabilities, one would be best served by doing three things. first, one should address misconceptions which grow out of the moral model about the cause of disability, hopefully replacing them with a christian understanding. then, one should also attempt to impact the lives of persons having impairment to better their lives as much as possible. finally, however, one should also focus significant effort at changing societal discrimination. the responsibility of the physician in changing societal discrimination o’brien & o’brien characterize the delivery of human services in the following manner. when service providers set up programs to assist people who are excluded, they will often mindlessly follow this recipe:  group outsiders together  set them physically apart  isolate them socially  amplify stigma  arouse a sense of differentness  control the details of their lives  enforce material poverty as a condition of assistance  offer more benefits to those more like “one of us”  expect obedience and gratitude in return 15 these criticisms might be leveled at human services just about anywhere. the good news is that services needn’t be this way and the changes required are more attitudinally based than means based. it is easy to see that o’brien & o’brien’s characterization is antithetical to inclusion in the community. this formula may too often reflect societal perceptions, particularly in third world places. it seems almost unavoidable that human services will develop such that people with disabilities are objectified and/or treated as if they were a commodity. particularly in the west, but also elsewhere in the world, the resources spent and generated in the delivery of services to persons with disabilities can be distracting and dehumanizing. income is distracting in that people are tempted to look away from supports genuinely needed which might be freely provided by the community rather than billed for by agencies. they are dehumanizing in that people become resource generators because of the problems they face in their lives. but it is not exclusively money that is used in this type of commerce. in uganda, a woman told me of how a witch doctor told her he could easily cure her child with a disability if she lived with him as his sexual partner for a month. as desperate as she was, she consented and the result was a different kind of pain at the end of her month of being victimized. 14 mcnair nov 2015. christian journal for global health, 2(2):10-15. professionals may unknowingly contribute to models that may be counterproductive. human services are too often delivered in an unexamined fashion. questions about how services are delivered may not be embraced or sought. as a result, change can be difficult if not impossible. systems develop and peoples’ jobs and incomes (legitimate or otherwise) are invested in the system remaining as it is. too often one only discovers the flaws of human services when they submit themselves to them. 16 all human service workers, but perhaps christians especially, need to be as unwavering as possible in advocating for outcomes that will truly make a difference in peoples’ lives. for example, dr. hans reinders, a leading dutch philosopher and theologian, has said in regard to persons with developmental disabilities, “the most important thing in life is friendships. and people in human services act as if they didn’t know that.” 17 if we on the contrary do recognize that, then some of our efforts need to be faced internally, toward the agency for whom we are working to ensure that as a part of their efforts, they are facilitating relationships and friendships as an aspect of the care they are providing. dr. richard koch was a physician who was a pioneer in the treatment of persons with disabilities in america. in the 1970s he directed america’s national collaborative study on phenylketonuria (pku). in part due to his efforts, children around the world are tested for pku at birth as disability can largely be prevented through diet. he would often decry how persons with disabilities needed a program which was not their experience in america at that time. because of his efforts and others like him, human services leading to the right to a public school education developed in the united states for those with developmental disabilities. human services have the potential to move society to the next stage of community inclusion of persons with disabilities. however, human services must be developed that are not exclusively medical model based. this is not always intuitive as medical model-based solutions are most often developed by the professional for people in need. the thought of including outside agents as a part of an intervention is probably not how professionals have been educated to think in the diagnosis of problems and prescription of solutions. yes, a social environment that is changed to reflect the love of christ towards all people is highly desirable. however, social connections that reduce discrimination and invite friendship, whatever their motivation, are also desirable. in each of these areas, social model approaches invite the social environment to play a role supporting individuals with disabilities. a good medical system will seek to develop supports within the community such that people do not rely exclusively on medical providers. conclusions the degree to which segregation is the outcome of human supports (medical or otherwise) is the degree to which it needs to be changed. the major focus of all human services should be community development in terms of creating a socially inclusive community. we do not ignore impairments in individuals, but provide medical model supports as appropriate. however, concomitantly we invest major effort into what might be called social model interventions. interventions are aimed at assisting people to do the right thing toward those with disabilities. professionals focus efforts on facilitating the development of real friendships in their own lives and those of community members. physicians, as community leaders, are in a unique position to encourage social change. they can facilitate change through their professional work in their goals, design of service delivery, broadened notions of intervention which include community engagement and developing relationships, and criteria for evaluation of services. they can also facilitate change in their personal lives through community participation, personal relationships with devalued people, and advocacy. 15 mcnair nov 2015. christian journal for global health, 2(2):10-15. references 1. kaplan, d. the definition of disability [internet]. the center for an accessible society; [cited 2015 september 20]. available from http://www.accessiblesociety.org/topics/demographi cs-identity/dkaplanpaper.htm 2. ada national network (nd) what is the definition of disability under the ada? available from https://adata.org/faq/what-definition-disabilityunder-ada 3. world health organization. (2001). international classification of functioning, disability and health: short version. geneva, switzerland: world health organization (p. 28). 4. altmaier, e. & hansen, j. (eds.), (2012). the oxford handbook of counseling psychology. ny, ny: oxford university press. 5. wasserman, d., asch, a., blustein, j. & putnam, d., (2011). disability: definitions, models, experience. in stanford encyclopedia of philosophy. available from http://plato.stanford.edu/entries/disability/ 6. kubler-ross, e. & kessler, d. (2005). on grief and grieving: finding the meaning of grief through the five stages of loss. ny, ny: scribner. 7. berger, p. & luckman, t. the social construction of reality. middleton, great britain: penguin books; 1966. 8. altmaier, e. & hansen, j. (eds.), (2012). the oxford handbook of counseling psychology. ny, ny: oxford university press. 9. wolfensberger, w. (1998). a brief introduction to social role valorization: a high-order concept for addressing the plight of societally devalued people and for structuring human services (3 rd . ed.). syruacus, ny: training institute for human service planning, leadership & change agentry (syracuse university). 10. world health organization, (2011). world report on disability. geneva, switzerland: world health organization. 11. altmaier, e. & hansen, j. (eds.), (2012). the oxford handbook of counseling psychology. ny, ny: oxford university press. 12. oliver, m. the individual and social models of disability. presented at: joint workshop of the living options group and the research unit of the royal college of physicians; 1990 july 23; [cited 2015 september 20]. available from http://www.leeds.ac.uk/disabilitystudies/archiveuk/oliver/in%20soc%20dis.pdf 13. oliver, m. understanding disability: from theory to practice. basingstoke: macmillan, 1996. p. 22. 14. shakespeare, t and watson, n. the social model of disability: an outdated ideology? research in social sciences and disability 2002; 2: 9-28. http://dx.doi.org/10.1016/s1479-3547(01)80018-x [cited 2015 september 20]. available from http://disabilitystudies.leeds.ac.uk/files/library/shakespeare-socialmodel-of-disability.pdf 15. o’brien, j & o’brien, c. members of each other: perspectives on social support for people with severe disabilities. in nisbet, j (ed.) natural supports in school, at work, and in the community for people with severe disabilities. baltimore, md: brookes; 1992. p. 17-63. 16. basnett, i. health care professionals and their attitudes toward and decisions affecting disabled people. in albrect, seelman & bury (eds.), handbook of disability studies. thousand oaks, ca: sage publications; 2001. p. 450-467. 17. reinders, h s. the power of inclusion and friendship. presented at: 35 th annual meeting of the american association on intellectual and developmental disabilities; 2011 june 9; st. paul, mn. peer reviewed competing interests: none declared. correspondence: jeff mcnair, california baptist university, united states. jmcnair@joniandfriends.org cite as: mcnair j. disability and human supports. christian journal for global health (nov 2015), 2(2):10-15. © mcnair j this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ http://www.accessiblesociety.org/topics/demographics-identity/dkaplanpaper.htm http://www.accessiblesociety.org/topics/demographics-identity/dkaplanpaper.htm https://adata.org/faq/what-definition-disability-under-ada https://adata.org/faq/what-definition-disability-under-ada http://plato.stanford.edu/entries/disability/ http://www.leeds.ac.uk/disability-studies/archiveuk/oliver/in%20soc%20dis.pdf http://www.leeds.ac.uk/disability-studies/archiveuk/oliver/in%20soc%20dis.pdf http://dx.doi.org/10.1016/s1479-3547(01)80018-x http://disability-studies.leeds.ac.uk/files/library/shakespeare-social-model-of-disability.pdf http://disability-studies.leeds.ac.uk/files/library/shakespeare-social-model-of-disability.pdf http://disability-studies.leeds.ac.uk/files/library/shakespeare-social-model-of-disability.pdf mailto:jmcnair@joniandfriends.org http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ field report/brief communication may 2023. christian journal for global health 10(1) dust: a meditation from afghanistan m shawn morehead a a md, mph, founding program director, gadsden regional medical center family medicine residency, alabama, usa “… for he knows how we are formed, he remembers that we are dust.” psalm 103:14 on one particular morning from the rooftop of our house in kabul, i noticed the dust. dust in afghanistan is familiar and constant; a companion on all roads and ruins, obscuring and coating, a benign frustration, and a mortal hazard. daily, i watched the dust as symbolic reminder of the complexities of this war-torn land and its proud people. dust here comes in various hues of red and brown, sparking images of decades enduring spilt blood across a dying landscape. death has never been far from the daily consciousness of any dweller in this land; an ever-unspoken reminder of the harsh realities of this place. personally, i know little of it apart from history books, and the memories of those who have spoken about it. however, i have seen the eyes of a longing generation; one that would step over long-drawn boundary lines to glimpse an unknown, imperfect, yet hopeful future. i would do my best to scale that wall with them, guide them down a narrower path; open the gate so they too might enter in. they are proud, loving, hospitable, arrogant, full of life, full of fear, just as we are. there exists little to distinguish our dust from theirs save our understanding of he who has formed us and why. he remembers that we, as they, are all dust and will one day return to our roots. yet we will not stay; we are and will be changed, resurrected, made new. so should they. submitted 23 april 2023, accepted 2 may 2023, published may 2023 competing interests: none declared. correspondence: dr. m shawn morehead, gadsden, al, usa shawnmorehead@gmail.com cite this article as: morehead ms. dust: a meditation. may 2023; 10(1):53. https://doi.org/10.15566/cjgh.v10i1.767 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:shawnmorehead@gmail.com https://doi.org/10.15566/cjgh.v10i1.767 http://creativecommons.org/licenses/by/4.0/ commentaries may 2023. christian journal for global health 10(1) activities of international, medical and humanitarian ngos in ukraine under martial law volodymyr v. shablystyi a kseniia e. kosiachenkob vasyl s. berezniakc, roman a. katorkind, viktor y. konopelskyie a doctor of law science, professor, head of the department of criminal and legal disciplines of dnipropetrovsk state university of internal affairs, dnipro, ukraine b candidate of law science, associate professor, associate professor of the department of civil and legal disciplines of dnipropetrovsk state university of internal affairs, dnipro, ukraine c doctor of law science, senior researcher, head of the department of criminal law and criminology, dnipropetrovsk state university of internal affairs, dnipro, ukraine d phd in law, head of the science laboratory of criminal legal and sociological studies, dnipropetrovsk state university of internal affairs, dnipro, ukraine e doctor of law science, professor, head of the department of criminal law and criminology, odessa state university of internal affairs, odessa, ukraine abstract as a result of russia's full-scale military offensive on the territory of ukraine, numerous international, non-governmental organizations have commenced providing assistance to the population through the implementation of different programs. such assistance is manifested in various aspects, from humanitarian to financial. this article outlines the experience and legal basis for the operation of several international, non-governmental, medical and humanitarian organizations in ukraine working under martial law imposed as a result of the war. to the purpose and objectives of the study, the work uses a combination of general and special methods of scholarly knowledge. the article uses the doctrinal provisions of science on the legal framework for the activities of international, medical and humanitarian, non-governmental organizations in ukraine, as well as statistical data on the activities of public associations during the period of martial law. this study was conducted taking into account the experience of non-governmental organizations in other countries. the authors found that during the legal regime of martial law in ukraine, international, non-governmental organizations such as medecins sans frontieres, the international committee of the red cross, and oxfam play a leading role in providing humanitarian and medical assistance to war victims. these organizations play a key role in promoting democracy while helping to mitigate violence and the psychological trauma of war victims. it is the authors’ contention that such assistance furthers democratic governance, helps curb violence, and addresses the psychological trauma occasioned by the war. key words: life, health, crimes, criminal offenses, non-governmental organizations. shablystyi, kosiachenko, berezniak, katorkin & konopelskyi 34 may 2023. christian journal for global health 10(1) introduction over the past decades, there have been a consistent increase in the number of international, non-governmental organizations and in their growing authority and influence in modern international, legal relations. most often, this process is associated with insufficient resources and capabilities of states and international, intergovernmental organizations to deal with humanitarian crises. with the end of the cold war, a strengthening of democratic processes in the field of domestic and international relations reduced ideological involvement in economic, social, and cultural problems and has become part of the policy of individual states.1,2 that is why the activities of ngos have become a main form of public participation in addressing humanitarian issues.3 this trend is natural for a democratic state since the very category of "democracy" is translated from greek as "rule of the people." people's participation in all processes of public life (including political, humanitarian, medical, educational, and legal spheres) is a natural phenomenon that leads to a constant growth in the number of regional, national, and international, non-governmental organizations. the activities of international, nongovernmental organizations are regulated by international law as well as national legislation of the respective state. for example, article 71 of chapter x "economic and social council" of the united nations (un) charter states that "the economic and social council may make appropriate arrangements for consultations with non-governmental organizations concerned with matters within its competence. such arrangements may be made with international organizations and, where appropriate, with national organizations after consultation with the member of the united nations concerned.4,5 thus, it is a common practice for various un councils to take into account proposals of international, nongovernmental organizations, which is once again a manifestation of the principles of democracy at the international level. on february 24, 2022, the russian federation attacked ukraine, unleashing a fullscale war accompanied by war crimes and offenses against peace and security, humanity, and international law and order. as a result, a humanitarian crisis has arisen on the territory of ukraine, which can only be resolved by coordinated actions of several different actors. these actors include international, nongovernmental, medical and humanitarian organizations. the activities of such organizations are multidirectional and deserve special attention from the scholarly community. since many human rights violations and violence on a large scale are recorded during wartime, the participation of non-governmental , international organizations in such situations is more than necessary.6 non-governmental organizations are an important institutional component of the human rights protection process, as they operate at the local, regional, national, and international levels.7 their activities are aimed not only at addressing immediate needs but also at publicizing problems faced by ordinary civilians. civil society organizations make proposals to state institutions on how to address problems. for these reasons, a comprehensive study of the activities of international, non-governmental organizations both in ukraine and abroad is relevant. methodological framework many scholars address the peculiarities and legal basis for the functioning of international nongovernmental organizations. for example, lutsyshyn and zazuliak (2018) examined the role of foreign ngos in protecting human rights in ukraine during the russian-ukrainian conflict.7 it highlighted the effective actions of these organizations in raising awareness, addressing violations, and providing assistance to victims in both ukraine and the occupied territories. chernyavska (2007) examined the main conceptual approaches and substantiated the methodological basis for the study of world politics in the context of globalization, and accordingly, international ngos as subjects of world politics in these new 35 shablystyi, kosiachenko, berezniak, katorkin & konopelskyi may 2023. christian journal for global health 10(1) conditions.2 tkachenko (2011) focused on exploring and describing the specific characteristics and legal aspects pertaining to international ngos within the framework of modern, international law, and delved into the unique legal nature, rights, responsibilities, and regulatory frameworks surrounding these organizations in the context of international law.3 mack (2008) examined the challenges of noninternational, armed conflicts and strategies to promote compliance with humanitarian law, based on the icrc's field operations and lessons learned.19 it emphasized the importance of bridging the gap between good intentions and the reality of suffering by influencing the behavior of warring parties and increasing respect for international humanitarian law. gasser (1998) demonstrated that respecting and promoting international humanitarian law is crucial for limiting the suffering caused by warfare, protecting human values, and fostering a more humane world.6 among the general methods, corbett and connors (1999) used dialectical, formal-logical, system-structural, and system-functional methods; each method provided a unique perspective and set of tools for analysis and interpretation.24 the dialectical method is a philosophical approach that involves examining and understanding phenomena through the recognition and analysis of contradictions, conflicts, and opposing forces; in this study, it emphasized the dynamic and interconnected nature of reality, focusing on the process of change and development.24 the formallogical method considers the legal status and functions of international, non-governmental organizations in wartime. the formal-logical method is a method of inquiry based on formal logic and deductive reasoning. it involves the application of logical principles such as deduction, induction, and syllogism to analyze and draw conclusions based on premises and logical relationships between concepts.25 the systemicstructural and systemic-functional methods are the analytical approaches that aim to understand and explain phenomena by examining their structural elements and their interrelationships within a system. they focus on identifying the components, their organization, and the hierarchical or functional relationships that exist among them, emphasizing the analysis of systems in terms of their functions, purposes, and results, and fisher (2010) helped to describe the independence of international, medical and humanitarian ngos, as well as analyzed their internal organization and considered the peculiarities of status through the implementation of their functions.26 it used the following special methods of scholarly cognition of legal science: comparative legal method and method of legal interpretation. the comparative method is a research approach that involves examining and analyzing similarities and differences between different cases or entities in order to draw conclusions or make generalizations and was used to identify the common and distinctive features between the activities of such public associations as medecins sans frontieres, the international committee of the red cross, and oxfam. the method of legal interpretation involves analyzing the language, structure, context, and purpose of the legal text to determine its intended meaning and application and was used to interpret the provisions of the law and to reveal the content of concepts, which made it possible to identify some aspects of the legal regulation of the relations under study. results and discussion international ngos have been an important part of civil society since their inception and functioning and can play a significant role in conflict resolution. they have considerable experience and the potential to introduce new tools for solving both global and local problems. since the main goal of ngos is to achieve lasting peace, members of organizations can be representatives of different sectors of civil society. this contributes to a comprehensive approach to overcoming difficulties in conflict resolution. regarding national legislation regulating the activities of international ngos, it should be noted that according to the constitution of ukraine, no one may be forced to join any association of shablystyi, kosiachenko, berezniak, katorkin & konopelskyi 36 may 2023. christian journal for global health 10(1) citizens or restricted in their rights for belonging or not belonging to political parties or public organizations. all associations of citizens are equal before the law.8 more detailed information on the activities of international, nongovernmental organizations in ukraine can be found in the law of ukraine of 22.03.2012 no. 4572-vi "on public associations." according to the fourth part of article 2 of this legal action, public organizations of other states and international, non-governmental organizations operate on the territory of ukraine by this law and other laws of ukraine, international treaties of ukraine, ratified by the verkhovna rada of ukraine.9 thus, the current legislation of ukraine creates opportunities for the active work of international, non-governmental organizations (including medical and humanitarian organizations) in the territory of this country. given the above, international, nongovernmental organizations may exercise the rights provided for in part one of article 21 of the said legislative act. this provision stipulates that to achieve its goal(s), a public association has the right to 1) freely disseminate information about its tasks, goals, and functions; 2) to apply the procedure established by law to state authorities, authorities of the autonomous republic of crimea, local self-government bodies, their officials with proposals and applications; 3) to receive by the procedure established by law public information held by state authorities and other public information managers; 4) to participate in the development of draft regulatory legal acts issued by state authorities by the procedure established by law. based on the foregoing, it is considered that the listed rights of non-governmental organizations (including international, medical and humanitarian organizations) are not exhaustive and are limited to certain areas of activity that are directly provided for by law. it should also be added that according to part two of article 21 of the law of ukraine "on public associations," a public association with the status of a legal entity has the right to: 1) be a party to civil legal relations, acquire property and non-property rights by the law; 2) by the law, to carry out an entrepreneurial activity directly, if it is provided for by the charter of a public association, or through legal entities (companies, enterprises) established by the procedure established by law if such activity corresponds to the purpose (goal) of the public association and contributes to its achievement. information on the entrepreneurial activity carried out by a public formation shall be entered into the unified state register of legal entities, individual entrepreneurs, and public formations; 3) establish mass media to achieve its statutory goal(s). international ngos are actively involved in medical and humanitarian activities in countries where armed conflicts, disasters, and other emergencies are ongoing. unfortunately, ukraine is currently one of these countries. as a result of the full-scale war initiated on february 24, 2022 by the russian federation, every day hundreds of thousands of ukrainian citizens face a humanitarian and medical crisis and are victims of criminal offenses by the russian military and mercenaries, terrorist groups, and collaborators. in such circumstances, activities are regulated by several legislative acts. in particular, by article 11 of the geneva convention (iv) relative to the protection of civilian persons in time of war of 12.08.1949, the high contracting parties (in this case, the aggressor country—the russian federation and ukraine) may at any time agree to entrust to an organization offering all guarantees of impartiality and efficiency the performance of the duties assigned to the protecting powers under the present convention.10 in addition, by article 3(2) of the geneva convention (iii) relative to the treatment of prisoners of war of 12.08.1949, an impartial humanitarian body, such as the international committee of the red cross (whose activities will be reviewed further), may offer its services to the parties to the conflict to assist wounded and sick soldiers.11 in times of war, it is difficult to overestimate the activities of non-governmental, medical and humanitarian organizations that not only provide the necessary assistance to civilians and wounded 37 shablystyi, kosiachenko, berezniak, katorkin & konopelskyi may 2023. christian journal for global health 10(1) soldiers but also perform several forensic functions. below, the authors undertake to examine the activities of some of these organizations in more detail. medecins sans frontieres since the beginning of the russian federation's full-scale war against ukraine in february 2022, medecins sans frontieres has been one of the first non-governmental, medical, humanitarian organizations to start working in the ukraine. this non-governmental organization was established in paris by a group of journalists and doctors in 1971. medecins sans frontieres (msf) is designed to help people affected by armed conflicts, various epidemics, and disasters. the organization's members are mainly doctors, as well as logistics and administrative specialists united and guided by their charter. the main task of the organization is to provide quality medical care. thus, the members of msf, risking their lives, are constantly in the heart of conflicts and disasters, assisting victims of natural or man-made disasters. for example, a person who has suffered damage to his or her health or lost relatives or friends as a result of war crimes or criminal offenses committed against peace, security, humanity, and international law and order (criminal offenses under parts xix-xx of the criminal code of ukraine) capable of subsequently choosing a criminally unlawful model of behavior for the sake of revenge (with revenge being either personalized–i.e., directed against a specific individual or legal entity) or abstract (i.e., directed against certain groups of people). in these situations, msf's activities can serve as a factor that mitigates such actions. assisting this category of people inspires faith in others and demonstrates humanism and respect for the individual.12 or, as a result of direct or indirect exposure to war, a person may choose to commit criminal offenses against property. again, the provision of free, professional, medical or humanitarian assistance can meet the relevant minimum needs of a person and prevent antisocial behavior. according to msf's statute, the organization consists mainly of doctors and healthcare professionals but is open to all other professions that can help achieve its goals. all members are guided by the principles that msf: 1) regardless of age, gender, religion, race, or political beliefs, helps people in difficulty, victims of natural disasters, man-made disasters, and armed conflicts; 2) is an independent and impartial actor in the name of universal, medical ethics and the right to humanitarian assistance, insisting on unimpeded access to the population and full freedom of action; 3) consists of members who are neutral in their political, religious, and economic views, obliged to respect their professional code of ethics; 4) whose volunteers are aware of all possible risks during the performance of their tasks, and therefore, do not claim any form of remuneration for themselves or their appointees other than that provided by the association.13 msf is actively involved in assisting victims of the war waged by the russian federation against ukraine, responsible for wounded and killed civilians/military personnel, destruction of infrastructure and personal property, and a humanitarian crisis. under such conditions, it is quite difficult to provide quality and timely medical care. in addition, there is a shortage of doctors and other healthcare professionals. this argument is confirmed by msf where its official website states that people who remain where hostilities are taking place or under constant rocket attacks from the russian federation face lack of food, clean water, medicines, and electricity. doctors experience a shortage of essential medicines, especially for surgical, trauma, and intensive care units. in addition, there is a need for specialty medicines (e.g., insulin for diabetics, asthma medicines, hiv/aids patients, etc.).14 according to the statistics provided by the organization, 703 msf employees are currently working in ukraine of whom 570 are citizens of ukraine and 133 are nationals of other countries. at the same time, new staff (surgeons, other doctors, nurses, psychologists, etc.) are joining the above-mentioned employees every day. shablystyi, kosiachenko, berezniak, katorkin & konopelskyi 38 may 2023. christian journal for global health 10(1) msf has deployed its personnel in multiple cities across distinct regions within ukraine. members work both in the logistics centers of western ukraine and in the regions and cities where there are active hostilities. thanks to msf’s contribution, the lives and destinies of many ukrainians affected by the russia-ukraine war have been saved. msf's continues to be active outside of ukraine, demonstrating resilience and belief in the organization's mission. in august 2021, the taliban entered the city of kabul, afghanistan and initiated a regime change. horrors took place there and, unfortunately, continue to this day. many of the wounded, sick, and raped needed and still need medical care. while many people and organizations have left afghanistan, msf teams have remained to provide essential medical care, including outpatient care. volunteers at the kahdestan clinic provide treatment for various diseases, as well as sexual and reproductive health examinations. after the end of hostilities, the number of casualties began to decrease as hospitals and clinics are gradually returning to work, meaning that there is a slight increase in the supply of medical services.15 international committee of the red cross in addition to msf, the international committee of the red cross (icrc) has launched an active campaign to help civilians and wounded soldiers. the icrc is an international, nongovernmental organization whose mission is: 1. to support and promote the fundamental principles of the international red cross and red crescent movement (hereinafter the movement): humanity, impartiality, neutrality, independence, voluntariness, unity, and universality.16 effective assistance to victims of armed conflict is only possible if the above principles are strictly obeyed. for example, disregard for the principles of impartiality and independence will be grounds for not allowing representatives of this organization to enter the territory controlled by one of the warring parties, which, in turn, will lead to the termination of the icrc's activities in any meaningful sense. 2. in the event of the establishment or resumption of the activities of a national society that meets the conditions for recognition, to recognize such a society by the provisions of the statute, as well as to notify other national societies of such recognition. therefore, the icrc is authorized to recognize relevant national, nongovernmental organizations that intend to operate under the auspices of the movement. for example, the ukrainian red cross society (urcs), which operates in ukraine, was recognized by the icrc in september 1993.17 therefore, the activities of non-governmental organizations under the auspices of the movement depend on their recognition (or non-recognition) by the icrc. this function of the icrc is very important, as it excludes the possibility of discrediting the movement in the international arena by unethical organizations or those that do not comply with the basic principles and provisions of international, humanitarian law. 3. by the geneva conventions, to carry out its activities in good faith by the rules of international, humanitarian law applicable in armed conflicts, as well as to respond to any complaints based on violations of these rules. as noted above, by the geneva conventions, with the consent of the parties involved in the military conflict (in this case, the russian federation and ukraine), icrc representatives may be admitted to the relevant territory to carry out a humanitarian mission or provide medical assistance. in addition, the staff of this public organization records the facts of violations of international, humanitarian law, which is a deterrent. 4. since the icrc is a politically neutral organization whose humanitarian activities are carried out during various types of armed conflicts, as well as during internal confrontation, it must make efforts to ensure the protection and assistance of military and civilians during such events and their direct results. 5. ensure the operation of the central tracing agency, as provided for by the geneva conventions. 6. promote the training of medical personnel and the preparation of medical equipment in 39 shablystyi, kosiachenko, berezniak, katorkin & konopelskyi may 2023. christian journal for global health 10(1) advance of armed conflicts in cooperation with national societies and authorities, military and civilian medical services at the local level, and other competent authorities.18 such measures allow transferring the necessary knowledge and practical skills to the relevant medical professionals that will be needed during the active phase of a military conflict. increasing the professionalism and awareness of healthcare workers allows them to diagnose relevant diseases and injuries promptly, make quick and correct decisions, respond promptly to changes in the patient's condition, etc. 7. explain the provisions of international, humanitarian law applicable during armed conflicts, disseminating information, and preparing any developments. 8. to fulfill the tasks and assignments set by the international conference. by the charter, the international committee of the red cross, as a fully independent and politically, economically, and religiously neutral institution, may take any humanitarian initiative and mediate in conflict resolution. and it can consider any issue that requires consideration by such an institution. thus, the role of the icrc in providing humanitarian and medical assistance to victims of military conflicts cannot be overestimated.19 naturally, this international, nongovernmental organization is actively involved in assisting victims of the war waged by the russian federation against ukraine since february 2022. this assistance is multifaceted and covers many aspects in the humanitarian sphere, including education and medicine. in general, the icrc has been working in ukraine since 2014, when russia started the war in eastern ukraine and annexed the autonomous republic of crimea. with the outbreak of a fullscale war in february 2022, the icrc expanded its activities to the territories directly affected by the hostilities. today, the ngo's staff works in lviv, kamianets-podilskyi, vinnytsia, kyiv, poltava, dnipro, odesa, sloviansk, luhansk, and donetsk. in addition, new offices have been opened in neighboring countries—the republic of moldova, hungary, the republic of poland, and romania. as in the case of msf, icrc not only provides humanitarian and medical assistance during the russian federation invasion, but also significantly expanded its activities in ukraine and neighboring european countries. in the latter case, hundreds of thousands of ukrainians forced to leave the territory of ukraine as a result of the military conflict were able to receive professional assistance from the icrc. during the war, the icrc, together with the ukrainian red cross society and other red cross partners, has provided medical care to the population, as well as emergency assistance to the wounded and sick. the organization has also set up a support hotline to help treat psychological wounds sustained during the armed conflict. it also conducts psychosocial support sessions and training on psychosocial support for ukrainian red cross staff and volunteers. the latter activity is very relevant and significant, as ukrainians are faced with the consequences of russian aggression daily, staying amid hostilities, becoming victims of enemy shelling and bombing, and receiving information about the war and crimes committed on the territory of ukraine by the military and mercenaries of the aggressor state. such tension can lead to serious health disorders and even become a cause or basis for committing criminal offenses, so such hotlines have a positive impact on protecting the lives and health of citizens, and in some cases, even become a beacon that saves people from rash and sometimes even fatal actions. the statistics on the icrc's activities in ukraine for the period from february 24 to august 2022 are impressive. this public organization, together with the ukrainian red cross society and other partners, has provided emergency assistance to people living in conflict zones and displaced as a result of armed hostilities. in particular, it provides food for more than 800,000 people, as well as hygiene items, kitchen sets, household appliances, mattresses, blankets, and other essentials for more than 300,000 internally displaced persons. more than 200,000 people received financial assistance to cover immediate expenses. in moldova, the icrc, together with the shablystyi, kosiachenko, berezniak, katorkin & konopelskyi 40 may 2023. christian journal for global health 10(1) red cross society of the republic of moldova, delivered food and hygiene kits to 5,000 families, and another 600 families received cash assistance in transnistria.20 these data suggest that the icrc is a leader among non-governmental organizations that provide medical and/or humanitarian assistance to victims of the war in ukraine. the icrc's activities are a benchmark for a large number of state and international, nongovernmental associations. the icrc was actively involved in the conflict zones in afghanistan during the 2000s. during this period, six physical rehabilitation centers were established to help victims. the organization's staff regularly visited detainees held by the afghan government and international forces, and since 2009, has also had occasional access to people held by the taliban. in addition to providing direct medical care, they provided basic first aid training and first aid kits. in august 2021, when nato-led forces withdrew from afghanistan, the icrc remained in the country to continue its mission of assisting and protecting victims of the conflict. since june 2021, more than 40,000 people affected by the armed conflict have been treated in icrc-supported facilities. oxfam the international ngo, oxfam, is actively working to provide medical and humanitarian assistance to victims of the war waged by the russian federation against ukraine. this public association was founded by a confederation of independent, non-governmental organizations in 1995. the association has had an effective impact on global poverty and injustice. today, oxfam operates in more than 70 countries. oxfam unites 21 organizations located in australia, belgium, brazil, canada, colombia, denmark, france, germany, hong kong, hong kong special administrative region of china, ireland, india, italy, mexico, the netherlands, new zealand, south africa, spain, turkey, turkey, the united kingdom, and the united states.21 with the outbreak of russia's full-scale war against ukraine in february 2022, oxfam launched its humanitarian operations in ukraine and neighboring democratic states. in particular, the ngo channels financial and technical assistance through more than 20 local partner organizations in ukraine, the republic of moldova, the republic of poland, and romania to help people affected by the war. these activities provide immediate, life-saving assistance and protection daily in a variety of areas: water and sanitation, shelter, food, financing, legal assistance (including the risks of becoming victims of human trafficking and gender-based violence), psychological assistance, and various integration services (such as, language courses or job search support). overall, the organization has assisted over 719,000 people affected by the war in ukraine.22 based on the above, during the war in ukraine, oxfam has been conducting activities that cover the medical, humanitarian, social, and criminological spheres. for example, through local ngos, oxfam coordinates financial flows aimed at assisting victims of russian military aggression, including the provision of medical services and procurement of necessary medicines and equipment and is actively involved in the prevention of criminal offenses through training and lectures that help to deactivate the determinants of crimes and criminal offenses. in the context of our study, it is worth paying attention to the organization's activities in iraq. oxfam iraq seeks to build resilience in conflictaffected areas of the country by restoring existing basic services and providing long-term interventions in the areas of water, sanitation, and hygiene and to promote emergency food security and reduce vulnerable livelihoods in coordination with local authorities and partners. by leveraging their advocacy expertise, we hope to influence approaches to humanitarian assistance to ensure that the rights of all people affected by the current conflict are promoted and protected.23 as we can see, the organization's activities are quite diverse and adapted to the needs of the affected population. these areas of activity can significantly reduce the number of victims during the war and neutralize the causes and conditions of criminal offenses, especially against civilians. 41 shablystyi, kosiachenko, berezniak, katorkin & konopelskyi may 2023. christian journal for global health 10(1) conclusion ukraine was attacked by the russian federation on february 24, 2022, which resulted in a full-scale war with numerous military and statesponsored crimes against peace, security, humanity, and international law and order. this led to a humanitarian crisis in the country of ukraine, which can only be resolved through the joint efforts of various actors. among these actors are international, non-governmental, medical and humanitarian organizations that assist millions of citizens affected by the war. the work of these organizations has many aspects and requires special attention from the scholarly community. since the outbreak of a full-scale war in ukraine, we can observe a revival of the activities of international, medical and humanitarian, nongovernmental organizations focused on assisting the victims of this conflict. the leading role in this area belongs to such public associations as medecins sans frontieres, the international committee of the red cross, and oxfam. thanks to these and other organizations, millions of ukrainians have received timely medical and humanitarian aid. in addition, such work can significantly reduce the crime rate in this country, as it has a positive impact on the dynamics of the spread of criminal offenses. common to other similar organizations is that they provide medical assistance in areas affected by conflicts, epidemics and other humanitarian crises. during armed conflicts, the focus is on providing medical assistance to victims of violence and conflict, as well as providing medical services in areas where access to them is limited. they provide medical assistance in emergency situations such as bullet and blast injuries, burns, mental trauma, epidemics, famine, and water shortages. in addition, they also work to prevent disease and provide preventive health care in conflict zones. medecins sans frontieres, the international committee of the red cross, and oxfam are engaged in ensuring the protection of the rights and dignity of war victims, as well as providing the necessary assistance and support to these people. they also provide humanitarian aid to victims of armed conflicts: shelter, medical aid, food, water, clothing, and other material goods, as well as psychological support to victims of violence. cooperation between the government and international organizations helps to provide the necessary assistance and to ensure human rights in conflict zones. references 1. anisimov d, shablistiy v. doping as a global problem of the 21st century on account of its illegal influence on the results of official sports competitions. wiadomosci lekarskie. 2021;11(2):3092–7. 2. chernyavska ln. subjectivity of international non-governmental organizations in world politics. author's abstract. thesis, kyiv: kyiv national 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(2018). statute of the international committee of the red cross. 2018. available from: https://www.icrc.org/en/document/statutesinternational-committee-red-cross-0 19. mack m. increasing respect for international humanitarian law in non-international armed conflicts [internet]. 2008 feb. available from: https://www.icrc.org/sites/default/files/topic/file_ plus_list/0923 increasing_respect_for_international_humanitari an_law_in_noninternational_armed_conflicts.pdf 20. international committee of the red cross [internet]. humanitarian crisis in ukraine and neighboring countries. 2022. available from: https://www.icrc.org/en/humanitarian-crisisukraine 21. oxfam international [internet]. our history. 2023. available from: https://www.oxfam.org/en/our-history 22. oxfam international [internet]. oxfam's response to the ukraine crisis. 2022b. available from: https://www.oxfam.org/en/what-wedo/emergencies/oxfams-response-ukraine-crisis 23. oxfam international [internet]. iraq. 2022a. available from: https://www.oxfam.org/en/whatwe-do/countries/iraq 24. corbett epj, connors rj. classical rhetoric for the modern student. oxford university press: usa;1999. 25. copi im, cohenc, mcmahon k. introduction to logic. routledge. 2016. 26. fisher j. systems theory and structural functionalism [internet]. researchgate. 2010. available from: https://www.researchgate.net/publication/273947 370_systems_theory_and_structural_functionalis m peer reviewed: submitted 3 feb 2023, revised & accepted 22 may 2023, published 29 may 2023 competing interests: none declared. correspondence: volodymyr v. shablystyi, ukraine volodymyr_shablystyi@edu.cn.ua cite this article as: shablystyi vv, kosiachenko ke, berezniak vs, katorkin ra & konopelskyi vy. activities of international medical and humanitarian ngos in ukraine under martial law. christ j global health. may 2023; 10(1):33-42. https://doi.org/10.15566/cjgh.v10i1.749 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank#text about:blank#text about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank abstract key words: life, health, crimes, criminal offenses, non-governmental organizations. introduction poetry & prayers may 2023. christian journal for global health 10(1) for one who has suffered an injury jessica smith culver a a certified natural health professional, new road health coaching, oregon, usa o christ my healer, you are intimately familiar with the pains of flesh and blood. even before you bore the many sufferings of the cross, your body, human as mine, endured the various batterings of life in a fallen world i now experience. so be with me now in this injury. my body has suffered a wound that reminds me of my frailty and prevents my participation in the normal business of daily life. i find my freedom to work and play suddenly limited, my movements restricted, my rest interrupted. the simplest duties, so easily fulfilled in my wholeness, the simplest delights, so readily enjoyed, are unexpectedly hindered by the hurt i have suffered. i am unaccustomed to such restriction of my abilities, and keenly feel the weakness of my position. o lord, let me not in my weakness of body excuse weakness of character, but rather let me faithfully honor you in times of pain as well as times of ease. give me grace to grow through this temporary discomfort. when i am tempted to complain, remind me to be content in all circumstances. when i am tempted to give way to frustration and anger, teach me patient endurance. when i am tempted to indulge in self-pity, show me anew the sufferings of christ, that i might humbly imitate his example through my lesser pain. as this injury to one part of my body has so greatly affected the whole, i am reminded that i too am a small but necessary part of the greater body of christ. use this occasion to form in me a greater love for your beloved church, o lord. let me love and care for my fellow members by serving them in the ways i am able, and by graciously allowing them to serve me in my need. keep me from any ingratitude or pride that might hinder our fellowship. i praise you, o god, that you have wondrously created my body with the ability to heal, mysteriously restoring my bones, muscles, tissues, and cells by the marvelous natural processes you have so perfectly ordained. even while i wait for this renewal of my damaged flesh to be fulfilled, may my soul find healing in these days of retreat from my usual labors and pastimes. as i recover, let me find a needed inner renewal in quiet communion with you. turn my heart always to hope in the final healing of all things, 57 culver may 2023. christian journal for global health 10(1) when all injury will be restored, all brokenness renewed, and all pain erased forever. i praise you, lord christ, for the assurance of this gift in your wounded body, now resurrected and eternally glorified. amen. peer reviewed: submitted 7 march 2023, revised & accepted 8 april 2023, published may 2023 competing interests: none declared. correspondence: jessica t culver, oregon, usa jessica@newroadhealthcoaching.com cite this article as: culver jt. for one who has suffered an injury. christ j global health. may 2023; 10(1):56-57. https://doi.org/10.15566/cjgh.v10i1.759 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:jessica@newroadhealthcoaching.com https://doi.org/10.15566/cjgh.v10i1.759 http://creativecommons.org/licenses/by/4.0/ editorial december 2021. christian journal for global health 8(2) vulnerable populations and communal capacity-building welcome to the second issue of the christian journal for global health for 2022. it might be described as a “mini issue” with one original article, three short reports, and three poems. the journal has experienced somewhat of a reduction in acceptable submissions and has declined publication more often this year than in previous years. perhaps this is a post-covid phenomenon where we are now seeing the longer-term consequences of nearly two years of reduced work capacity. it is very much hoped that the restrictions due to covid-19 will not lead to persisting productivity loss, including in the area of research. or that habits of inactivity justified by infection risks do not become habits of torpor. nevertheless, there is distinct value in what we do have. the pandemic has exacerbated disparities and increased vulnerability of certain groups, and the church retains a key role in addressing these. arun sharma, nicole bishop, and nathan grills set out to evaluate the impact of self-help groups on women’s empowerment. they used qualitative measures to develop themes arising out of interviews with widows in uttarakhand, india. interventions had produced increased agricultural productivity, more financial security, increased social recognition, and better solidarity among widows as a group. fotarisman zaluchu examined gender imbalance in the indonesian island of nias where christianity predominates. using interview techniques, he found that naïve biblical interpretations served to reinforce preexisting cultural stereotypes that were to the disadvantage of women’s health. somewhat in contrast, zaluchu also studied the role of churches in disseminating information on preventing childhood stunting, a condition affecting 25 to 48 percent of the population. the churches were effective in facilitating the outreach of the teams and building capacity through culturally appropriate teaching methods that incorporated native clothing and dance. a short report by jim harries provocatively asks whether western approaches to public health, dominated as they are by thinking that emphasizes the individual in a material universe, are really effective in societies where world views are communal, relational, and spiritual. dr. harries presents a “middle road” approach, writing from an experience of many years’ residence among the people groups about whom he writes and with intimate familiarity with their languages. it is certainly true that western aid programs in lmics reflect the cultural priorities of people paying for the aid, a situation that is rather difficult to distinguish from old-fashioned imperialism even if military force is not the tool of influence. three poems are a special feature of this issue. the journal welcomes poetry, and we are particularly indebted to our poetry editor, sarah larkin, to help us evaluate them. oyebode dosunmu presents a prayer for us to know, have, hope, and see and a second poem, present sufferings, future glory about endurance and hope in spiritual formation. finally, a poem by brian quaranta warns us about the ethical problems of physician assisted suicide with reminders from orpheus (we might add, lot’s wife) about the allurement of death’s longed-for backward glance. a book review by william cayley on mekdes haddis’s work a just mission highlights the importance of setting aside power and cultural hegemony toward mutual respect and collaboration for the building of a better world. this is the world into which jesus of nazareth was born in vulnerability to mary to redeem all nations. the editors of the christian journal for global health extend to all our readers, reviewers, and authors the very best wishes for a blessed christmas and a flourishing new year. https://journal.cjgh.org/index.php/cjgh/article/view/699 https://journal.cjgh.org/index.php/cjgh/article/view/699 https://journal.cjgh.org/index.php/cjgh/article/view/651 https://journal.cjgh.org/index.php/cjgh/article/view/649 https://journal.cjgh.org/index.php/cjgh/article/view/671 https://journal.cjgh.org/index.php/cjgh/article/view/685 https://journal.cjgh.org/index.php/cjgh/article/view/687 https://journal.cjgh.org/index.php/cjgh/article/view/711 https://journal.cjgh.org/index.php/cjgh/article/view/709 original article may 2016. christian journal for global health, 3(1): 36-45. human, snake, and environmental factors in human-snake conflict in north bihar — a one-year descriptive study. takanungsang longkumer a , lois joy armstrong b , vishal santra c , philip finny d a mbbs, pgdipfm, duncan hospital, raxaul, bihar, india (a unit of emmanuel hospital association) b bsc, mphtm, duncan hospital, raxaul, bihar, india c ba, menv mgmt, simultala conservationists (foundation for wildlife), nalikul, hooghly, west bengal, india d md, dnb(med), dnb (endo), duncan hospital, raxaul, bihar, india abstract background: the state of bihar has the third largest number of snakebite deaths in india. the purpose of this study is to explore the factors related to human-snake conflicts in northwest bihar and southern nepal. using these findings, various strategies were proposed to reduce the incidence of snakebites. method: data were collected from 609 patients at duncan hospital in raxaul, bihar, india between 1 july 2012 and 30 june 2013. patients were included if they had a history of snakebite or unknown bites. patients with symptoms of envenomation but no known bites were also included, as were patients who were dead on arrival due to a snakebite. results: the 10-19 year old age group is the peak age group (28.4%) for snakebite. there is a slight preponderance of males (52.7%). 51.4% of bites occurred on the foot/ankle. the envenomation rate was 12.6%. the mortality rate of those envenomed that arrived at the hospital alive was 6.3%. fourteen people were dead on arrival at the hospital. 75% of people were unable to identify what, or what type of snake, bit them. common wolf snakes (lycodon aulicus) were the most common snakes brought to the hospital, followed by spectacled cobra (naja naja). patients who brought snakes to the hospital and attempted identification were all successful at identifying cobras, but all those who brought in common wolf snakes incorrectly identified them as kraits. the highest monthly frequency of snakebites occurred between june and september; while on a daily basis, the highest frequency occurred between 1700hrs-2200hrs, the time in which 39.1% of all bites occurred. 59.2% of the bites occurred in and around the house. farming, housework, sleeping, playing, and toileting in fields were the activities most commonly occurring when bitten. sleeping on the floor increased the risk of envenomation [or= 5.8, 95%ci 1.8-18.6], while sleeping under a mosquito net decreased the risk of envenomation [or= 0.17, 95%ci 0.04-0.6]. 37 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. conclusion: snakebite is a rural hazard in northern bihar, not just an occupational hazard. use of toilets and sleeping on beds with well tucked in mosquito nets may help prevent snakebites. education to reduce the risk of snakebites should begin in childhood and be regularly reinforced prior to the rainy season. prevention measures should include environmental management such as keeping eating areas clean and keeping food storage and sleeping areas a distance apart. introduction human-snake conflict has been present for centuries, but in india, there is still much to learn about this neglected problem. the country has over 300 identified species in its various environments, out of which more than 60 are venomous. 1 humans are mostly envenomed by four of these species that encroach upon human habitats and agricultural fields as well as the areas around them, namely: spectacled cobra (naja naja), common krait (bungarus caeruleus), russell’s viper (daboia russellii), and saw scaled viper (echis carinatus). 1 many snakebite deaths occur in settings where there is poor recording of causes of deaths, and so the best available estimates are used. in 1998, chippaux estimated that worldwide, there are 125,000 deaths per year and 10,000 of those from asia. 2 india, we know, makes up a large part of this figure. the best indian estimate is currently 45,900 deaths per year due to snakebite from the work of the million death study. 3 they suggest, that in keeping with this data, the number of deaths worldwide is well over 100,000 per year. 3 snake venom acts in a variety of ways including: paralysis caused by neurotoxicity, bleeding disorders, local tissue damage, renal tissue damage, and rhabdomyolysis. some may have just one action and others may have a combination of the above list; some may even show regional variation within a species. currently in india, there is only anti-venom for the four main species: spectacled cobra, common krait, russel’s viper, and saw-scaled viper. each year in bihar, 4500 deaths are attributed to snakebites. this makes it the state with the third highest number of snakebite deaths in india after uttar pradesh and andhra pradesh. 3 bihar is one of india’s poorest and least resourced states in terms of its health services. 4,5 duncan hospital in the east champaran district of bihar admits approximately 500 patients annually from both northern bihar and the plains of southern nepal who have been bitten by snakes. while data on epidemiology, outcomes, and determinants of snakebites are available from nepal, 6-8 the same information is lacking from bihar. envenomation is a deadly consequence of snakebites, especially in regions like east champaran, where victims often travel for many hours to reach a health facility. unpublished data from a retrospective chart review showed that 367 people presented to duncan hospital, raxaul, in 2011 with snakebites, bites of unknown origin (but suspected of being a snakebite), and signs of envenomation with no known bite. most patients in this data set were between 11-15 years old and 13.3% presented with neurotoxic envenomation. no syndromes of coagulopathy were seen. 51% of the patients with neurotoxic symptoms also had tissue damage or inflammation at the local bite site, which are findings consistent with the effects of a cobra bite. the venomous snakes were assumed to be cobras and kraits, as these are the venomous snakes common to this region. the overall envenomation rate at duncan hospital (13.3%) was lower in the 2011 data set in comparison to the 52% envenomation rate of sharma et al. 7 probable reasons for this are that our region is inhabited by a large number of nonvenomous snakes or that many people die prior to reaching health facilities. this study was designed to look at which human, snake, and environmental factors influence the likelihood of being bitten by a snake 38 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. in the east champaran region of north-west bihar and southern nepal. this information is aimed at providing public education on how to prevent snakebites and, therefore, decrease the mortality and morbidity due to snakebites. data on the factors relating to mortality of snakebites will be published elsewhere. materials and methods information on human, snake, and environmental factors related to snakebites were collected from 615 people who presented between 1 july 2012 and 30 june, 2013. patients were included if they had been bitten either by a snake, or an unknown source, or presented with symptoms of snake envenomation without a known snakebite. in the retrospective chart review, bites from unknown sources had shown an envenomation rate of 8.2%. this is only 40% lower than the 13.3% of envenomation rate in known snakebites. bites from unknown sources were therefore included in the present study. patients who were dead on arrival who had been bitten by a snake were included in the study. the study was explained to patients and/or their attending relatives in a relevant language, and verbal consent was obtained to collect the data. patients were included in the study if they presented to the hospital within 24 hours of the time of the bite or had symptoms of envenomation. the following observations were recorded: location of bite, time of bite, time taken to reach the hospital, location of victim at time of bite, and victim activity at time of bite. patients were asked to attempt identifying the snake if seen. dead snakes brought to the hospital were photographed and preserved in formalin. at the end of the study, the preserved snakes were identified to the species level by a person skilled in the classification of snakes. information was also obtained related to delays encountered during travel to the hospital, first aid or treatment prior to arrival at the hospital, and treatment given at the hospital. data was collected on pre-printed case report forms and, subsequently, converted into an electronic format. epi data 3.1 was used to generate descriptive statistics. vassarstats (www.vassarstats.net) was used to analyse further data. permission to conduct this study was obtained from the emmanuel hospital association research and ethics committee (proposal number 77). results out of the 615 patients from whom data was collected, six cases were excluded for the following reasons: scorpion bite (1), spider bite (1), did not meet inclusion criteria for time of presentation to the hospital (1), snake’s blood splashed into eyes while killing a snake (1), not bitten by a snake or any other animal (2). some of these patients were initially included as their anxiety made it difficult to get an accurate history. 352 (58%) of the patients came from india and 256 (42%) from nepal. one person did not have an address recorded. human factors table 1 shows that males made up 52.7% of the population (n=321), and 47.3% of the population was female (n=288). 28.4% of the population was between 10 and 19 years of age. only in the 30-39 year old age range did we find more women bitten than men. table 1. age and gender age (yrs) total male female 0-9 54 35 19 10-19 173 93 80 20-29 125 63 62 30-39 123 53 70 40-49 69 35 34 50+ 65 42 23 total 609 321 288 the distal limbs (foot and hand) were the most common bite sites (n=457, 75.8%), and 51.4% of the bites were on the foot and ankle. significantly, more bites were present on the right side of the body (n=304) compared to the left (n=286, p=0.033). fang marks were present in 42% of the http://www.vassarstats.net/ 39 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. patients (n=256), but evidence of fang marks was obscured by incisions or burn marks in 7% (n= 43) and absent in 34.3% (n= 209) cases. 19.4% of the patients with fang marks were envenomed, and 3.8% (n=6) of patients without fang marks were envenomed. a total of 77 people (12.6%) were envenomed, including all 14 patients who were dead on arrival at the hospital. out of the envenomed patients who arrived at the hospital alive, four died in the hospital (mortality rate = 6.3%). two patients were referred to outside centres; two were discharged at the request of relatives and were expected to die as they had not regained any signs of consciousness during the 72 hours post resuscitation. activity at time of snakebite complete data on victims’ activity at the time of the snakebite is recorded in table 2. table 2. activity at time of snakebite note.*this includes house building, demolition, maintenance – 2, getting off a bed – 2, geting or putting on shoes – 2, killing or removing snake – 2, putting hand in or closing rat hole – 2, road making, brushing teeth, catching a mouse, working (vague), bike riding – all 1 each. additional information was collected from the 69 victims who were sleeping at the time they were bitten. 19 people were sleeping on the floor and 47 on a bed (data missing = 3). twenty six individuals used a mosquito net and 40 did not use a mosquito net (data missing = 3). location of victim at time of bite 59.2% of the bites occur in and around the house. 29.3% of bites occurred in fields and jungles. complete information on locations where victims were bitten are recorded in table 3. table 3. location of victim at time of snakebite location number percentage outside but in the vicinity of the house 194 31.8 fields and jungles 179 29.3 inside house 167 27.4 road and pavements 35 5.7 waterbodies 22 3.6 others (school, factory, railway, temple) 4 0.65 not recorded 8 1.3 total 609 100 snake factors 214 people (35%) did not see what bit them, but they came to hospital because they thought it was most likely a snake. 234 (40%) had seen a snake bite them, but could not identify the type of snake. 152 (25%) people made an attempt to activity number percent farming 139 22.8 walking/running 115 18.9 housework 77 12.6 sleeping 69 11.3 playing 55 9.0 toileting in field 50 8.2 sitting/standing stationary 26 4.2 collecting water/fishing 9 1.4 moving bricks/sticks/objects 9 1.4 opening/closing gates or doors 5 0.8 leaning on wall/fence/roof 4 0.6 doing pooja/worship 4 0.6 missing 32 5.2 other* 15 2.4 total 609 40 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. identify the type of snake. of the identified snakes, 86 claimed to have been bitten by a krait, 46 by a cobra, 14 by a water snake (local name pani saap), 3 by a rat snake (local name dhaman), 2 by a wolf snake, and 1 by a king cobra. the following were identified from the collection of preserved snakes: common wolf snake (lycodon aulicus) (21), spectacled cobra (naja naja) (11), common kukri snake (oligodon arnensis) (1). there were no common kraits (bungarus caeruleus) collected during this study, but some have been brought to the hospital by patients since the study was completed. no russell’s vipers were brought in by patients during this study, and to date, they still have not been recorded in the area. of the 11 cobras brought in for identification, seven of these caused envenomation (63.6%). twenty people who brought in snakes had attempted identification of these snakes. ten out of ten victims correctly identified cobras; however, ten out of ten victims identified wolf snakes as common kraits. out of those who identified the snake as venomous, 19.5% were envenomed, while 7.7% of patients were envenomed though the snakes were identified by victims or their families as non-venomous. out of those who presented with bites of unknown predators, 14% were envenomed. environmental factors 79.1% of snakebites occurred during bihar’s rainy season that runs from june to september. only 4 snakebites (0.6%) occurred within the coldest winter months of december and january. 39.1% of all snakebites occurred between 1700hrs and 2200hrs, with the highest frequency between 1900h and 2000 hrs (figure 1). figure 1. snake envenomation according to time of day there were 55 people who had complete data for the time of bite and the syndrome of envenomation. twenty eight envenomations occurred in the daylight hours (0600 to 1800hrs), and 27 envenomations occurred at night (18000600hrs). dusk and dawn only vary around 30 minutes either side of this during the year. during the period 1800-0600 hrs, 44.4% of the envenomations had solely neurotoxic symptoms in comparison to 21.4% between 0600-1800 hrs. neurotoxic syndromes associated with tissue damage were higher between 06001800hrs (78.6%) compared to between 6pm and 6am (55%). when tested for difference in proportions, 2 4 0 0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0 1 5 0 0 1 6 0 0 1 7 0 0 1 8 0 0 1 9 0 0 2 0 0 0 2 1 0 0 2 2 0 0 2 3 0 0 0 10 20 30 40 50 60 70 80 time of day (24 hour clock) f re q u e n cy ( n o .) snakebite frequency 41 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. they were found not to be significant (p= 0.0689, two tailed test). envenomation syndrome all of the 77 envenomed patients had neurotoxic envenomation syndrome. tissue damage was recorded in 38 cases, while 29 had no tissue damage present. in nine patients, there was no documentation regarding the presence or absence of tissue damage. one patient from nepal presented with bleeding from the mouth and nose. the patient had been administered four vials of anti snake venom (asv) at a peripheral hospital, and on arrival at duncan hospital, his clotting parameters were within the normal range. he was the first patient with a syndrome of clotting abnormality seen at the hospital in 7 years. the snake was not seen by the patient. the bite occurred in the himalayan foothills of nepal. risks of envenomation the odds ratio for being envenomed while sleeping on floor in comparison to someone who slept on a bed was 5.8 [95% ci = 1.8-18.6]. the odds ratio for being envenomed while sleeping under a mosquito net in comparison to someone who did not sleep under a mosquito net was 0.17 [95%ci = 0.04-0.6]. recommendations and discussion two tables of recommendations with their rationale are given below. the first lists recommendations for health care workers (table 4), and the second gives recommendations for community education (table 5). as their rationale is given in the table, it will otherwise not be discussed in this discussion unless extra explanation is required. table 4 – recommendations for health care workers recommendation for health care workers rationale 1 use the months of april and may to:  procure the necessary stocks of asv  train health care workers in snakebite management  educate the community on snakebite prevention and first aid. 80% of bites occur during the months of juneseptember so preparedness and prevention need particular attention in the time leading up to this “epidemic” season. 2 envenomation should not be excluded by the absence of fang marks. 3.8% of people without fang marks were envenomed. krait bites, in particular, can be hard to visualise, even a short time after the bite. 3 consider snakebite in the differential diagnosis of unexplained altered sensorium, alteration to speech and swallowing, and abdominal pain, especially during the rainy season. patients can present with symptoms of envenomation, without any history of being bitten by a snake. 4 bites by an unknown predator need to be taken seriously and observed for signs of envenomation. 14% of people, who were unable to identify what predator bit them, were envenomed. 5 don’t rely on the ability of patients or relatives to identify snakes. identification of snake species is poor, although it is better for cobras. 6 antivenom should only be given to patients showing symptoms of envenomation. envenomation of patients only occurred in 63.6% of the cases where cobras were brought. to give anti venom without symptoms of envenomation exposes people to the risk of adverse reactions and is costly, especially in a setting where demand exceeds supplies. 7 consider the production of a bivalent asvfor regions of north india and nepal. saw scaled and russell’s vipers are not present in this region and a bivalent anti venom is likely to cause less adverse reactions. 42 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. table 5 – recommendations for community education recommendations for community education rationale 1 a large part of the public health education needs to be directed to children and young people, to both genders. the 10-19 year old age group is the peak age interval for bites. numbers of males and females bitten are almost equal. 2 encourage the use of footwear and long pants/trousers. 67% of bites occur on the feet and legs. 3 the use of a stick to scare away snakes, prior to working in an area with one’s hands. this would decrease the number of bites where hands are put into snake micro habitats without prior visualisation of the area. 4 improved lighting using:  torches when walking outside  lighting in and around houses. 40% of bites occur between 1700-2200 hours. 59.2% of bites occur in and around the house. lighting will enable better visualisation of snakes. 5 provision of toilets and education regarding their use. 8% of bites occurred when people were going to the fields for the purpose of open defecation. 6 encourage people to sleep on a bed and under a well tucked-in mosquito net. 10% of people were bitten while they were sleeping. sleeping on the ground, increases your risk of envenomation, sixfold. sleeping under a mosquito net, decreases your risk of envenomation, six fold. 7 provision of buffer zones between fields and housing areas. 59.2% of bites occur in and around the house. snakes are attracted to the rodents who come for grain being grown. keeping these distances separate may help in decreasing the encroachment of snakes in housing areas. 8 make sleeping areas separate from food storage, preparation and consumption areas. the presence of rodents in food related areas is prone to attract snakes. if people sleep in places away from areas of the house connected with food, this may decrease the risk of people connecting with snakes. in contrast with previous studies, a majority (59%) of the snakebites in the present study were located in and around houses. 7, 9-12 in this study, only 29 % of victims were bitten in fields and jungles, which suggests snakebites to be primarily a rural hazard affecting both males and females, not just an occupational hazard affecting males. the high frequency of bites on lower limbs is to be expected as the ground is the normal habitat of most snakes. the use of footwear covering the whole foot and long pants covering the lower limbs would be expected to reduce the incidence of snakebites, but as the majority of people live below the poverty line in rural india, this would be an expensive change of practice. although the presence of fang marks made it much more likely that a person had been envenomed, their absence did not mean that envenomation could be excluded as 3.8% of patients who did not present with fang marks were envenomed. the inability to see bite marks is most likely with the common krait (bungarus caeruleus) bites, as juvenile or sub-adult kraits have extremely small, fine fangs that do not leave a visible mark that lasts for long after the bite has occurred. additionally, krait venom does not cause tissue damage and this also makes the bite site less visible. seventy-five percent of people were unable to identify or provide the hospital with any information identifying the snake by which they were bitten. if specific anti-venoms were available, health care professionals would be unable to rely on patients for information about which species bit them. however, if the absence of the two main vipers in this region can be mapped more carefully, there may be a case to consider making a bivalent venom to cover the neurotoxic bites of the spectacled cobra and the common krait. this could be relevant for this heavily populated region of northern indian and the plains of nepal. 6-8 of the people who did not know what bit them, 14% showed signs of envenomation. this can be attributed to the high frequency of bites that occur after dark (around 1800hrs) and the lack of electricity in rural areas that renders victims unable to see what bit them. this is slightly higher than the overall envenomation rate of 12.6% and indicates that bites by unknown 43 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. predators need to be taken seriously. victims were able to identify cobras more than any other snake while non-venomous common wolf snakes were commonly mistaken for kraits (figure 2 and 3). common wolf snakes have a number of similar features to common kraits, and another aim of public education should be teaching the community how to distinguish between the two species in order to prevent the killing of the non-venomous common wolf snake. a poster of the common snakes of this region could be helpful to educate the community regarding snake identification. figure 2: common krait figure 3: common wolf snake the highest frequency of snakebites occurred between 1900hrs to 2000hrs (just after dusk) and 40% of all snakebites occurred between 1700hrs to 2200hrs, showing it to be a time of significant human/snake conflict. crepuscular snakes, most active at dusk and dawn, are most likely to be hunting at this time. in addition, human activity also increases in the cool of the evening. in the evening, the use of a strong torch when going out and adequate lighting at home can help make snakes more visible and prevent people from inadvertently stepping on snakes. neurotoxic bites, “without tissue damage,” occur more frequently at night, and this frequency matches the habits of the common krait that usually hunts between midnight and 6 a.m. conversely, the neurotoxic bites with tissue damage, consistent with cobra bites, are more likely to occur in the daytime. the high incidence of bites in and around the house may also be attributed to overcrowded houses, which often do not have clear demarcations between the kitchen, food store room, and bedroom. without these clear boundaries, food and grain storage facilities, which entice rodents, can be in close proximity to sleeping areas. in order to prevent snakes, the natural predator of rodents, from entering the home, it is important to keep food as inaccessible to rodents as possible. additionally, environmental management, including the construction of buffer zones between the fields/jungle and housing areas, can decrease the likelihood of snakes encroaching on residential areas. in east champaran, only 19.4% of people have a toilet facility. this means over 80% of the population use open fields for toileting. 13 in this study, 8% of people were bitten when they went out to the fields for sanitation purposes, including three who were envenomed. provision of toilet facilities close to houses and educating people to use them will assist in lowering the incidence of snakebites. the national snakebite management protocol provides the countrywide basis for care of patients with snakebite. 14 the regional document is the who searo guidelines. 15 both documents have sections on snakebite prevention, although most of the documents deal with snakebite management. none of the recommendations given in this study disagree with the national protocol or the who searo guide44 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. lines, but they do provide some extra information that could decrease the incidence of snakebites in this region. the recommendation of a bivalent anti-venom is a regional recommendation that is not relevant to the whole country. however, it is important, as the country is increasingly recognising there are regional issues regarding snakebites and their management. there are continuing needs for improvements in snakebite first aid and management; in addition, it would seem only prudent that further work needs to be done to prevent snakebites. first, there needs to be community based studies to provide accurate incidence rates of snakebites and their mortality and morbidity. second, there needs to be community intervention projects, using locally relevant recommendations. finally, there needs to be re-evaluation of community interventions to show which are the most useful in decreasing the incidence of snakebites and their associated mortality. references 1. whitaker r, captain a. snakes of india – the field guide. 1 st ed. chennai: draco books; 2008. 2. chippaux j-p. snake-bites: an appraisal of the global situation. bull who 1998; 76:515-24. 3. mohapatra b, warrell da, suraweena w, bhatia p, dhingra n, jotkar rm, et al. snakebite mortality in india: a nationally representative mortality survey. plos negl trop dis. 2011;e1018. http://dx.doi.org/10.1371/journal.pntd.0001018 4. department of health, government of bihar. monitorable goals of the 11 th plan. 2009. http://planning.bih.nic.in/ppts/pr-05-02-12-2009.pdf 5. state health society bihar. manpower management. 2008 http://www.statehealthsocietybihar.org/manpowermgmt.html 6. sharma sk, khanal b, pokhrel p, khan a, koirala s. snakebite re-appraisal of the situation in eastern nepal. toxicon. 2003;41:285-9. 7. sharma s, chappuis f, jha n, bovier pa, loutan l, koirala s. impact of snake bites and determinants of fatal outcomes in southeastern nepal. am j trop med hyg. 2004;71(2):234-8. 8. pandey dp. epidemiology of snakebites based on field survey in chitwan and nawalparasi districts, nepal. j med toxicol. 2007;3(4):164-8. 9. kirte rc, wahab sn, bhathkule pr. record based study of snake bite cases admitted at shri vasantrao naik government medical college and hospital, yavatmal (maharashtra). indian j public health. 2006;50: 357. 10. majunder d, sinha a, battacharya sk, ram r, dasgupta u, ram a. epidemiological profile of snake bite in 24 parganas district of west bengal with focus on underreporting of snake bite deaths. indian j public health. 2014;58(1):1721. http://dx.doi.org/10.4103/0019-557x.128158 11. david s, matathia s, christopher s. mortality predictors of snake bite envenomation in southern india — a ten-year retrospective audit of 533 patients. j med toxicol 2012;8:118-23. http://dx.doi.org/10.1007/s13181-011-0204-0 12. kalantri s, singh a, joshi r, malamba s, ho c, ezoua j et al. clinical predictors of in-hospital mortality in patients with snakebite: a retrospective study from a rural hospital in central india. trop med int health. 2006;11(1): 22-30. http://dx.doi.org/10.1111/j.1365-3156.2005.01535.x 13. annual health survey 2010-11, bihar. [internet].[cited 2014 june 30]. office of the registrar general and census commissioner, india; 2012. www.jsk.gov.in/ahs10/bihar.pdf 14. national snakebite management protocol. directorate general of health services. ministry of health and welfare, government of india. 2009. 15. warrell, da. guidelines for the clinical management of snake bites in the south-east asia region. searo office of who: new delhi. 2010. http://apps.searo.who.int/pds_docs/b4508.pdf http://dx.doi.org/10.1371/journal.pntd.0001018 http://planning.bih.nic.in/ppts/pr-05-02-12-2009.pdf http://www.statehealthsocietybihar.org/manpower-mgmt.html http://www.statehealthsocietybihar.org/manpower-mgmt.html http://dx.doi.org/10.4103/0019-557x.128158 http://dx.doi.org/10.1007/s13181-011-0204-0 http://dx.doi.org/10.1111/j.1365-3156.2005.01535.x http://www.jsk.gov.in/ahs10/bihar.pdf http://apps.searo.who.int/pds_docs/b4508.pdf 45 longkumer, armstrong, santra, finny may 2016. christian journal for global health, 3(1): 36-45. peer reviewed competing interests: none declared. correspondence: takanungsang longkumer, duncan hospital, india. taka.longkumer@gmail.com lois joy armstrong, duncan hospital, india. loisjarmstrong@gmail.com vishal santra, simultala conservationists, nalikul, hooghly, west bengal, india. vishal.herp9@gmail.com philip finny, duncan hospital, india. philip.finny@gmail.com cite this article as: longkumer t, armstrong lj, santra v, finny p. human, snake, and environmental factors in human-snake conflict in north bihar a descriptive study. christian journal for global health (may 2016), 3(1):36-45. © longkumer t, armstrong lj, santra v, finny p this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:taka.longkumer@gmail.com mailto:loisjarmstrong@gmail.com mailto:vishal.herp9@gmail.com mailto:philip.finny@gmail.com http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ original article a descriptive study of community health evangelism as a model for integral mission jason paltzer a, keyanna taylor b, janak patel c a mph, phd, visiting professor, wisconsin lutheran college and founder/director of the center for community health ministry, usa b bs, mph, phd student at university of california, los angeles, usa c bs, baylor university, usa abstract background: integral mission health models are often employed by faith-based organizations to address social, physical, and spiritual wellbeing. given the use of these models like community health evangelism (che), the evidence regarding their effectiveness in practice is limited. the purpose of this descriptive study was to identify variation in the initiation, development, implementation, and impacts of community health evangelism as reported by organization members of the global che network. methods: a digital survey in english, spanish, and french was sent via email to global che network members resulting in 27 complete organizational responses for analysis. survey questions ranged from qualitative open-ended questions to categorial and ranking type questions. descriptive statistics and inductive thematic analytical methods were used to describe the data. data were summarized according to organizational size to better understand this influence on the practice of che. responses represent organizations in africa, asia, north/central america, and europe. results: the community selection process, committee and che volunteer selection criteria, the function of the community champion, time to che volunteer home visitation, and achievement of key impacts were some of the areas that showed variation. measured impacts included understanding of integral mission, use of lepsa(s) as a teaching strategy, multiplication, and community ownership. discussion: the study aimed to understand the implementation of che in the field and identify areas of variation and adaptation that could lead to opportunities or barriers in achieving the desired impacts of che. the results show variation in each of the four phases and provide a starting point to further study che as an integral mission model. the paper suggests additional opportunities for future research to identify core components that could strengthen and improve the effectiveness and practice of integral mission models. key words: integral mission, community health evangelism, implementation research paltzer, taylor & patel 54 introduction and background community health evangelism (che) is the practice of creating transformational outcomes and impact in communities to improve their overall health and well-being. transformation is based on understanding the community’s worldview, beliefs, and values as the foundation for creating sustained behavior change on the family level while addressing broken systems and infrastructure on the community level. che combines a christian worldview and values with local ownership and engagement to create a model of wholistic developmental work. the global che network is an association of people and faithbased organizations (fbos) that use che to serve impoverished communities in primarily rural settings around the world. it represents over 975 members including at least 70 organizational members in over 138 countries.1 che was developed in 1979 by stan rowland and tested over the next decade as a program of campus crusade in uganda and kenya. the motivation to grow community health was influenced by the declaration of alma ata from the world health organization in 1978 and the work of medical missionary and global health pioneer, carl e. taylor. the declaration of alma ata promoted health for all and expanded the definition of health, health care, and wellbeing. the community health worker model grew from this declaration and extended the practice of health into the hands of people in the community as agents of change and decision makers for health. che builds on this initiative by integrating community engagement with biblical values through participatory lessons that help families reframe their beliefs according to biblical values. che uses a training of trainers (tot) approach that facilitates multiplication and shifts the focus of the program from the supporting organization to the community. three trainings complete the program—tot 1 (che foundation and process), tot 2 (roles of the committee and training ches), and tot 3 (measuring and multiplication). see https://chenetwork.org/about-che-training/ for more information about the training structure. research shows that fbos are successful at supporting development efforts in underrepresented or marginalized communities.2-4 many fbos are holistic in that they implement diverse strategies to address the multiple dimensions of poverty including health, education, and livelihood. for example, church-based interventions have been proven successful in targeting minority communities for hypertension/weight management programs in the united states.5 fbos have been used in all stages of program implementation such as needs assessment/asset mapping, program planning, and evaluation.2-3, 6-7 multiple factors affect the success rate of fbos’ implementation of interventions. the size of the religious organizations, varying financial capabilities, the extent of partnerships in the community, ability of volunteers to help with the program, and spheres of influence have been noted in literature.12-14 in addition, religious leaders can have a significant impact on the success of the program or intervention. these leaders are often trusted gatekeepers in the community and are well respected. their attitudes and beliefs are important factors that can affect an acceptance and adoption of a health intervention.15-17 the available community assets and resources are often different as well as the motivation to organize those assets for the good of the group. this can influence the time for implementation, program sustainability, and long-term community ownership depending on how the fbo responds to such differences. furthermore, the political and social climate in the region can affect a program’s effectiveness.17-19 for example, the existing stigma around antiretroviral use in sub-saharan africa often presents a challenge in health promotion efforts or interventions.10 lastly, the diversity and unique experiences of community members can affect a program’s effectiveness. for example, a person’s socio-economic status or cultural identities can affect access to healthcare or violation of human rights. che organizations interface with many of these influences and systems. for this reason, it is https://chenetwork.org/about-che-training/ 55 paltzer, taylor & patel june 2022. christian journal for global health 9(1) important to examine the implementation of che programs by fbos to increase their chances of transformational impact in serving communities with differing characteristics and cultures. the purpose of this descriptive cross-sectional study was to identify common core competencies, implementation steps, and field-based adaptations of the che model to provide insight for future che communities. a second objective was to identify self-reported achievement of the che values. while there has been extensive research conducted on church-based, health programs, there are significant gaps in the literature regarding interventions that use integral mission health models such as che. one gap in the literature is a comparison of che programs across countries. this could impact future development of faithbased, public health interventions given the cultural beliefs and geopolitical characteristics that influence community selection, entry, training, and implementation. fbos will continue to serve a vital role in development as well as disaster management as observed during the covid-19 pandemic.18 che is one model that could serve as a critical strategy for organizations looking to strengthen the local christian church in carrying out her mission to share the centrality of jesus’ love for whole-person health leading to community transformation. given the potential for fbos to successfully implement programs using the che model, this descriptive study describes the some of the variation in implementation along with achievements of che in the field and discusses opportunities to strengthen the model to achieve the che values. this study was done in collaboration with the global che network. ethics review was not obtained given the survey focused on program characteristics and did not include individual or personal information. methods the purpose of the qualitative descriptive study was to evaluate global che network organizations’ implementation of che within model communities. an online survey was developed to assess implementation of che using a variety of closed and open-ended questions. the survey included a total of 23 items and assessed aspects of che programs including: 1) program initiation; 2) program development; 3) program implementation; and 4) program impact. the population surveyed were member organizations of the global che network. the survey was developed using the qualtrics software and a link to the survey was sent via email and by means of the global che network newsletter. the survey was available in english, spanish, and french. the survey was launched 8/18/2020 and closed 11/8/2020. a follow-up survey was sent on 1/17/2021 to gather clarifying information regarding three questions about che home visits initially assessed in the survey. the follow-up survey was closed on 2/18/2021. eighty-two responses were collected through the qualtrics survey link, and two additional responses were submitted via word document or pdf and entered into qualtrics. of the total 84 responses, 27 blank surveys were removed. responses were considered blank if there was no associated respondent name or organization name provided as it was not possible to confirm the validity of the response coming from an implementing che organization rather than an individual “informational” member. fifty-seven responses were considered for further analysis. of the 57 respondents, responses were considered invalid if more than 50% of the questions were left unanswered. this left a total of 27 valid responses for the analysis. measures the survey assessed che program initiation, development, implementation, and impact. program initiation evaluated the steps used to identify the community, community characteristics that were used to select the community for che implementation, and how trainers entered the community. che program development was evaluated by assessing the che approach utilized, how ches and committee members were identified and selected; strategies utilized to strengthen relationships between ches, committees, members, and trainers; the role of the paltzer, taylor & patel 56 community champion; and the length of time between community selection and the first che home visit. program implementation was evaluated by assessing the number of households being visited by ches, the frequency of home visits, the number and type of additional community activities implemented by ches, and the primary area of projects the che program has supported. lastly, program impact was evaluated by assessing achievement of six che values. this included assessing whether programs integrated physical and spiritual wellbeing, program multiplication, community ownership, the use of the lepsa(s) (learner-centered, problemsolving, self-discovery, action-oriented, spiritual) learning methodology, the holistic prevention of disease, and the use of local resources. the survey is available upon request from the authors. the organizations were categorized as “small” or “large” based on the number of active che communities. this was done to help evaluate potential differences between organizations with larger support teams, experience, and resources given the influence these might have on the ability and capacity of the organization to support the che process. the distribution of the organizations based on number of che communities created a clear bimodal distribution with five communities as the dividing point. this distinction was by no means a perfect indicator of “size” but was helpful as a strategy to analyze the data for the purpose of the study. analysis plan responses in spanish were translated to english by a member of the research team and french responses were translated to english using an online translation software (www.deepl.com/ fr/translator). open-ended questions were analyzed using thematic coding and analysis. an inductive approach was utilized to examine how global che network organizations implement che. codes were developed from a preliminary review of survey responses by the team of researchers and each response was subsequently coded independently by two researchers. codes were consolidated and were then categorized into themes by the research team collaboratively (table 1). closed-ended quantitative questions were analyzed by calculating frequencies. microsoft excel was used for managing and analyzing the survey data. table 1. qualitative codes and themes topic(s) themes codes characteristics used to select the community for che implementation. community physical, material, or human capacity • community has limited resources and/or physical needs • community is marginalized • community leadership is present • church involvement in the community community acceptance and vulnerability • community is open to external assistance • community desires program as a vehicle for development • community is spiritually open • community recognition of holistic health how che committee members were identified and selected how ches were identified and selected processes community • community consensus processes leadership • community leadership (elders, leaders, champion, trainers) processes church • church characteristics – individual characteristics • individual characteristics 57 paltzer, taylor & patel june 2022. christian journal for global health 9(1) strategies used to strengthen the relationships between ches, committee members, and trainers formal strategies to strengthen relationships • working together / meetings / planning • education / training • community service projects informal strategies to strengthen relationships • prayer / bible study • relationship building / informal connection / visiting the role of the "community champion" in developing the program the role of the "community champion" in implementing the program management role • recruiting ches • planning / organizing / mobilizing / identification • trainer / expansion / committee • programming / organization / liaison • physical / financial support mentor role • advocacy / motivation • spiritual mentoring / faith • observer / supervisor / support results table 2 describes the characteristics of the respondents with the majority coming from africa followed by asia. where the analysis stratifies by the size of the organization, the number of che communities supported by the organization was used for the categorization, with those serving more than five categorized as “large.” the strategy has limitations but valuable to obtain potential differences based on the number of communities served. water and sanitation, education, and agriculture were the primary service areas among the respondents. table 2. respondent characteristics (n = 27) n (%) region africa 12 (44.4) asia 7 (25.9) north & central america 6 (22.2) europe 1 (3.7) missing 1 (3.7) number of communities supported by the organization ≤5 communities (small organizations) 10 (37.0) >5 communities (large organizations) 17 (63.0) primary area of service (multiple areas often selected) water and sanitation 18 (66.7) education 17 (63.0) agriculture 14 (51.9) tailoring and sewing 9 (33.3) animal husbandry 8 (29.6) justice, equity, or advocacy 3 (11.1) transportation 2 (7.4) other 11 (40.7) program initiation table 3 describes the self-reported steps (open-ended question) used by the organizations to identify a community. a general information gathering and assessment approach was the primary method for identifying a community. in other situations, a community champion, churchbased referrals, an informal relationship, or program feasibility (proximity, ease of access, etc.) was used to identify the community. an assetbased approach is highlighted in that most organizations selected the community because of the physical, material, or human capacity (assets) available in the community. in some situations, the vulnerability and acceptance of external support determined the selection of the community. the results show a multi-step approach to selecting a community the number of strategies organizations use to select a community. paltzer, taylor & patel 58 table 3. program initiation steps and community selection small organizations (n=10) large organizations (n=17) total (n=27) steps used to identify the community information gathering / assessment 6 6 12 feasibility 3 3 6 church based referrals / partnerships 1 5 6 gatekeeper / community champion 1 5 6 building informal relationships 1 5 6 need/desire for material development 1 3 4 desire for spiritual growth 0 4 4 prayer 1 3 4 community invitation 1 2 3 vision seminar 0 3 3 site selection tool 0 2 2 characteristics used to select the community community physical, material, or human capacity 8 9 17 community acceptance and vulnerability 4 9 13 table 4 shows the variation in the suggested steps described in the che tot 1 training. building relationships through informal interactions is the first step for most che organizations. step 2 is generally a formal community needs assessment or survey followed by community awareness raising whether through a school screening or other awareness strategy. the identification of a community champion was scattered throughout the process with the champion identified as steps 1, 2, or 3. in general, small organizations relied on identifying a community champion as the first step whereas larger organizations first engaged in informal interactions before identifying the community champion. this suggests that small organizations might depend on a specific individual from the very beginning whereas larger organizations may engage in more informal connections and community meetings before identifying and engaging a local community champion. table 4: closed-ended responses to the steps suggested through the che training. building relationships through informal interactions community needs assessment or formal baseline survey community awareness raising (e.g., school screenings) identification of a community champion or person of peace other step 1 15 1 1 7 0 step 2 6 8 1 6 2 step 3 1 3 11 5 0 step 4 0 6 6 3 3 step 5 0 1 0 0 5 total 22 19 19 21 10 59 paltzer, taylor & patel june 2022. christian journal for global health 9(1) program development table 5 describes the general che approach used, the process to select the committee and community health evangelists, and the focus of the community champion during development and maintenance of the program. the primary approach used was the community-based approach followed by the church-based approach. the other che approaches were used but not very common. selecting the committee members was done using three main strategies—community consensus, selection by community leaders, and individual characteristics as observed by the training team. the community leaders may have used individual characteristics as part of the selection process but was not specifically stated in the data. larger organizations tended to use existing community leadership to select committee members more often than smaller organizations. when it came to selecting the community health evangelists, the dominant approach was selection through leadership of the established committee. this is in line with the model suggested by the che training. individual characteristics were used likely in combination with the leadership model. in some cases, church leadership or community consensus was used to select the che volunteers. the majority of organizations used formal strategies to strengthen the relationship between the committee and the che’s. formal strategies include organized meetings, service projects, and joint education opportunities. the role of the community champion often changed from serving as a mentor or manager/organizer during the development of the program to either dropping off completely or focused on an active management role during the maintenance of the program. this transition could be a critical factor in the success of a che community. table 5. program development approaches including committee selection, che selection strategies, and role of community champion. small organizations (n=10) large organizations (n=17) total (n=27) approach used most often community-based approach 5 9 14 church-initiated approach 3 4 7 church-based approach 0 2 2 government and clinic-initiated approach 1 1 2 church council approach 0 1 1 family-based approach 1 0 1 identification and selection of committee members processes community 4 8 12 processes leadership 2 7 9 characteristics individual characteristics 3 5 8 processes church 0 3 3 identification and selection of ches processes leadership 4 12 16 characteristics individual characteristics 4 5 9 processes community 1 3 4 processes church 0 3 3 strategies to strengthen relationships formal strategies to strengthen relationships 10 13 23 informal strategies to strengthen relationships 5 11 16 community champion role in development management role 8 8 16 mentor role 5 8 13 community champion role in program maintenance management role 6 10 16 mentor role 3 1 4 note. including committee selection, che selection strategies, and role of community champion. paltzer, taylor & patel 60 figure 1 shows a difference in the time between community selection and a community health evangelist visiting homes. small organizations tend to take longer (greater than 12 months) in developing and organizing the committee before a home is visited whereas larger organizations do this in less than 12 months. the difference in this timeframe could be another factor in overall achievement of transformation outcomes leading to multiplication or related to efficiency factors of organizations working in more communities. figure 1. length in time in months from community identification for che and first che home visit program implementation table 5 describes the implementation of the che program. most organizations have che’s visiting households on a regular basis with many of them individually visiting less than 25 families at any given time. che’s typically conduct visits on a weekly basis. che’s also organize community-level events around common topics of general health and disease and che program activities including supporting the committee, community surveys/assessments, prayer sessions, and training of other ches. nutrition and child/youth education activities were also common more so among larger organizations. table 5. program implementation including home visitation and community-level activities. small organizations (n=10) large organizations (n=17) total (n=27) if ches are regularly visiting households yes 8 14 22 no 2 1 3 not sure 0 2 2 number of unique households regularly being visited by a che <10 2 1 3 10-25 3 6 9 26-50 0 4 4 51-100 1 0 1 >100 0 2 2 how often che visited are made twice weekly 2 1 3 weekly 1 4 5 bi-weekly 0 1 1 monthly 1 0 1 additional community-level activities organized by ches health / disease 4 5 9 programmatic che responsibilities 2 5 7 food 3 3 6 education / youth 0 5 5 wash 3 1 4 other 4 6 10 figure 2 shows the distribution of common seed development projects implemented by the che committees and evangelists. water and sanitation, child education, and agriculture were the top three project areas. justice, equity, and advocacy projects appear to be a growing area for che communities. 0 20 40 60 80 < 12 mo. ≥ 12 mo. pe rc en t of r es po nd en ts months small organizations large organizations 61 paltzer, taylor & patel june 2022. christian journal for global health 9(1) figure 2. primary area of projects supported by che programs program impact table 5 describes the extent to which organizations believe they are impacting communities based on four values of che, understanding of holistic health or integral mission, local ownership or control, use of the lepsa(s) methodology, and use of local resources or asset-based community development. understanding of holistic health or integral mission is an area to explore given that more than half of large che organization communities have an incomplete understanding of integral mission and, therefore, the connection of spiritual faith to their health and well-being. the results suggest that smaller organizations might achieve a greater level of understanding of this value. few che communities seem to have a perceived level of complete control of their development. a limitation of this value is the understanding how “complete control” is defined as a standard definition was not provided in the survey. the most common response was that communities have a “moderate” amount of control and is an area to consider for improving che strategies. local resources were primarily assets of physical space and materials following by people’s time. many che communities were not providing monetary support to the activities or in support of the program. this confirms the need to be flexible on what projects are determined based on the resources often available in rural areas. table 5. organizations self-assess the perceived degree to which they are achieving the values of che. small organizations (n=10) large organizations (n=17) total (n=27) community understanding of holistic health yes, the community has a very good understanding of the physical and spiritual integration 5 6 11 yes, somewhat but not completely 3 9 12 a little, could be a lot stronger 2 1 3 level of community control complete control (full sustainability of the program by community members) 1 2 3 a lot of control 3 7 10 a moderate amount of control 5 8 13 no control (complete dependency on external partners for program implementation) 1 0 1 0 2 4 6 8 10 12 14 16 18 20 n um be r of r es po nd en ts project areas paltzer, taylor & patel 62 small organizations (n=10) large organizations (n=17) total (n=27) use of the lepsa(s) learning methodology yes 7 16 23 not sure 3 0 3 use of local resources space (buildings, etc.) 7 13 20 stuff (material resources) 5 13 18 staff (people) 6 8 14 spending 2 5 7 multiplication is another che value. the mean number of additional communities adopted che from the hub community was approximately 3.4 additional communities. the range was large with two communities having multiplied to more than 20 communities each. this diverse capacity for multiplication is likely dependent on the geographical context, population density of the area, and intended use of che by the organization. this is an important aspect given the intention of che is to be a model that is easily multiplied to neighboring communities. discussion this study describes the initiation, development, implementation, and impact of che communities. the objective was to identify specific processes that lead to strategies, competencies, or components to increase the effectiveness and sustainability of che in lowerincome rural communities. based on the results, organizations and communities show variation in key areas relating to committee and che selection, the role of the community champion, communitylevel activities, seed development projects, and time from introduction to che visitations. program initiation community selection is the first component of building a che program. a variety of methods were stated as activities in selecting a community. the most common included some form of information gathering, reliance on a community champion, other informal relationships, or a church-based referral/request. other times, the team would identify communities based on specific human, material, or physical capacity or expressed acceptance of a christian health program. when respondents were asked to list the order of steps, considerable variation was observed between steps two through five. the placement of conducting an assessment, building community awareness, and selecting a community champion or person of peace varied. this is one area for further study as this order may determine overall community involvement and ownership over time as an important impact. the values expressed during this initiation period are also important including expectations of external resource contribution for seed projects, the purpose of the model, and multiplication strategy. the che trainers can strengthen the importance of following the five steps in the order they are taught to ensure strong understanding of the program leading to effective selection of the committee and ches to lead the program. program development one realization when initiating a che program is the difference in how committees and ches are selected. committees are primarily selected by community consensus while ches are selected by the church or committee in line with the recommended che approach. this approach could be discussed on the community level to integrate a participatory element into selecting the che’s as well. assuming committees have the trust of the community to make this selection, the current process would be more efficient. the selection of the committee and the che’s are significant steps in the overall success of the che model. when individual characteristics were selected as the identification method, the data did not provide who was involved in determining these characteristics and an area for future research. the relationship between the committee, che volunteers, and the community is also important. given the reliance on local 63 paltzer, taylor & patel june 2022. christian journal for global health 9(1) relationships within the che model, strengthening these relationships can be done through formal and informal strategies. such strategies included bible studies, formal meetings, community or neighborto-neighbor service projects, and professional development trainings. organizational characteristics of the training team could be important to help explain if some organizational types tend to rely more on formal, informal, community, or church-based relationship building strategies. the role of the local church within a che program was not a specific focus on this survey but integration within a local church may be a key indicator of a successful che program. it is uncertain as to the extent of this integration when a community-based approach is used. the most common approach type followed was the community-based approach followed by a churchinitiated approach. the community-based approach starts with a school screening to build awareness and identify local leaders from the community to set up the initial committee. once families are visited by ches, the expected outcome is that growth groups form among multiple families which then come together to form a church. the expected time from community selection to che’s visiting families is typically 12-18 months. the results show some difference in this timeframe based on the size of the organization. the role of the community champion appears to transition during the life of the che program in each community. it is important for the organization or training team to recognize this and support the champion during this transition. in the beginning, the champion is instrumental in relationship building, recruiting ches, planning awareness events or trainings, liaising between partners, and providing initial financial/in-kind support. as the program gets going, the champion shifts to an advocacy, spiritual mentoring, and/or supervisory role or involved with multiplication. in addition, communities and organizations might define “community champion” and “person of peace” differently as both individuals are discussed in the che training. this also might account for the difference in the management versus mentorship roles described in the data. program implementation implementation of a che program involves che volunteers modeling health behaviors, visiting homes, conducting health lessons, and organizing community events or projects along with the committee. most respondents stated that che volunteers were visiting homes on a regular basis while a few were uncertain. the recommended number of homes for one che volunteer to serve at a time is between 10-15 and is the range for most respondents. a few are visiting many more than this and suggests a different structure where the che volunteers might be given a compensation and working more hours per week compared to a volunteer che. this high visitation load could also explain why some programs are not seeing a better understanding of integral mission and community control/ownership as the lessons might be cut short for time. the survey also asked about additional responsibilities of che volunteers, which included disease management, program evaluations, committee meetings, organizing food and nutrition programs, youth education events, and water, sanitation, and hygiene (wash) programs. che committees also organize communitylevel development projects or seed projects. these projects targeted wash, nutrition/agriculture, tailoring, and animal husbandry. other initiatives focused on social justice and transportation issues. stronger guidance around community-level or service-oriented projects might be beneficial for committees as they work to support the familylevel changes to create community transformation. it is uncertain if the community-level projects are determined by the organization, the committee, the che volunteers, the community, or a combination of these groups. the length of time between community identification and che volunteers visiting homes varied based on the existing number of communities being served by the organization. as the organization increases in scope with more communities, the timeline shortens. the survey did not get into reasons for this, but some initial paltzer, taylor & patel 64 thoughts could be related to learning the process and developing an efficient pathway to complete each step in a shorter time. another aspect could be related to the balance in developing relationships upfront as the organization establishes a presence in the region. once trust is built in a couple of areas, it might be easier for that organization to build strong relationships based on past presence and exposure in the region. as mentioned earlier, the definition used to determine “size” was not ideal but does suggest that this is one characteristic to consider that influence the impact of che. program impact the che values provide a framework to measure the impact of che programs. based on organizational understanding of the values, the results show good progression toward achieving the values of che in addition to areas for improvement. participatory learning: the use of lepsa(s) as the learning strategy is well received and applied. it is important to provide organizations an objective way to assess the use of participatory strategies among ches educating families in the home. integral mission: the understanding of integral mission or wholistic health was high among 11 of the respondents, however 15 of the respondents expressed this understanding as somewhat or a little. the understanding of integral mission is an important feature of che. the actual teaching of biblical lessons within the health lesson is an assumption based on the training but might need to be followed up and measured as an area to maintain fidelity to the che model. modeling faith in the homes of che volunteers and connection to a local church may also be considerations to increase the movement of organizations into a higher level of understanding integral mission. another aspect of this could be the perspective of the che organizer, trainer, and leader in how integral mission is taught, modeled, and emphasized throughout the process. for example, is there difference if a physician or a pastor is leading the initiative? local assets: the use of local assets is a foundational strategy for asset-based community development. the survey asked what types of assets are commonly used to support che programs and development projects. the use of space and buildings was the most common mentioned asset leveraged in a community followed by in-kind material contributions. inkind contributions include building materials, tools, land, vegetable seeds, food, some technology, and other natural resources. a few che programs have seen direct financial contributions for micro-enterprise groups, local churches and businesses, government support for projects, and individual contributions to purchase food for events. it is expected that the level of local assets leveraged links directly to the perceived level of community control and requires further study to assess this relationship. community control: three organizations reported that communities have complete control over the program with another ten having a lot of control, which is in line with a partnership model for program management. more than half of the respondents’ stated that communities have a moderate or little to no control over the program. the movement toward community ownership and control is an important feature of participatory holistic development and another opportunity for further research. one limitation of this question could be the understanding of “control” and “ownership” across cultures and regions. a collective culture may understand this concept differently than a more individualistic culture. the intent of this value is to help communities feel a sense of empowerment and dignity in the work, growth, and benefits of the program. lastly, multiplication was measured as 3.4 additional communities from the hub or “model” community. the intent of multiplication is that communities are transformed to the point that other surrounding communities take notice and desire to receive the same type of training. one pathway for multiplication is for the local committees and che volunteers to share their knowledge and structure allowing other communities to adopt che as a development program. other approaches that are likely used to add communities involves the 65 paltzer, taylor & patel june 2022. christian journal for global health 9(1) original training team equipping other communities nearby the model community. the questions around multiplication involve knowing how the daughter communities observed the model communities, who initially shared the knowledge about che to the daughter communities, who requested training from the daughter communities, and who provides the training and organizational support for daughter communities. this could be done by the model community leaders or the initial training team and still be considered multiplication. areas for future study as noted in the discussion, areas for future study include better understanding of the combination of characteristics used to select the community, initial inputs provided, structure and guidelines for seed projects, and the use of local resources throughout the program that most effectively lead to community ownership. a better understanding of why the initiation process is often not completed in the suggested order also deserves more study given the focus of che to take a participatory, asset-based approach to community health and development. understanding the integration of faith, the bible, and health requires competency and confidence among che volunteers to teach the lessons as developed so the biblical teachings are shared through participatory methods. following up with che volunteers regarding their comfort level and reporting back spiritual conversations with families could help in understanding the effectiveness of this method for integral mission. additional questions for future research include: 1. does training in the mother tongue influence program fidelity and ultimately the strength of che in the region? 2. what, or who, ultimately decides how ownership is transferred to the community or committee? 3. what role does the champion or person of peace play in the transition from start-up to multiplication? 4. does the gender of the che volunteer influence the services and interactions with families? 5. does the receptivity of the christian faith as a minority or majority faith in the region impact the strength of che? 6. what is the progression of a family/household through the che model in order for the che volunteer to reach additional families in the community over time? 7. which lessons tend to be the best received when connecting the gospel with physical and social health? do cultural aspects determine the effectiveness of specific lessons? 8. how do che volunteers encourage the connection with a local church to grow discipleship? 9. how should the community selection criteria change when the area is peri-urban or urban? limitations this study was a descriptive study of che organizations. the database included informational members as well as organizational members resulting in a smaller sample size than expected. the current global che network is limited in its capacity to ascertain organizational members and is currently updating the website and directory to better classify members in the network. as of december 2021, the number of registered organizations is closer to 70. given the number of organizational members and the response rate, the study was limited to a descriptive study to generate hypotheses. strengths the qualitative nature of some of the questions allowed us to describe components of the che programs as implemented and identify hypotheses for future studies. the survey was offered in spanish and french allowing for inclusion of diverse che programs in different regions of the world. paltzer, taylor & patel 66 conclusion community health evangelism has great potential to be a faith-based holistic health model for community transformation and poverty alleviation. it is currently being used throughout the world in different cultures and environments. understanding the model is important to strengthen the foundation for subsequent iterations and adaptations in the field. as che is multiplied, there are opportunities for other strategies to work themselves into the model, thus, changing the overall intent of having a model promoting integral mission. such research is important to help maintain fidelity to the core elements of che that make it an effective holistic and transformational approach to evangelism. references 1. about the network [internet]. 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https://doi.org/10.4278/ajhp.110516-qual-200 15. endeshaw m, alemu s, andrews n, dessie a, frey s, rawlins s, et al. involving religious leaders in hiv care and treatment at a universityaffiliated hospital in ethiopia: application of formative inquiry. glob public health. 2017;12(4):416-31. https://doi.org/10.1080/17441692.2015.1069868 16. gee l, smucker dr, chin mh, curlin fa. partnering together? relationships between faithbased community health centers and neighborhood https://www.chenetwork.org/ https://doi.org/10.1177/1090198106288498 https://doi.org/10.1111/phn.12048 https://doi.org/10.1177/1090198106291985 https://doi.org/10.1097/00004650-200204000-00011 https://doi.org/10.1097/00004650-200204000-00011 https://doi.org/10.4278/ajhp.130820-qual-438 https://doi.org/10.1080/17441692.2018.1524921 https://doi.org/10.1371/journal.pone.0097131 https://doi.org/10.2989/16085906.2010.545650 https://doi.org/10.1002/casp.897 https://doi.org/10.1080/13557858.2017.1346180 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https://doi.org/10.1007/s10943-015-0119-1 20. vilakati pn, villa s, alagna r, khumalo b, tshuma s, quaresima v, et al. the neglected role of faith-based organizations in prevention and control of covid-19 in africa. t roy soc trop med h. 2020;114(10), 784-6. https://doi.org/10.1093/trstmh/traa073 peer reviewed: submitted 21 mar 2022, accepted 28 apr 2022, published 20 june 2022 competing interests: none declared. correspondence: dr. jason paltzer, phoenix, az, usa jpaltzer1@gmail.com cite this article as: paltzer j, taylor k, patel j. a descriptive study of community health evangelism as a model for integral mission. christ j global health. june 2022; 9(1):53-67. https://doi.org/10.15566/cjgh.v9i1.643 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1097/01.smj.0000168338.87518.cc https://doi.org/10.1097/01.smj.0000168338.87518.cc https://doi.org/10.2105/ajph.2006.085662 https://doi.org/10.1007/s10943-017-0428-7 https://doi.org/10.1007/s10943-015-0119-1 https://doi.org/10.1093/trstmh/traa073 mailto:jpaltzer1@gmail.com https://doi.org/10.15566/cjgh.v9i1.643 http://creativecommons.org/licenses/by/4.0/ abstract key words: integral mission, community health evangelism, implementation research introduction and background methods results discussion conclusion references letter to the editor may 2023. christian journal for global health 10(1) letter in response to biomedical services fit amongst people with relational worldviews to the editor dr harries’ article proposing a “middle road” between indigenous healing systems and biomedical services from the west helpfully articulates both the economic barriers to acceptance of “modern medicine” and the importance of understanding the “felt needs” of those who are ill or suffering.1 however, the contention that “the medical means of proving that something actually works . . . are beyond implementation or even comprehension by many people indigenous to africa” deserves further exploration. while it is true that understanding the details of the randomized controlled trials (rcts) and meta-analyses that undergird contemporary evidence-based medicine (ebm) is a challenge for both patients and clinicians, fundamentally clinical research is simply about studying what happens when two similar groups of people do something different. that simple concept (reducible even further to “do something and see what happens”) can easily be related in a story, and providentially, we have the very first clinical trial in recorded history as part of the christian story. at least two published histories of clinical research2,3 identify the story of comparative diets in daniel 1:3-19 as the first clinical trial in recorded history: daniel then said to the guard whom the chief official had appointed over daniel, hananiah, mishael and azariah, ‘please test your servants for ten days: give us nothing but vegetables to eat and water to drink. then compare our appearance with that of the young men who eat the royal food, and treat your servants in accordance with what you see.’ so he agreed to this and tested them for ten days [daniel 1:11-14, niv] the population was small, the study groups were not randomized, and the follow-up was short. nevertheless, king nebuchadnezzar was impressed with the results, and those of us interested in ebm should be impressed that the original concept of a clinical trial is at least over 2300 years old (depending on assessments of authorship and dating for daniel). not only does the story of “daniel and the diet” illustrate that a quest for verifiable clinical certainty is providentially part of the christian story, it also provides a model for sharing the fundamental concepts of clinical research in an easily-understood story based in a real-life setting, and it provides a means for sharing both the christian story and a model for demonstrating the basics of ebm at the same time. william edward cayley, md, mdiv, professor, university of wisconsin department of family medicine, usa references 1. harries j. biomedical services’ fit amongst people with relational worldviews, and a ‘middle road.. christ j global health.2022;9(2):28-31. https://doi.org/10.15566/cjgh.v9i2.671 2. bhatt a. evolution of clinical research: a history before and beyond james lind. perspect clin res. 2010 jan;1(1):6-10. pmid: 21829774; pmcid: pmc3149409. https://pubmed.ncbi.nlm.nih.gov/21829774/ 3. collier r. legumes, lemons and streptomycin: a short history of the clinical trial. cmaj. 2009 jan 6;180(1):23-4. pmid: 19124783; pmcid: pmc2612069. https://doi.org/10.1503/cmaj.081879. in reply cayley’s interpretation of daniel seems to follow a convention unfamiliar to many in africa. his reader might wonder whether he credits the biochemical properties of the food for the https://doi.org/10.15566/cjgh.v9i2.671 https://pubmed.ncbi.nlm.nih.gov/21829774/ https://doi.org/10.1503/cmaj.081879 54 difference in final appearance between the two parties? this stance by cayley is not surprising when one considers that ‘god did it’ or ‘god made the difference’ are unacceptable statements in mainstream scholarship today. could the difference in appearance of the two groups who ate different diets, be due to god’s divine intervention? christians might accept that god works through biochemistry and should take credit for biochemically-sourced changes. many contemporary westerners however consider the fact that changes can be predicted using biochemical understanding gives reason to not believe in god. such questioning of whether god necessarily stands behind biochemistry may be reason for cayley to prefer to consider the outcome of daniel’s predicament a historical antecedent to today’s system of clinical trials, rather than an instance of “divine intervention.” i.e., he is responding to sceptical westerners who have bought into a positivistic mechanical-world philosophy, by telling them “look, what we do now, is a product of faith in god by previous generations.” this approach validates the bible on account of its foundational formative role in enabling the creation of today’s modernity, an approach taken by scrivener.4 cayley tells us: “that simple concept (reducible even further to ‘do something and see what happens’) can easily be related in a story, and providentially, we have the very first clinical trial in recorded history as part of the christian story.” does he perceive that his taking the bible as a simple way of justifying contemporary medical research might be less than complimentary of people who do not link those two things? yet, frankly, at least from a traditional african point of view, daniel’s experience could be understood very differently. daniel and his colleagues’ apparent better health could be hypothesised to be related to the presence of blood in the prescribed food, consumption of which was prohibited by moses’ laws (in the case of wine, the bible discourages drunkenness)5 thinking that such prohibition itself anticipated mechanisms of causation that were physical / chemical, begs the question of my original article.6 an avenue of exploration more likely to prove fruitful, is consideration of the relationship between diet and what could be considered in english ‘wholistic wellbeing’, i.e., ‘emotional health,’ as a source of physical wellbeing.7 following mosaic laws would have rendered daniel and his friends content that they were being true to those of their own people’s beliefs and traditions that represented “their god.” such adhering to prescriptions of their own god would have rendered life purposeful and enlivened god’s promises with respect to their own personal situations. god’s concern for the poor and victims, such as themselves as captured slaves, expressed in opposition to sin (on the basis of an understanding that sin is that which victimizes the innocent), was then a foundational basis for their own personal hope that was not shared by their babylonian colleagues. the latter interpretation shows the route from the bible to ‘science’ to be less direct than that proposed by cayley. the bible takes us to belief in one ‘rational’ god. that belief brings causation of other gods into question, including ‘spirits’, i.e., emotional binds between people that cause them to fear the envy, anger, frustration and so on of others.8 it was such bringing-into-question, i suggest, that could in due course have enabled modern people to reach the comprehension of material causation of the nature presupposed in cayley’s assumptions regarding the ‘clinical trial’ nature of the scenario with daniel and his friends. the above high valuation of a community’s adhering to its ancestral prescriptions to bring wellbeing implies that biomedical interventions may be inappropriate even if verified as helpful by randomized controlled trials. an example would be social distancing that rent families and communities asunder in the height of the covid19 pandemic. this suggests that there is room for a ‘middle way’ of respecting beliefs of people that cannot be verified as evidence-based medicine. jim harries, phd, ma, adjunct faculty, william carey international university; chairman, alliance for vulnerable mission, uk 55 may 2023. christian journal for global health 10(1) references 4. scrivener g. the air we breathe: how we all came to believe in freedom, kindness, progress, and equality. epsom, surrey: the good book company. 2022 5. leviticus 17:10-12, deuteronomy 21:20. 6. it simply raises the question as to whether eating blood is ‘bad for your health’ is to be understood in a ‘modern’ biochemical way. 7. cowie h, boardman c, dawkins j, dawn j, emotional health and well-being: a practical guide for schools. london: paul chapman publishing, 2004. p3. 8. my experience of observing spirit exorcisms in east africa has me realise that there is often a close relationship between what we in english term ‘spirits’ with what we in english interpret as ‘emotions.’ the editors’ response we appreciate dr. cayley’s letter to the editor, and dr. harries’ response, which creates some helpful reflection on the nature of science and observations in a relational world. in response to harries’ contention that the indigenous mind cannot implement or even comprehend evidencebased health studies, cayley describes a simple comparison in the old testament between two dietary approaches to well-being and observations of the outcomes. there are no biochemical assumptions about the process. the comparison does not even rule out god's providential blessing of daniel and his friends on the basis of their obedience to jewish dietary laws or their relationship to god and others. as the authors dr. cayley cites have described, this comparison is not fundamentally different from a modern clinical trial, given the qualifications that cayley mentions. dr. harries makes assumptions about both what dr. cayley might presuppose (the trial is all biochemical and not relational) and how indigenous africans might think about the material world (all relational/spiritual and not material). a clinical trial might seek to correlate the blessings that result from right relationships with god, others and the material world ie. avoiding certain prohibitions leads to better health outcomes, because that is what god directs and is pleased with, and it is the way the universe is designed (moral and rational; observable and controllable). in this biblical narrative, we are not told what presumptions daniel had about the dietary differences. that local meat might have had blood is one possible explanation, but so is the possibility that pork or other impermissible meats might have been served. the reasons for daniel's reservations are a matter of speculation, as harries rightly contends. but his reasons do not have anything to do with the trial he proposed. no presumptions are required for mechanisms of causation, and it could therefore be considered an ancient clinical trial. as dr. cayley points out, a "modern" approach to discovering the truth about something is actually an ancient and god-ordained way of discovering truth, and comprehensible across cultures. to the editor short communication / field report dec 2022. christian journal for global health 9(2) biomedical services’ fit amongst people with relational worldviews, and a “middle road” jim harriesa a phd, ma, adjunct faculty, william carey international university; chairman, alliance for vulnerable mission, uk introduction people with relational worldviews consider that an individual’s misfortune, which can include illness, arises largely from their failure to relate amicably with others, or others with them.1 amongst those who hold relational worldviews, including many african people, solutions to people’s ills are known to require the resolution of aberrant relationships (or those considered to be aberrant). the effectiveness of such solutions varies, but the aim is fundamentally the same, to address the aberrant relationship. people already having known solutions to their ills begs the question of the role of alternatives, such as biomedical solutions, introduced from outside by the west. outside solutions present a crowded field of prescriptions, many of which have been considered effective for many generations. the biomedical alternative immediately suffers from the problem that in its application, it very often seems to ignore the assumed cause—poor relationships. for example, someone may be convinced (“know”) that their malady has been caused by a particular person’s envy of them, perhaps for having taken away their husband. in contrast to solutions known by people with relational worldviews, biomedical practitioners often explain mechanisms that result in loss of social functionality using scientific principles of psychology. they consider humans to be biological systems that function in a way that can be assisted using cures that follow laws of chemistry and physics. they use biological, chemical, physical, and other appropriate knowledge to devise interventions that promote healing. my reader should note that the following critique is not to deny that biomedical cures are potentially valuable. it is to consider how to best take advantage of their potential value. evaluation of the appropriateness of contemporary medical practices amongst relationally oriented people is problematized by the financial and other powers that lie behind biomedical advocacy. those powers and influences that arise from western nations create enormous pressure in favor of overt acceptance of contemporary scientifically based wisdom. munk finds that african people’s agreeing with westerners may not indicate that they value what they are doing.2 the ways in which the global health sector is subsidized sometimes results in enormous material and prestige rewards for those who are seduced by the benefits. this makes “research,” through consulting with local people and hearing what people say, fraught with the danger that they may be avoiding “biting the hand that feeds” them, i.e., saying yes to please experts, even when the answer from their community and / or from deep in their own hearts may not be “yes” at all. munk advocates for people to blow the whistle on this practice.2 at least two factors come into play here. first, african people familiar with a patron client system being interviewed by those who are powerful may well see their role as being to please the powerful. secondly, african people’s english is often a way of trying to articulate indigenous reality using a foreign system of communication learned in school. basic medically oriented terms can mean very different things. for example, the term used to translate 29 harries dec 2022. christian journal for global health 9(2) “medicine” may also refer to a tree (as in the luo language of kenya). healing may imply forgiveness rather than anything biomedical as such. an injection may be associated with kinga (swahili, i.e., a guard or barrier) countering spiritual attack, such as that by witches. revealing what actually goes on, “blowing the whistle” to use munk’s oral terminology,2 is risky for everyone. (while munk’s book does not refer to blowing of whistles, her lecture does. i intentionally draw on the more emotionally charged comments that arise when she engages orally when commenting on her book.) it requires medically oriented readers, listeners, and overhearers (people influenced by this article who do not or cannot read it with the care anticipated by its author) to be wise. without wisdom, truth might pass them by. i hope this point is taken as the wellbeing of millions is at stake. in other words, people with relational worldviews may promote biomedicine not because they find it to be the best, or even because they find it to be helpful, but because powerful westerners (and other wealthy influential people) believe in it.3 in fact, it is possible for a missionary from the west to believe that modern medicine is generally not appropriate in african contexts.3 concepts of illness associated with biology are largely absent from indigenous worldviews. if not pushed by powerful outsiders, belief that misfortunes such as illness have biological causes may seem as ridiculous to africans as it may be to tell a western person that their bout of malaria has been caused by a long dead grandparent. my reader should note that the medical means of proving that something actually works—double blind, statistically verifiable trials—are beyond implementation or even comprehension by many people indigenous to africa. it may also be the case that individuals able to grasp benefits of biomedicine may not be able to convince their community that operates on the basis that poor relationships cause misfortunes, including illness. symptomatic improvements occurring following use of a biomedical solution do not in themselves resolve relational problems. biomedical treatment finds its place in the midst of the rest of life’s endeavours at improving relationship. yes, it can help, like a plaster on a wound, but the plaster doesn’t stop another wound from occurring! biomedical services, because they originate in the west, have often come to africa in hand with massive subsidy. the subsidy has justified a level of acceptance of modern medicine that would otherwise have been unlikely given it is just one amongst many remedies, that is by many, considered less effective than others. however, indigenous healing systems are, unfortunately, not an ideal panacea for people’s ills. they are deeply riven through with destructive consequences. in simplified terms, this is because they build on the “feel good” factor that someone gets when their enemy (a competitor, a rival, someone wealthier than them, someone thought to be envious of them) suffers. healing, then, arises from a kind of schadenfreude, joy that is an outcome of someone else’s sorrow. that is to say, traditional healing draws on the power of the shed blood or suffering of others.5 traditional healers being very aware of this, prescribe types of healing that will satisfy their customers’ desire to see the perceived breaker of good relationship (the person perceived as bewitching them) suffer. while animal blood sacrifices may sometimes be substituted for human blood, “human victims were probably offered long before animal victims were substituted for human.”5 a middle road the above scenario may, at least in some cases, leave room for a “middle road.” so far, we have a dual system of healing. the inappropriateness of the biomedical system arises because of its vast expense, perceived by some as being a way for foreigners to make money out of sick people and it’s not seeming to actually deal with the perceived cause of the misfortune concerned. the problem with the relational solution is innate to the means it uses to bring healing: identifying those causing one’s harries 30 dec 2022. christian journal for global health 9(2) problems and then endeavouring to banish them, or to inflict suffering onto them, or even to kill them.6 a “middle road” will fall somewhere between these two. one could see many african churches as on a “middle road.” from a western point of view, they may be getting a lot of things wrong. yet they seem to meet africans’ felt needs. a classic instance is the prosperity gospel, much-deplored in the west. even should a church not have what might be by some considered a “positive” contribution to make to its community, the church’s undermining of the hegemony of witchcraft powers can, and in many cases is, having an enormous impact on communities in which it is active. during the covid-19 outbreak, some authorities in africa and elsewhere sought to introduce herbal means of reducing panic regarding the pandemic.7 these could be advocated by governments as pseudo-modern medical cures, in the sense that any link between their use and making others suffer (witchcraft) would be tenuous, if at all. at the same time, herbal remedies were less costly than foreign alternatives, easier to administer, and did not have the appearance of enriching foreigners at one’s own expense. these cures, that medically one may consider as “innocent placebos” (i.e., there is no intention to harm one’s enemies) were an obvious third strategy. their availability could greatly curtail utilization of the witchdoctor’s more antagonistic services. the rallying call behind the means to tackle covid-19 was in many countries that of science. scientific measure, collection of data, and so on were to be used to ensure that only proven effective cures were promoted. this approach had many limitations, some of which have been recognized. for example, science is invariably and selectively considered, interpreted, and applied by people who are far from objectively oriented. two particular issues arose among those with relational worldviews, whose communities tend to be materially poor: 1. advocacy of the outcome of science seemed like a sales drive, giving the impression that the objective of promoting cures was for those selling them to make money. i personally find this understanding to be widespread in parts of africa known to me, that western medicine is advocated in africa as a means for westerners to make money out of the poor. 2. these solutions were typically promoted by fellow nationals of the “suffering poor.” that is, for linguistic and many other reasons, europeans were often not in the forefront in advocating for biomedical cures for the poor. the suspicion quickly arose, given indigenous people’s understanding of their own countrymen, that those promoting the biomedical cures were being paid to do so, meaning that they might not innately be deeply invested into or convinced by what they were advocating. thus, they could hardly be trusted. this left two alternatives: witchdoctor-cures or the middle road, i.e., “innocent placebos.” there is an extra “sting in the tail” in all this for christian believers. jesus’ being slaughtered on the cross resembles indigenous ways of killing witches (i.e., scapegoats) thought to be responsible for relational-frictions that bring about misfortune. (in this article, i consider the term “witchcraft,” when used to translate many indigenous african terms into english, to parallel the role of “scapegoats” articulated in detail by the french scholar rene girard.8) unlike other accused “witches” though, jesus rose from the dead. with the help of the holy spirit, his followers then understood what he had told them long before he was killed. as a result, they realized that killing and chasing suspect witches was not a cure for their ills, beyond the deceptive “feel good” factor one gets from having an impression of power by seeing the person you are envious of suffer. the undermining of this deceptive mechanism of curing relational tensions—that in turn multiplied such tensions—could be said to have been the beginning of humankind’s grasping the very kinds of insights that led to biomedical innovations. “the biblical vision punctures a universal delusion,” girard says.9 even though this “middle road” i am proposing (such as herbal cures/placebos in medical terms) 31 harries dec 2022. christian journal for global health 9(2) does not use means that are biomedically proven, at least it is not oriented to killing witches. denying the use of what i call “middle road” cures risks the killing, shunning, or chasing of more witches. hence a “middle road” can save lives, reduce tensions and enmity, and even contribute to a greater realization of rational scientific mechanisms, whenever people note that healing is possible without attacking a supposed witch—a possibility central to christianity. references 1. rasmussen sdh, rasmussen h. healing communities: responses to witchcraft accusations. international bulletin of missionary research. 2015;39(1):12-8, 13. 2. munk n. book discussion on “the idealist.” [updated 2013; cited 2014 oct 28]. available from http://www.c-span.org/video/?315084-1/bookdiscussion-idealist 3. wilson s. take nothing with you: rethinking the role of missionaries. orange, california: quoir; 2020, pp. 25-30. 4. harries j. re-strategizing mission (and development) intervention into africa to avoid corruption, the prosperity gospel, and missionary ignorance. transformation. 2021;38(4):359-72. 5. girard r. foreword by williams jg. in: i see satan fall like lightning. maryknoll: orbis, 2001. p. ix-xxiii, xvi. [see also chapter 3, on satan] 6. girard r. i see satan fall like lightning. maryknoll: orbis. pp. 24. 7. bbc news [internet]. coronavirus: caution urged over madagascar’s “herbal cure.” 2020 apr [cited 2022 august 30]. available from: https://www.bbc.co.uk/news/world-africa-52374250 8. girard r. the scapegoat. [translated by freccero y]. baltimore: johns hopkins university press, 1986. 9. girard r. i see satan fall like lightning. maryknoll: orbis. p. 1-2. peer reviewed: submitted 31 may 2022, accepted 4 sept 2022, published 20 dec 2022 competing interests: none declared. correspondence: dr jim harries, uk jimoharries@gmail.com cite this article as: harries j. biomedical services’ fit amongst people with relational worldviews, and a “middle road”. christ j glob health. dec 2022; 9(2):28-31. https://doi.org/10.15566/cjgh.v9i2.671 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org http://www.c-span.org/video/?315084-1/book-discussion-idealist http://www.c-span.org/video/?315084-1/book-discussion-idealist https://www.bbc.co.uk/news/world-africa-52374250 mailto:jimoharries@gmail.com https://doi.org/10.15566/cjgh.v9i2.671 about:blank introduction references case study nov 2015. christian journal for global health, 2(2):52-60. the call and rise of disability leaders in uganda: the first christian-based bachelors program in disability studies and special education at africa renewal university ashley a hall a a head of department, disability studies and special education, africa renewal university introduction a residue of rain smacked my face as i withdrew from the airport. it was my first trip to uganda, and i had the privilege of being a co-leader on a joni and friends, cause 4 life mission trip, where we served at the kampala school for the physically handicapped (ksph). the trip included home visits to the families of current students attending ksph. on a home visit, i embraced a precious mother, sarah, who had two vibrant boys with cerebral palsy. she wept as she divulged her testimony on encountering jesus christ through the abuse her two sons endured in various schools throughout uganda. one particular account had the team teary-eyed as she described how one of her sons came home with a massive welt on the top of his head. “he fell off his chair during class today,” expounded the educator after the mother’s investigation. sarah was jaded and revolted from the maltreatment, and perhaps the lies, from the caretakers and teachers. what was a mother to do with her sons who incurred injuries and affliction for years but also needed an education? the mother’s face exhibited relief after discussing how god provided a secure establishment for her sons in the current placement at which they were at last, ksph. for the rest of the families, and much of the world, the anecdote isn’t straightforward; many families continue to encounter such afflictions with little resolution. for a year and a half, i brokenheartedly prayed and sought god for how i could play a vital role in the lives of persons inhabiting uganda and, more specifically, members who serve persons with disabilities, whether in a small or a large capacity. god said, “go,” and in august of 2014, i moved to uganda. i ventured out on the undertaking of writing curriculum for a bachelor’s degree program at africa renewal university. with much trial and tribulation, it was achieved. a bachelor of arts in disability studies and special education (dsse) was recognized as a legitimate bachelor’s degree program from the national council of higher education for the nation of uganda. more importantly, it has been identified as a bachelor degree program in east africa that confronts disability from a sound christian platform. the design of the dsse program strives to enhance the quality of life for persons and families affected by disabilities by empowering and transforming christ-like leaders into disability ministry trailblazers. there is a prospect of persons with disabilities becoming productive and active within their societies – a positive, tangible, and potentially historic development. facts about disability in east africa persons with disabilities are the largest marginalized and unreached sub-group of individuals in the world. the united nations 53 hall nov 2015. christian journal for global health, 2(2):52-60. reports one billion people in the world with disabilities, and eighty percent of the one billion individuals reside in developing countries. 1 uganda, a developing nation, hosts over 6 million people with disabilities. 2,3 in past and present countries of war, for every child killed in warfare, three are injured and acquire a permanent disability. 4 as the world remains at war, and, particularly, nations within africa, the statistic on persons with disabilities surges. further, more than ninety percent of children with disabilities in developing countries do not attend school, which potentially leads to a mere three percent of literate adults with disabilities globally. 5,6 many children and women with disabilities are subjected to violence, rape, abuse, neglect, and other atrocities, for which there is a 1.7 times greater risk than those without disabilities. 7, 8 around eighty percent of working-age individuals with disabilities residing in developing countries are unemployed. 9 finally, access to medical health is exceedingly sparse due to factors such as cost, limited availability, architectural barriers, and inadequate skills in health practitioners, to name a few. health factors contribute greatly to the continued suffering, sickness, ailments, and high mortality rates in the lives of persons with disabilities in east africa. 1 the souls affected by disabilities are facing an epidemic. the disability community remains illiterate, uneducated, unemployed, indisposed, and a target of perilous abuse. history of higher education in uganda there is one university in uganda, kyambogo university, which hosts a special needs and rehabilitation program. the program is composed of three departments: adult and community education, community and disability studies, and special needs studies. the university offers various certificate, diploma, and bachelor level courses. kyambogo university defines itself as a secular institution. 10 an attempt to identify and solve the problem: why a disability studies and special education bachelor’s program at africa renewal university? uganda and east africa are in a crisis, and that crisis is a shortage of christian disability ministry leaders in all sectors of the professional field. the dsse program strives to generate solid christian disability pioneers by empowering and training them to become special educators, advocates, pastors, caretakers, government officials, social workers, and more. to say that leaders who join the dsse bachelor’s program will solve most of the tragedies throughout uganda involving persons with disabilities would be an unattainable goal, simply because we live in a fallen world, and the needs of people are many. however, the program seeks to equip leaders to bring transformation into the lives of persons and families with disabilities and attempts to alleviate some of the wounds they are bearing. in addition to the need for leaders, factors such as irrational perspectives, wrongful teaching, the shortfall of compassion in christians and the church, the scarcity of higher education programs and training, lack of resources, and the overall absence of an action plan also contributes greatly to the state in which persons and families affected by disabilities are found. these are discussed briefly below. a few factors in uganda fashion an unsettled and inadequate educational structure. a discussion of the hurdles in special needs 54 hall nov 2015. christian journal for global health, 2(2):52-60. classrooms and special needs schools produces a familiar account. first, lack of training for educators, particularly special educators, is a recurring problem. special needs teachers do not feel equipped for their job and the tasks that come along with it. other factors contributing to the shortage of special educators in uganda are burn-out rates, lack of pay, scarcity of resources, and overcrowding in the classrooms. this sometimes leads them to venture on to other endeavors instead of remaining in the field. lastly, before the dsse program at aru was implemented, kyambogo university was the sole university in all of uganda that provided sound training in special education and disability studies. this brings up the next point, a shortfall of higher education programs overall that equip pioneers for special education and other disability services. between these pitfalls, special education programs and special educators in uganda are in a perilous position. there is no doubt that special education in uganda requires some revamping; this is the reason behind training and empowering scholars in the dsse program in the area of special education. let us not overlook how followers of christ in east africa exhibit compassion towards persons with disabilities. which persons are the last to receive employment, last to be accepted into society, last to be embraced by the church, last to sense companionship, last to engage in education, last to receive medical attention, and last to experience justice? it is persons with disabilities, and it is evident they are greatly disadvantaged. christians and the church are typically distinguished for their tenderness towards sub-groups such as these. however, if we were to investigate the humanity in christians and the heart of the church in uganda, including its role in suffering, what is our status? why are there so little disability ministries in the churches and communities when persons with disabilities are such a neglected group of individuals? why are the strained families affected by disabilities receiving little to no christian guidance and counsel? the answer, in part, is due to misconceptions that are common throughout uganda and many other parts of africa. they are the following: people affected by disabilities are cursed by god, their parents sinned in the past so god is punishing them, they do not have enough faith to be healed, or they must be possessed by a demon. 11 these are some of the chief beliefs that christians (and other religions) believe in uganda and east africa and that are taught throughout the churches. these methods of thinking cause the body of christ to repel persons with disabilities rather than embrace them. the misconceptions also promote negative attitudes and distorted teaching that all lead to the lack of an action plan for the disability community. persons and families affected by disabilities are left with little support from the church and often times feel defeated, humiliated, confused, and/or stigmatized. to presume that the prime dilemma for persons with disabilities throughout the globe is the suffering they undergo would be an understatement. let’s consider the lack of concern for the disability community amongst christ-like leaders and the church as an additional affair to tackle. therefore, the bachelor’s of dsse includes a course, theology on suffering and disability, along with seeing that a christian worldview is embedded throughout its other courses that address these complications prevalent in uganda and in the church. other questions to ponder regard the momentous struggles persons and families take on when disability strikes: where does a parent send their child to be diagnosed or assessed for a disability in a remote village? where does a family transport a child born with clubfeet for 55 hall nov 2015. christian journal for global health, 2(2):52-60. an operation? how will they obtain the means for the operation and where will they receive the rehabilitation services afterwards? how does a single mother find sustainability when her husband abandons her due to birthing a child with a disability? how does a victim report a crime at a police station that is not wheelchair accessible? how does an injured soul receive medical attention at an inaccessible hospital? what emotional damage does a person boast after being discharged from a church because they were not healed during a miracle service? what rights do adults retain when they have experienced their twentieth job interview and remain unemployed? what parent rights exist when there are no local schools in the village that will welcome or educate their child? what are the repercussions when a staff member pummels a child at school? what is the legal procedure for defending a malnourished or famished child? where will they find any child protection or social workers to assist with this tragedy? where do families and individuals go to collect a wheelchair or other assistive devices, averting their loved ones from slithering in the dirt for years and, particularly, a wheelchair or assistive device free or low in cost? who will fit and size them for the chair? the bachelor of dsse attempts to lighten some of these unsolved mishaps subsiding in uganda by educating, equipping, and transforming scholars in the dsse program. the components of the bachelor in disability studies and special education at africa renewal university the bachelor in disability studies and special education (dsse) at africa renewal university is a 3-year, bachelor degree program, with 120 credit hours. it consists of 23 disability studies and special education courses and 16 general education courses. all dsse courses require 45 contact hours within a 15week semester system. each course meets once-a-week for a 3-hour time block. students are also required to spend approximately 1 to 3 hours, additionally, per week on assignments, projects, and readings per class. the dsse program seeks to raise up trailblazers for disability ministry in east africa. the bachelor of dsse is distinctive in that it promotes theology on disability, disability ministry, disability studies, and special education, encompassing a christian worldview in its entirety. the courses and curriculum coach pioneers to advocate, generate awareness, counsel, evangelize, educate, spearhead initiatives and projects, reform law, and much more for the welfare of families and persons affected by disabilities in east africa. theology on disability the course, theology on suffering and disability, is a 45-hour, 15-week course, with 12 hours specifically geared for the study of theology, suffering, and disability. it provides students with insight on what god and the bible say about disability, evil and suffering, and spiritual wholeness. this component of the program confronts the common misconceptions about individuals affected by disabilities in uganda and various global regions, bringing truth and transformation into the hearts of future disability innovators. topics such as “the importance of ministering to people with disabilities,” “proper views of healing,” and “the gospel of luke: a framework for disability” deepens the analysis of theology on disability. 12 theology on suffering and disability vigorously examines biblical foundations and suffering through the book of job, psalms, proverbs, the history books, the prophets, the gospels, and the epistles. further, these components that make up the 56 hall nov 2015. christian journal for global health, 2(2):52-60. course are also implanted and re-emphasized in other courses throughout the dsse program as part of christian worldview feature. disability ministry the disability ministry material in the dsse program covered in the theology on suffering and disability course consists of 2 modules: 1. overview of disability ministry (10 hours) and 2. the church and disability ministry (13 hours). additionally, subject matter representing a christian worldview and the christian response to the minor and major dilemmas in uganda is discussed throughout the special education and disability studies courses in the dsse program. topics for disability ministry are vast and commence with the church and the body of christ. the church as the cornerstone in disability ministry is stressed in many of the lectures. the study of the church entails operations and services, the major challenges within and outside the walls, and the responsibility and ownership over the disability community. this also includes an attempt to alter the church’s opposing perceptions regarding ministry for persons and families with disabilities. pastoral care and disability are not only highlighted to convey the responsibility of god ordained leaders in the church, but also to underline the level of commitment required from pastors and the body of christ. the disability ministry material explores methodologies on how to start a disability ministry, along with ministering to and discipling children, teens, adults, and the elderly, and how this ministry can be triumphant. the program exercises diverse outreach and evangelism procedures through assorted domains such as churches, communities, schools, daycare centers, hospitals, villages, recreational outlets, projects and slums, and more. ideally, this element of the dsse program equips disability leaders to incorporate and strengthen friendships with people and families affected by disabilities into their own personal lives, something that often appears novel in east africa. disability studies the disability studies component presents an assortment of discourses, debates, and analysis of the historical and contemporary accounts, procedures, and perspectives in uganda, east africa, and other regions of the world. the scope of disability studies (ds) is vast, and it avoids highlighting solely the identification of characteristics of disabilities, the suffering and circumstances in the lives of the disability community, and other common dilemmas, though they are vital themes examined in the program. rather, the disability studies element features sociological, psychological, holistic, philosophical, biological and medical, and historical foundations that spotlight the perplexities persons with disabilities brave in africa. further, the ds component provides 7 courses that examine the livelihood of persons with disabilities that sums up to 315 hours (45 hours each) on critical subject matter for disability studies. the courses are as follows: introduction to disability studies; exceptional people: a broad study of disabilities; global perspectives of disability; history, policy, and legislation on disability; persons with disabilities as portrayed in film; legal and ethical issues on disabilities; and disability, health, and wellness. below are features from one of the courses. the ds component provides the course, disability, health, and wellness, examining and assessing an array of factors that contribute to the overall health of the disability community. themes such as nutrition and diet, physical fitness, weight management, stress 57 hall nov 2015. christian journal for global health, 2(2):52-60. management, and even how to create wholesome hobbies and interests are analyzed in this course. in addition, this course explores the common medical ailments such as cuts, abrasions, pressure sores, common sicknesses, and diseases, along with what proper treatment should look like. other essential topics such as cpr and the utilization and repairing of equipment (i.e., wheelchairs, walkers, prosthetics, etc.) are studied by means of application. sex education, sexual abuse, sexually transmitted diseases, hiv and aids, family planning, and marriage and procreation are also highlighted in this course. disability studies and special education exactly 9 courses in the dsse program, totaling 405 contact hours, represent a little bit of both disability studies and special education subject matter. physical disabilities and physiotherapy; introduction to occupational therapy; speech disorders and speech therapy; hearing impairment and sign language; intermediate sign language; visual impairment and braille; foundations of autism spectrum disorder; mental illness and psychological disorders; and community integration and vocational training consist of educational procedures and implications, but also underline societal, medical and biological, historical, christian based, and/or psychological procedures, approaches, and explanations. let us look at the physical disabilities and physiotherapy course as an example. the course has three main components: 1. physical disabilities (6 hours); 2. educational considerations (15 hours); and introduction to physiotherapy (24 hours). the physical disabilities portion studies the definitions, characteristics, features, causes, and prevalence rates of physical disabilities common to east africa. the educational considerations subject matter examines these implications: identifying and diagnosing, assessing and evaluating, progress monitoring, and teaching strategies. introduction to physiotherapy section inspects the following: the human body, definitions and vocabulary, exercise, strength training and stretching, preventing and managing physical disabilities and rehabilitation, and assembling and using equipment. physical disabilities and physiotherapy, along with the other courses mentioned above have been chosen and designed in this manner for several reasons. for one, these courses reflect the realities in which special educators and other practitioners serving in the classrooms and other environments throughout uganda are expected to deliver these therapies and/or services to their students, even though training and resources are lacking. for example, the majority of special educators or caretakers at a school or day care center have not received adequate training in the “therapies” department, but have many children who are in need of one or all types of therapy services. often times, the school, organization, and/or business cannot afford to hire therapists. therefore, the teachers are expected to provide therapy type services to the best of their ability, whether they are trained or not. secondly, if a school or organization can afford to hire a physiotherapist or occupational therapist, they may be overwhelmed. an example is the kampala school for the physically handicapped. they have one physiotherapist and one occupational therapist onsite. the current population of students is more than 160. if you divide the therapist’s working hours with service delivery sessions, and include other common ugandan factors that interrupt or delay therapy sessions such as lunches and breaks, rain, injury, sickness, heat, etc., many students end up not receiving sufficient increments of therapy services. 58 hall nov 2015. christian journal for global health, 2(2):52-60. these specific courses are not designed to develop leaders into physiotherapists, occupational therapists, speech therapists, sign language interpreters, etc. rather, these particular courses are designed to empower scholars in the dsse program, to educate on the many sectors of therapy services, to expose the challenges between therapies and disability, and to build them up to be well-rounded and skilled disability leaders, meeting the many faceted needs of the disability community. special education the special education element of the bachelor in dsse is comprised of six diverse courses equipping pioneers destined for ministry in educational, communal, rehabilitative, and holistic frameworks. there are an additional 6 courses specifically designed for educating persons with disabilities, not including the therapy, visual impairment, and hearing impairment courses. the special education element consists of 270 total hours. the following are the courses that make up for the special education component: movement for people with disabilities; instructional planning and curriculum; teaching strategies for mild to severe disabilities; assessment for educational and societal interventions; behaviour management for children and youth with disabilities; and counseling, consultation, and collaboration. below is a description of one course in the dsse program that highlights and emphasizes the need for training leaders in the area of physical education. movement for people with disabilities was an addition in the dsse program to equip future trailblazers for all facets in the physical education realm. the course is comprised of three modules: 1. overview of the body (8 hours); 2. creating lessons (12 hours); 3. student teaching (25 hours). the overview of the body module investigates the skeletal system, muscular system, neurological system, respiratory system, development stages and milestones, and more. the creating lessons module studies dance, sports and recreation, dramatics, music, and arts and addresses the procedures and processes in accommodating students and modifying and adapting lessons in order to meet the needs of all students with various disabilities during physical activity happenings. lastly, the student teaching component coaches students on how to write and design actual physical education lesson plans, where students will mimic a real educator and perform the actual lesson plan while the other students of the course impersonate themselves as students with different disabilities. hopeful outcomes the provision for the bachelor of disability studies and special education is to bring restoration, hope, and salvation to individuals and families affected by disabilities in the nation of uganda and other surrounding east african countries by means of equipping disability pioneers. front-runners will rebuild the body of christ by generating disability ministries, support groups, bible studies, and community outreaches throughout the churches and communities in uganda. uganda will boast special needs or inclusive classrooms where all students can finally engage in vigorous learning. persons with disabilities could potentially attend and partake in common sporting and recreational events. rehabilitation centers and hospitals can nurse the disabled with affection, compassion, and integrity. reformed laws and litigation could flourish as advocates position themselves in the political and governmental spheres, being the voice in the wilderness for the least of these. perhaps uganda could offer wheelchair or even 59 hall nov 2015. christian journal for global health, 2(2):52-60. universal accessibility, where persons using assistive equipment can travel and advance to any location without hassle or inconvenience. it is through the humanity, humility, and christlike intentions of the trailblazers in the dsse bachelor program that uganda may be revolutionized in terms of disability. moving forward and next steps africa renewal university received its first intake of students in september of 2015. all together there were 12 students who joined the program during the first intake. in september of 2016, aru looks to receive its second batch of students for the program. each year in september, aru will offer a new intake. there have been discussions on the probability of adding a night or weekend component to the program for working professionals, but no decisions have been made yet. africa renewal university believes that it is critical for a bachelors program to remain deep-rooted and durable. aru also believes that east africans should take up leadership positions and responsibilities within the institution to avoid the long-term presence or operations of an american or person(s) from the west. aru strives to employ, instruct, mentor, and empower east africans to carry on projects such as the bachelor of dsse. therefore, in january of 2016, aru will be employing an east african as the head of department over the bachelor of dsse. references 1. disability and health: world health organization factsheet [government report]. geneva: world health organization; [2014 dec]. available from http://www.who.int/mediacentre/factsheets/fs352/en/ 2. national population and housing census 2014: provisional results [government report]. uganda bureau of statistics; [2014 nov]. available from http://www.ubos.org/onlinefiles/uploads/ubos/nph c/nphc%202014%20provisional%20resul ts%20report.pdf 3. abimanyi-ochom j, mannan h. uganda’s disability journey: progress and challenges. afri j dis. 2014;3(1):1-6. http://www.ajod.org/index.php/ajod/article/view/108 4. disability statistics: facts & statistics on disabilities & disability issues [government report]. dis world; [2015 july 27]. available from http://www.disabled-world.com/disability/statistics/ 5. efa flagship initiatives: the right to education for persons with disabilities, towards inclusion [government report]. united nations educational scientific and cultural organization; [n.d.]. available from http://www.unesco.org/education/efa/know_sharing/ flagship_initiatives/persons_disabilities.shtml 6. human development report 1998 [government report]. united nations development programme; [1998]. available from http://hdr.undp.org/sites/default/files/reports/259/hdr _1998_en_complete_nostats.pdf 7. factsheet on persons with disabilities [government report]. united nations enable; [n.d.]. available from http://www.un.org/disabilities/default.asp?id=18 8. crime in england and wales 2002/2003 [government report]. simmons j, dodd t. 2003. available from http://webarchive.nationalarchives.gov.uk/2011022010521 0/rds.homeoffice.gov.uk/rds/pdfs2/hosb703.pdf 9. facts on disability in the world of work geneva, switzerland [government report]. international labour organization; [n.d.]. available from http://www.who.int/mediacentre/factsheets/fs352/en/ http://www.ubos.org/onlinefiles/uploads/ubos/nphc/nphc%202014%20provisional%20results%20report.pdf http://www.ubos.org/onlinefiles/uploads/ubos/nphc/nphc%202014%20provisional%20results%20report.pdf http://www.ubos.org/onlinefiles/uploads/ubos/nphc/nphc%202014%20provisional%20results%20report.pdf http://www.ajod.org/index.php/ajod/article/view/108 http://www.disabled-world.com/disability/statistics/ http://www.unesco.org/education/efa/know_sharing/flagship_initiatives/persons_disabilities.shtml http://www.unesco.org/education/efa/know_sharing/flagship_initiatives/persons_disabilities.shtml http://hdr.undp.org/sites/default/files/reports/259/hdr_1998_en_complete_nostats.pdf http://hdr.undp.org/sites/default/files/reports/259/hdr_1998_en_complete_nostats.pdf http://www.un.org/disabilities/default.asp?id=18 http://webarchive.nationalarchives.gov.uk/20110220105210/rds.homeoffice.gov.uk/rds/pdfs2/hosb703.pdf http://webarchive.nationalarchives.gov.uk/20110220105210/rds.homeoffice.gov.uk/rds/pdfs2/hosb703.pdf 60 hall nov 2015. christian journal for global health, 2(2):52-60. http://www.ilo.org/wcmsp5/groups/public/--dgreports/--dcomm/documents/publication/wcms_087707.pdf 10. special needs and rehabilitation [internet]. kyambogo university; [n.d.]. available from http://kyu.ac.ug/index.php/courses/special-needsandrehabilitation 11. rene j. a global call to reach people with disabilities. in: beyond suffering: a christian view on disability ministry. agoura hills: christian institute on disability, joni and friends international disability center; 2011. p. 1-6. 12. tada j, bundy s, verbal p. beyond suffering: a christian view on disability ministry. agoura hills: christian institute on disability, joni and friends international disability center; 2011. peer reviewed competing interests: none declared. correspondence: ashley a hall, africa renewal university, africa. ashleyhall1400@gmail.com cite this article as: hall aa. the call and rise of disability leaders in uganda, africa: the first christianbased bachelors program in disability studies and special education at africa renewal university. christian journal for global health (nov 2015), 2(2): 52-60. © hall aa this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_087707.pdf http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_087707.pdf http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_087707.pdf http://kyu.ac.ug/index.php/courses/special-needs-and-rehabilitation http://kyu.ac.ug/index.php/courses/special-needs-and-rehabilitation mailto:ashleyhall1400@gmail.com http://creativecommons.org/licenses/by/3.0/ original article an analysis of the relationship between resilience and clinical competence in nurses: a descriptive-correlational study parvin aziznejadroshana, soghra goliroshan b, mojtaba qanbari qalehsari c, seyed javad hosseini d, zahra geraili e, fatemeh shaker zavardehi f a phd, assistant professor, non-communicable pediatric disease research center, health research institute, babol university of medical sciences, babol, i.r.iran b msc, phd student in nursing, social determinants of health research center, health research institute, babol university of medical sciences, babol, i.r.iran c phd, assistant professor, department of nursing, faculty of nursing and midwifery, babol university of medical sciences, babol, iran d msc, nursing faculty member , nursing care research center, health research institute, babol university of medical sciences, babol, iran. e msc, phd student in biostatistics, social determinants of health research center, health research institute, babol university of medical sciences, babol, iran f student of medical laboratory science, babol branch, islamic azad university, babol, iran abstract objective: resilience and clinical competence are two important components of providing nursing care to patients. the goal was to determine the correlation between clinical competence and resilience in the nurses at babol university of medical sciences, iran. methods: this descriptive and correlational study was conducted in 2019 and 2020. a total of 424 nurses working in the intensive care units and general wards of six hospitals affiliated with babol university of medical sciences were selected using the stratified sampling technique. liu’s nursing clinical competence questionnaire was used to assess the clinical competence of the nurses, and connor-davidson resilience scale was used to assess the nurses’ resilience. the descriptive statistics, pearson’s correlation coefficient, t-test, and one-way anova methods were used in data analyses. results: the mean score on the seven dimensions of clinical competence was high (174.86 24.19). the nurses had the highest mean scores on “clinical care” and “management and leadership” dimensions (4.77 31.50 and 4.7 28.61, respectively). they also had the lowest mean scores on the “mentoring and teaching” and “professional progress” dimensions (3.53 19.10, 3.41 19.14, respectively). the mean standard deviation of the nurses’ resilience score was 73.36 12.66. the results of pearson’s correlation test indicated a positive significant relationship between all clinical competence dimensions and nurses’ resilience (p<0.001, r=0.493). conclusion: given the strong relationship between resilience and clinical competence, this study suggests that nursing managers should carry out proper ± ± ± ± ± ± ± aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi 44 planning to improve the resilience of nurses as well as enhancing their clinical competence. key words: clinical competence, resilience, nurse introduction nurses are the largest group providing services in health systems, and nursing quality directly influences the efficacy of the health system.1 clinical competence refers to the wise and constant use of technical and communicative skills, knowledge, clinical reasoning, emotions, and values in the clinical environment.2 assessment of nurse performance plays an important role in guaranteeing high quality clinic care to achieve desired patient outcomes.3 clinical competence is the major challenge to patient care.4 currently, one of the most important problems is the lack of clinical competence among nurses, which has caused problems in the provision of nursing services 5. in this regard, nurses lacking the necessary skills in health and treatment centers can pose a risk to society’s health.6 hence, the use of competence measurement criteria not only improves nurses’ and managers’ understanding and awareness of competence but also reveals skill and cognitive deficiencies.5 zakeri et al. (2020) showed that compassion satisfaction has a positive relationship with clinical competence while stress and burnout have a negative relationship with compassion satisfaction7. building resilience is introduced as a strategy for fighting nursing challenges such as stress, a major challenge in the nursing profession. nursing stressors include work overload, role conflicts, shortage of time, lack of self-care, weak interpersonal relationships with the profession, inability to provide high-quality care, competition, patient death, conflicts with physicians and colleagues, lack of support from superiors, and inadequate preparedness for meeting patient’s and their families’ emotional needs, which cause negative stress, vulnerability, or unpleasant incidents among nurses.8 the covid-19 pandemic has increased stress for nurses, indicating a need to build resilience through social and organizational support.9 almost sixty percent of nursing graduates leave their jobs in the first year.10 resilience reduces stress and burnout in nurses.10,11 resilience enables nurses to deal with workplace problems and protect psychosocial health and performance.12 resilience regulates levels of stress and disability under stressful conditions. in fact, resilience is a dynamic process of positively adapting to unpleasant and bitter experiences in life.13 resilience improves problem-solving skills in individuals. resilient individuals show higher levels of mental health, self-actualization, and selfconfidence and are less exposed to high-risk behavior.14 resilience enables nurses to negotiate healthcare system problems and improve their job satisfaction, health, and psychological wellbeing.15 studies have indicated that nurses with low resilience could not effectively cope with job challenges and recover from adversity. strengthening self-efficacy, choosing active coping, decreasing job stress, and enhancing educational training can effectively improve their resilience. the factors which influence the resilience of nurses include self-efficacy, coping style, job stress, and education level.16 resilience is linked to nurses’ clinical communication skills.17 thus, resilience is likely to be indirectly related to clinical competence. resilience plays a key role in nurses’ moral sensitivity and cultural competence.18 a study by orkaizagirre ‐ gómara et al. (2020) showed that nursing self-efficacy, general self-efficacy, resilience, and year of course degree predicted 34% of perceived competence scores among nursing students.18 the development of resilience in nursing can influence their readiness to care.19 if resilience can be shown to correlate with clinical competence, resilience can be developed among nursing students in order to enhance clinical competence. hence, this study was carried out to assess resilience and clinical competence of nurses at 45 aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi june 2022. christian journal for global health 9(1) babol university of medical sciences and to determine the relationships between them. methods this descriptive-analytical study is a crosssectional study conducted from november 2019 to december 2020. the study population included all the nurses (1147 nurses) working at six hospitals affiliated with babol university of medical sciences. babol university of medical sciences is a medical sciences university in iran, mazandaran, babol. it has more than 3700 enrolled students in all faculties. most medical staff in babol are native to the region. they are all muslims and culturally similar. samples were collected from the intensive care units and general wards. the sampling units for each ward were also selected in proportion to the number of nurses using the stratified random sampling technique. the research sample size was 350 at the 95% confidence level with a power of 80% and a minimum pairwise correlation of 0.15 for the variables. therefore, 424 questionnaires were distributed given a 20 to 25% attrition rate. the inclusion criteria for the nurses included being directly involved in the provision of care to patients, and no managerial positions, the lack of a severe physical and mental crisis in the past six months, at least one year of clinical work experience, and having at least a bsc degree. the research scales in this study were liu’s nursing clinical competence questionnaire (nccq) and connor-davidson resilience scale (cdrs). the demographic information of the participants was collected using 10 questions about the personal information (age, gender, marital status, education level, work experience, alternating shift type, ward type, average overtime, employment status, and job satisfaction). the questionnaires were provided to the nurses at the beginning of their shifts to complete them carefully and individually when they had more free time and deliver them to the researcher in the next shift. the nursing clinical competence questionnaire (nccq) was developed by liu et al. (2009).20 this scale consists of 58 statements that were validated in macao, china. based on the results of the confirmatory factor analysis, eventually three statements were ruled out and a 55-statement scale was introduced as a scale with adequate validity and reliability (the reliability of this scale was confirmed with the internal consistency approach with a general cronbach’s alpha of 90%, and it varied from 71% to 90% for the dimensions) to assess the competence of nurses in different clinical situations through selfassessments or assessments by colleagues. the nccq assesses nurses’ competence with regard to 7 dimensions: clinical care (10 statements), management and leadership (9 statements), interpersonal relationships (8 statements), moral/legal performance (8 statements), professional progress (6 statements), mentoring and teaching (6 statements), and interest in critical research-thinking (8 statements). the statements in this scale are ranked based on a likert scale from 0 to 4. score 0 refers to a lack of competence, score 1 refers to slight competence, score 2 shows partial competence, score 3 indicates adequate competence, and score 4 shows high competence. the overall score on this scale ranges from 0 to 220. higher scores show higher levels of competence. a high mean score in each dimension shows high competence in that dimension. for instance, a mean score higher than 3 (or a total score above 165–220) shows high competence, a mean score higher than 2–3 (or a total score above 110–165) shows average competence, and a mean score lower than 2 (or a total score below 110) shows low competence. the nccq is a standard tool for self-assessment of clinical competence. self-assessment has been demonstrated to assist nurses in maintaining and improving their practice by identifying their strengths and areas that may need to be further developed.21 reflective practice has a role to play at all stages of the “novice to expert” continuum.22 professional competence profiles encourage them to take an active part in the learning process of continuing education.23 the reliability and validity of the persian version of the nccq in the iranian nursing population are confirmed by ghasemi et al. (2014) aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi 46 with a content validity ratio of 0.94 for the entire scale, a content validity ratio of above 0.83 for each statement, and a total reliability of 0.97. the reliability of the different dimensions also was confirmed in the range between 0.68 and 0.87.24 the connor-davidson resilience scale (cdrs) (2003) consists of 25 questions and the answer to each question is ranked based on a 5point likert scale.25 for each alternative, scores 0 to 4 refer to fully correct (score 0), rarely correct (score 1), sometimes correct (score 2), often correct (score 3), and always correct (score 4). the score range varies from 0 to 100, and as the score acquired approaches 100, it shows more resilience. the cut-off point in this questionnaire is a score of 50. in other words, a score higher than 50 reflects a more resilient person. as the score increases above 50 points, the resilience level increases. the reliability of this cdrs instrument was reported by abolghasemi in iran with a cronbach’s alpha coefficient of 0.87.26 the research ethics committee of babol university of medical sciences approved this study (ethical code ir.mubabol.hri.rec.13 97.170). the participants were given a thorough explanation about the study objectives. the data resulting from this research was analyzed using descriptive statistics, independent sample t-test, analysis of variance, and pearson’s correlation coefficient methods. values p<0.05 were considered statistically significant. results the average age of the nurses was 34.37 8.42 years, with an age range of 22 to 53 years. 370 (87.3%) of the participants were female and 54 (12.7%) were male. most of the nurses were married (78.8%), had bachelor degrees (92%), had a work experience of less than 10 years (59.7%), and worked alternating shifts (86.3%). 44.8% of the nurses expressed average job satisfaction (table 1). table 1. demographic properties of nurses working at the hospitals of babol university of medical sciences variables n % sex female male 370 54 87.3 12.7 marital status single married 90 334 21.3 78.8 level of education bachelor master 390 34 92 8 work experience(years) < 10 10-20 20-30 253 122 49 59.7 28.8 11.6 shift work fixed rotating 58 366 13.7 86.3 ward general specialty 285 139 67.2 32.8 overtime hours per month < 50 50-100 100-150 > 150 96 175 114 39 22.6 41.3 26.9 9.2 employment status employed obligation contractual 298 81 45 70.3 19.1 10.6 the clinical competence of the nurses showed a significant relationship with variables such as age, work experience, overtime, employment status, and job satisfaction. however, there was no significant relationship with gender, marital status, education, shift, and ward type. the nurses’ resilience showed a significant relationship with the variables of age, work experience, and job satisfaction. however, it did not have a significant relationship with other variables (table 2). ± 47 aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi june 2022. christian journal for global health 9(1) table 2. relationship between nurses’ demographic variables and clinical competence and resilience variables clinical competence (mean+/sd) p-value resilience (mean +/-sd) p-value age >30 30 -39 40 -49 ≤50 174.12+/-66 181.16+/-96 177.05+/-19.37 185+/-22.03 <0.001 71.97+/-12.99 72.83+/-13.97 74.95+/-9.79 84.82+/-11.94 0.04 sex male female 176.82+/-23.57 161.42+/-24.29 0.79 73.78+/-12.77 70.44+/-11.54 0.7 marital status single married 172.66+/-24.62 175.45+/-24.08 0.45 72.48+/-13.85 73.59+/-12.33 0.19 level of education bachelor master 175.49+/-23.99 167.64+/-25.62 0.9 73.64+/-12.74 70.14+/-11.33 0.42 work experience (years) >10 20 -10 30 -20 171.642 +/-25.45 181.26+/-20.72 175.57+/-22.7 <0.001 71.59+/-13.06 76.62+/-11.4 74.36+/-12.02 <0.001 shift work fixed rotating 188.43+/-19.69 172.71+/-24.16 0.27 79.44+/-11.59 72.39+/-12.56 0.59 ward general specialty 173.52+/-25.09 177.61+/-22.06 0.2 72.76+/-13.05 74.57+/-11.76 0.11 overtime hours per month <50 50-100 100-150 >150 170.5+/-26.09 173.93+/-23.27 180.05+/-24.71 174.61+/-19.6 0.03 72.42+/-11.48 72.18+/-13.01 75.73+/-13.59 73.97+/-10.17 0.1 employment status employed obligation contractual 176.79+/-24.14 168.4+/-22.52 173.73+/-25.79 0.02 73.36+/-12.37 71.59+/-13.09 76.51+/-13.39 0.11 job satisfaction i don’t like little medium much too much 164.72+/-21.91 166.78+/-21.29 172.76+/-26.11 179.01+/-22.17 184.29+/-19.56 <0.001 56.56+/-69.52 65.85+/-75.11 70.56+/-74.26 75.14+/-78.62 69.86+/-78.29 <0.001 based on the results, the total average score on the seven dimensions of the nurses’ clinical competence was 174.86 24.19, indicating that the nurses working at babol hospitals assessed their competence as high. the nurses had the lowest mean scores on the skills linked to the “professional progress” and “mentoring and teaching” dimensions (19.14 3.41 and 19.10 3.53, respectively) while they gained the highest mean scores on the “clinical care” and “management and leadership” skills (31.50 4.77 and 28.61 4.70, respectively). the mean and standard deviation of the nurses’ resilience score was 73.36 12.66. the lowest and highest resilience scores were also 32 and 100, respectively. nurses’ resilience correlated positively with all eight of the clinical competence dimensions (p<0.001, r=0.49) (table 3). table 3. relationship of all clinical competence dimensions with resilience in nurses working at hospitals of babol medical sciences university areas of clinical competence mean +/sd correlation of competencies with resilience significance level with paired t-test ± ± ± ± ± ± aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi 48 ical care 31.5+/-4.77 r=0.34 <0.001 management and leadership 28.61+/-4.7 r=0.39 <0.001 interpersonal relationships 24.49+/-3.9 r=0.46 <0.001 ethical / legal practice 27.66+/-4.05 r=0.35 <0.001 professional development 3.41+/-19.14 r=0.41 <0.001 coaching & training 19.1+/-3.53 r=0.41 <0.001 tendency to research – critical thinking 24.35+/-4.8 r=0.47 <0.001 general clinical competence 174.86+/-24.19 r=0.49 <0.001 resilience 73.36+/-12.66 r=1 <0.001 note. the numbers in the table are mean +/standard deviation. discussion the results indicated a positive significant relationship between resilience and all the clinical competence dimensions in nurses in this setting in iran. this is consistent with the results of the study by min, which revealed the positive and strong relationship of resilience and adaptability with clinical competence and stress.27 therefore, improving nurses’ resilience could be a strategy to improve their clinical competence. more clinically competent employees feel more comfortable at work and can endure professional hardships more than others.28 nurses who are more resilient are more inclined to learn because they are more tolerant of stressful situations and can focus on their own development.29,30,31 as a result, the work environment becomes more enjoyable for him or her. it can be concluded that clinical competence and resilience have a positive effect on each other. nurses assessed their clinical competence high. however, in the study by aliakbari et al., the mean performance scores of the samples on all the nine skills were lower than average.32 in the present study, the nurses achieved the highest mean score on the “clinical care” and “management and leadership” skills as compared to the other areas, while they had the lowest mean scores on the professional progress and teaching dimensions. this considerable difference between the scores on these dimensions could be attributed to the nurses’ approach to clinical care. nurses place a higher priority on the area most closely related to clinical care.33 in the study by istomina et al. in lithuania, the nurses assessed their ability to teach their colleagues and students as weak.34 in the study by mir lashari et al., the nurses reported the lowest level of ability to teach others.35 in a study by vosoghi et al., the students gained the lowest score on the teaching dimension,36 which could be attributed to the use of fewer clinical nurses in training the nursing students. this study indicates that the resilience level was high in the nurses studied, which is consistent with the findings of shakerinia et al. that noted that the high resilience of nurses enables them to use their positive adaptive skills in coping with stress.37 in a study by amini (2013), there was an inverse significant relationship between burnout and resilience. in other words, with an increase in nurses’ resilience, their burnout decreased.38 in addition, in the study by obeidavi et al., there was a significant inverse relationship between resilience and job stress.39 the results of the research by salimi et al. (2017) revealed that the nurses’ resilience was relatively high while their intention to turnover was average.40 a deeper understanding of resilience helps develop strategies that contribute to the establishment of resilience.41 stressing the improvement in resilience by professors during bachelor degree programs helps improve resilience.42 an educational culture of trustworthiness appears to be a catalyst for the development of resilience in nursing students and could be achieved by educators modeling the values and interpersonal skills students are expected to demonstrate in their nursing practice. when thriving in an educational culture of trustworthiness, nursing students could carve out space for a movement beyond the routine, turning their attention beyond themselves. this develops the student’s ability to be credible in their caring presence in the lives of others, recognized as a readiness to care.19 educational strategies should be developed in the nursing curriculum and a supportive learning environment 49 aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi june 2022. christian journal for global health 9(1) should be created to foster resilience in the students.43 in the present study, gender, marital status, education level, shift, and ward type (general and intensive care units) variables did not have a statistically significant relationship with the student’s clinical competence. however, age, work experience, and job satisfaction showed a significant positive relationship with clinical competence. clinical competence also had a significant relationship with hours worked and employment status. in the research by kim, the clinical competence of married nurses who had longer work experience was more than others.44 in sum, it seems clinical competence is multifactorial. according to benner, with an increase in age and work experience, their experience, mastery of their job, and adaptation to the environment increase, while their competence increases proportionally.45 in the aforesaid study, there was no significant relationship between resilience and variables such as age, marital status, education level, shift type, ward type, overtime, and employment type. however, resilience had a significant relationship with age, work experience, and job satisfaction. in a study by salimi et al., resilience had a statistically significant relationship with education level, marital status, ward type, and shift, but it did not have a significant relationship with age, employment status, work experience, and service years.40 lee et al. showed that some of the demographic properties were linked to the nurses’ resilience, which confirmed our findings.46 limitations our study has some limitations. first, the participants’ psychological conditions at the time of completion of the questionnaires could have influenced the results, but these were not evaluated. the second limitation was the use of self-assessment questionnaires. but selfassessment assists nurses to maintain and improve their practice by identifying their strengths and areas that may need to be further developed. professional competence profiles encourage them to take an active part in the learning process of continuing education.25 third, the study was limited by the fact that the participants were excluded if they had any “physical or emotional distress” in the past 6 months and if they had less education than a bachelor’s degree. conclusion the results of this study indicated that there is a positive significant relationship between all dimensions of clinical competence of nurses and their resilience. therefore, it is recommended to develop official and nonofficial training programs to increase resilience in nurses and to particularly increase resilience in the nursing students. references 1. hasandoost f, ghanbari khanghah a, salamikohan k, kazemnezhad leili e, norouzi pareshkouh n. prioritization of general clinical competency indicators from nurses view employed in emergency wards. holist nurs midwifery. 2015;25(4):53-63. available from: http://hnmj.gums.ac.ir/article-1579-en.html 2. komeili-sani m, etemadi a, boustani h, bahreini m, hakimi a. the relationship between nurses' clinical competency and job stress in ahvaz university hospital, 2013. j clin nurs midwife. 2015;4(1):39-49. 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[persian] available from: http://jcnm.skums.ac.ir/article-1-103-en.html about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank aziznejadroshan, goliroshan, qalehsari, hosseini, geraili & zavardehi 52 46. lee kj, forbes ml, lukasiewicz gj, williams t, sheets a, fischer k, et al. promoting staff resilience in the pediatric intensive care unit. am j crit care . 2015 :24(5):422-30. https://doi.org/10.4037/ajcc2015720 peer reviewed: submitted 14 may 2021, accepted 13 jan 2022, published 20 june 2022 competing interests: none declared. acnowledgenments: i hereby express my gratitude to the research and technology deputy of babol university of medical sciences for supporting this research project. i also thank all the nurses at babol university of medical sciences, who helped in the course of this research. correspondence: soghra goliroshan , social determinants of health research center, health research institute, babol university of medical sciences, babol, i.r. iran. goliroshan61@yahoo.com cite this article as: aziznejadroshan p, goliroshan s, qalehsari mq, hosseini sj, geraili z, zavardehi fs. an analysis of the relationship between resilience and clinical competence in nurses: a descriptive--correlational study. christian journal for global health. june 2022; 9(1):4352. https://doi.org/10.15566/cjgh.v9i1.547 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit error! hyperlink reference not valid. www.cjgh.org about:blank mailto:goliroshan61@yahoo.com about:blank abstract introduction methods results discussion limitations conclusion references original article dec 2020. christian journal for global health 7(5) identifying communities’ perspectives on their health needs in impoverished villages to guide non-government organizations’ health promotion efforts in guatemala claudia balea a ba, school of world studies department, virginia commonwealth university, richmond, va abstract: objective: the aim of this mixed-methods study is to capture and understand impoverished guatemalan community members’ perspectives of their own health needs on a community level in order to guide hope of life (hol) non-profit organization’s health promotion interventions in the villages they serve. methods: this exploratory research deployed a modified health needs assessment survey with 96 participants from four impoverished villages in the department of zacapa, guatemala. survey responses were analyzed for significant differences in 4item individual, family, and community health scores across demographic variables and significant correlations with reported personal health conditions and children’s health conditions. five semi-structured interviews were also conducted with community leaders from three of the villages surveyed. interviews were audio recorded and responses were transcribed verbatim and translated from spanish to english. thematic analysis using hyperresearch qualitative analysis software version 4.5.0. was conducted to identify major themes. results: the mean age of the 96 participants surveyed was 40.4 years and the majority were women, married or in consensual union, and have children. women reported a significantly lower individual and family health score than men. the most rural village included in the study had significantly lower family health scores than the three suburban villages in the study. among the personal health problems reported by participants, alcohol consumption, dental problems, and malnutrition were significant predictors of lower individual health scores. themes that emerged from the interview analysis included the greatest community health needs, perceived negative community health behaviors, barriers to health care access, hol’s impact, and suggestions for community health promotion. conclusion: the results of this study reveal many unmet health needs and barriers to healthcare that guatemalan village communities face. community-based participatory research using a mixed approach voices communities’ perspective on their perceived needs and is an important tool to guide non-profit aid and intervention serving impoverished communities. 10 bale dec 2020. christian journal for global health 7(5) key words: global health, guatemala, community health, health needs, fbos, health promotion introduction the population of guatemala is close to 16.3 million with nearly two thirds of the population living on less than us$ 2 per day.1 poor, rural, and indigenous populations suffer some of the worst health outcomes in the country.2 despite progress in the past decade in improving population health among the most vulnerable groups, health disparities, and inequality in health outcomes and access to medical care remain an ongoing challenge.3,4 faith based organizations (fbos) and other non-government organizations (ngos) have been playing an increasing role in health promotion in guatemalan communities for decades, but remain under researched and are often underrepresented in conversations surrounding international community development and health promotion.5 hope of life international organization (hol) is one such faithbased, non-profit organization based out of río hondo, zacapa, guatemala, working to provide humanitarian aid to communities in eastern guatemala.6 through hol directly or world help organization serving as a liaison, churches, businesses, and schools in the united states can take part in the village of transformation project (vtp), which funds long-term, mission projects in one village community per funding us organization.7,8 the vtp includes a variety of community projects determined by established community needs and can include clean water wells, family homes, schools, church buildings, and sponsorship program establishment.7,8 the sponsorship program is continuously funded by us organizations to cover educational, nutritional, and medical expenses of children in these communities.7,8 no public health data has been collected to date concerning the rural and suburban villages in the department of zacapa, guatemala impacted by hol involvement. community-based participatory research (cbpr) is an approach to incorporate the voices of underserved groups into the research process to increase health equity and better development of health promotion interventions.9 this study incorporates a mixed-methods approach informed by cbpr to collect the perspectives of community members in four guatemalan villages impacted by the vtp. engaging community members and leaders allowed more culturally-centered approaches and valued community members as equal contributors to the health inequity solutions that nonprofit organizations set out to solve.10,11 the aim of this study is to capture and understand impoverished guatemalan community members’ perspectives of their own health needs on a community level in order to guide hol health promotion interventions beyond the current community projects in the villages they serve. community members’ perspectives and evaluation can be used to inform and guide decisions made by hol in order to best address the health needs of these communities, empower individuals in these communities, and improve their quality of life. appropriate targeting of hol health promotion efforts according to community needs can serve to improve health outcomes of the villages in the study and other villages impacted by hol programs and inform other ngos working in guatemala. methods this study applied a mixed methods approach using both quantitative and qualitative methods including a survey questionnaire with community members and semi-structured interviews with identified community leaders. quantitative data reported by community members was further 11 bale dec 2020. christian journal for global health 7(5) supplemented by qualitative interview responses from community leaders. this approach allowed for a broader understanding of perceived socioeconomic needs and health needs significantly affecting community members at individual and community levels. research materials were influenced by the 2018 john hopkins community health needs assessment and created to account for time constraints on data collection and cultural factors of the communities.12 this exploratory research project was conducted with university institutional review board approval (institutional review board of virginia commonwealth university: protocol number hm20015622). survey the sample consisted of participants that were residents of the community for over three years and at least 18 years of age. survey participants were conveniently sampled, and those who were identified to meet the study criteria were asked to participate and the purpose of the study was explained. if they agreed, they offered verbal consent prior to survey administration. surveys were anonymous, and no identifiers were recorded. each participant selfadministered the survey and completed it on paper, which was later transferred to an excel spreadsheet and the paper copy destroyed. survey questionnaires were written in spanish and read aloud in spanish as needed. survey questions were analyzed using an analysis of covariance (ancova) performed with the goal of identifying some number of independent variables (predictors) that have a linear relationship with the dependent variable. data fields in the survey measures included personal, family, and community health status score rated on a 4-item scale: excellent, good, normal, poor, not sure. these scores reflected subjective perception of participants’ own health status, their overall immediate family’s health status, and their overall community’s health status. results were converted to a numerical score 1–4, with 1 corresponding to poor and 4 corresponding to an excellent health score. a response of “not sure” was scored as a 2, effectively combining them with “normal” results. in many of the questions, these scores were treated as the dependent variable in a linear model with remaining survey demographic information treated as independent variables. if a predictor was identified as statistically significant by the ancova, a two-sample t-test or a tukey’s honestly significant difference test was performed (tukey test). a two-sample t-test was almost exclusively used when health scores were significantly different by gender. the tukey test was used to identify which villages had the greatest difference in health score and if any villages had a significantly lower score than all other villages. interviews the sample for the personal interviews consisted of community leaders of their respective villages, who had been residents of that community for over three years and were at least 18 years of age. potential participants identified as community leaders by community members were asked to participate and the purpose of the study explained. if they agreed, verbal consent was obtained, and interviews were conducted in spanish by the researcher and a preapproved hol guatemalan staff member. interviews were recorded and quickly transcribed and translated verbatim; audio files were kept confidential until deleted. the original methodological design called for eight interviews to be collected, two from each village surveyed, but due to time constraints and access to the villages, only five were collected, none from village a and only one from village c. the five participants interviewed included: a pastor and a village leader, who serves as a liaison between her village and hol, were interviewed from village b; the president of the school board, who also serves as a community advocate, was interviewed from village c; and a school principal and pastor were interviewed from village d. interview responses were transcribed and translated to english. themes from the interview responses 12 bale dec 2020. christian journal for global health 7(5) were coded by the author using hyperresearch qualitative analysis software version 4.5.0. a total of 96 participants completed the questionnaire from the four different villages classified as nonagricultural or agricultural and semi-urban or rural (table 1). table 1. classification of villages included in the study communities included in the study village id classification municipality, department a nonagricultural, semi-urban río hondo, zacapa b agricultural, semi-urban teculután, zacapa c agricultural, rural la unión, zacapa d agricultural, semi-urban cabañas, zacapa the average age of survey participants is 40.4 years and most participants are female, married or in a consensual union, and have children or grandchildren. (table 2) table 2. demographic information of survey respondents village id mean age (in years) female male married/ in union have children or grandchildren sample size a 49.5 7 3 4 9 n=10 b 40.0 28 3 17 30 n=31 c 36.0 17 11 19 23 n=28 d 36.2 22 5 24 25 n=27 total 40.4 74 22 64 87 n=96 results results of surveys figure 1. self-reported perceived health status at the individual, family, and community levels (n = 96) 13 bale dec 2020. christian journal for global health 7(5) a majority of participants reported poor personal, family, and community health scores (figure 1). results indicated that men reported a significantly higher individual health score than women with a p-value of 0.039. none of the other variables—village of residence, age, marital status, or whether or not the individual had children—tested as significant. the results indicated that men also reported a significantly higher family health score than women with a p-value of 0.025. whether a village was classified as rural (village c) or not (villages a, b, and d) was also found to be a predictor of reported family health score. the resulting t-test showed that villages a, b, and d combined had a significantly higher family health score than village c; the pvalue for the test was 0.001. no other variables tested significant. results indicated that village d was the only village to show a significantly higher community health score compared with village c, the most rural village with a p-value of 0.014. village d had a higher community health score than village b, but not significantly higher with a p-value of 0.08. figure 2. self-reported personal health problems experienced in the last three years among the most common health problems experienced by participants in the past three years, 49/96 participants reported dental problems, 35/96 reported malnutrition, 34/96 reported asthma or trouble breathing, and 24/96 reported mental health concerns (figure 2). demographic variables were controlled for in order to identify if any health concerns correlated with a lower health status score. the results indicated that alcohol consumption with a p-value of 0.003, dental problems with a p-value of 0.009, and malnutrition with a p-value of 0.03 were significant predictors for a lower individual health status score. 14 bale dec 2020. christian journal for global health 7(5) figure 3. self-reported health problems children or grandchildren experienced in the last three years eighty-seven of ninety-six (87/96) participants with children reported the health conditions experienced by their children or grandchildren under the age of 18 in the last three years (figure 3). among the most common health conditions of participants’ children or grandchildren under the age of 18 experienced in the last three years included 40/87 reporting malnutrition, while 23/87 reported children being overweight. 36/87 participants also cited birth-related problems and 28/87 cited dental problems among children. demographic variables were controlled for in order to identify if any health concerns reported for participants’ children or grandchildren related to lower family health status score. no child health conditions tested as significant predictors of family healthcare status at the alpha 0.05 level. results of interviews the top themes focused on the greatest community health needs, perceived poor community health behaviors, barriers to healthcare access, hope of life’s impact, and suggestions for community health promotion. all quotations were translated from spanish to english. greatest health needs all respondents mentioned malnutrition as being one of the most severe health needs for their respective villages. unclean environments and infectious diseases were also cited by three respondents from villages b and d. chronic conditions were also mentioned by respondent 5 from village d. many people don’t have sewage systems, their drainage is out in the open. so, when they do their laundry and everything, the chemicals from the soap they used go to the soil. it turns into mud and where we get mosquitoes and insects from (respondent 1). they don’t have the economic resources when they contract dengue fever. there’s a public hospital, but it doesn’t have the means 15 bale dec 2020. christian journal for global health 7(5) to treat this disease, and some kids have died. they brought down three children with dengue fever from the villages. they got bloated stomachs, bleeding from the nose or even from their ears, and a low platelet count. the disease can be deadly if there are not means to treat the children (respondent 4). . . . there’s much fever. it comes with vomiting, diarrhea, malnutrition, which has become an issue because there are no means to nourish these children. all these diseases stem from malnutrition. the children lack medicine, they lack vitamins. mothers don’t take enough vitamins during pregnancy, so many children with incapacities are being born (respondent 5). perceived poor health behaviors community leaders mentioned specific health behaviors they perceived as having a negative impact on their community’s health. respondents from villages b and d cited poor hygiene practices, such as poor hand washing habits, bathing practices, and consuming unclean drinking water. the respondent from village c reported lack of family planning despite available resources due to widely held attitudes of machismo or a strong sense of masculine pride among husbands and male partners. this respondent reported this attitude leads male partners to associate pride with a large family size despite insufficient resources. women who would like to receive birth control or family planning counselling are often not supported by their male partners or accompanied to the health center, located over an hour away from their community. a respondent from village d noted poor nutritional decisionmaking such as choosing food with low nutritional value over healthier alternatives. because sometimes kids get sick with parasites, and it’s because of that, lack of hygiene. if they taught them about hygiene, perhaps the children and even the adults would not fall sick (respondent 1). parents could put in place healthier habits when they cook, pay more attention on good nutrition for the children instead of buying them sweets (respondent 4). a while ago, when we didn’t have... the drugs we have now, people had a lot of children, and they didn’t have birth control. now it’s only because the men don’t want to — like i said, there is sexism, and they don’t try even though the woman wants to. that’s how things have always been. if you’ve visited the families, you can see a lot of them are big (respondent 3). barriers to healthcare access the most common barrier to health mentioned by all respondents was difficulty in accessing health center services and medicines. all the respondents reported from 30 minutes to over two hours’ travel time to the nearest health centers from their communities. they noted that many of the pharmacies and health centers were not sufficiently stocked with needed medications. they reported that community members often do not seek out healthcare treatment or medicines due to the lack of financial resources. respondent 3 from village c also reported safety as a concern especially in regard to transportation to receive healthcare services. respondent 3 notes that sexual assault and rape is a recurrent problem for women traveling to the health center over an hour away from their village community. for here, the greatest benefit would be a health center where we could have better medical attention, better drugs, a better health system, where a patient can go and tell the doctors their ailments. perhaps that way they can get better faster. because sometimes, due to the long distance from town, when a patient gets there, the drugs are out of stock and they 16 bale dec 2020. christian journal for global health 7(5) have to buy them. and sometimes you can’t afford them (respondent 3). but there’s people who don’t have any money and they can’t get treatment. they die because they don’t have money (respondent 4). sometimes [my wife] will say, “i want to go to the health center in peña blanca. it’s an hour’s walk away.” so, i make the trip with her. but other people don’t. they let the women go alone. and the thing is there have been rapes along the way. that’s a recurring issue we have. i think a closer health center would be beneficial and would be essential to help us solve a problem we’ve always had (respondent 3). but [a health clinic] needs to be organized and well-run. because there’s been aid brought to some other places, but those things get sold. and the people are left without resources, or medicine, or whatever. so, it needs to be run by good-hearted people, people who are willing to help, not make profit off of it. that’s not been possible because sadly, there hasn’t been an institution willing to do it (respondent 5). hope of life’s impact three respondents cited the benefit of the hope of life sponsorship program and other community projects as part of the village of transformation project in providing access to immediate or emergency healthcare for sick children. all respondents reported that hol had made an overall positive contribution to meeting health needs in their community. some respondents still feel that there is room to improve health outcomes in their community with hol support. hope of life is in charge of the medical and nutrition aspects. for example, if a kid is sick, he comes to me and i call [hope of life] to see if there’s a chance for a medical appointment. if they approve, they have to go there (respondent 2). some kids are sponsored, and for their medical appointments, i call the person in charge and she lets me bring one or two kids for treatment. but they have to be sponsored. the kids who aren’t sponsored are taken to the hospital, or given traditional remedies, because there’s no money for medical expenses (respondent 5). the most important thing [hope of life] has promised us is that if someone has a fall, breaks an arm or other bruises, we communicate that to them and they send us medicines and assistance to treat them. that’s the benefit we get from them (respondent 3). [the health needs of this community] have not been established yet. . . i haven’t seen much aid coming through. some specific needs, for [hope of life] gives them access to what they need. like i said, they’ve received that from [hope of life], but not from other institutions (respondent 1). recommendations for community health promotion three respondents from villages b, c, and d showed an interest in mobilizing the community and working with institutions such as hope of life to make improvements in preventative measures in health, uplifting well-being, and spirituality, as well as addressing existing needs. respondent 1 from village a noted a project committee to address community needs and another institution to provide public health education would be beneficial to improving health outcomes. respondent 3 from village c specifically cited the need for housing projects and educational scholarships. respondent 5 from village d suggested establishing a spiritual 17 bale dec 2020. christian journal for global health 7(5) program to improve the well-being of community members. first of all, create a committee, and then have that committee establish the projects to carry out. like i said, with the church, we start by bringing a pound of rice, a pound of . . . basic grains. so, if people could bring one pound of each thing to help them (respondent 1). so, there should be some institution that comes and says, “look, we’re going to talk about health. this is what you need to do and this is how you do it.” . . . if they taught them about hygiene, perhaps the children and even the adults would not fall sick (respondent 1). there are about 20, 25 homes that could be improved, perhaps one or two a year. there’ve been people who’ve told me, “why don’t we make a request to get at least some tin sheets?” because there are houses that don’t even have roofs (respondent 3). i think the people from hope of life can help us with scholarships for [the children here] to have a better education and have a better life than we’ve had (respondent 3). another thing [to make the village healthier] would be a spiritual program. . . [to] promote that we are safe with god. it’s the only way to — god is our doctor, he is our advocate, he is our provider, he is everything (respondent 5). discussion in order to guide future non-profit intervention, the effect of a wide range of communicable and noncommunicable diseases on individual health and communities’ health was examined. findings showed that women have poorer self-rated health than men. it has been shown that poor guatemalan women experience less access to education and health services and face discriminatory attitudes, including a culture of machismo among other patterns of exclusion.13,14 the rural village had lower individual health scores than the sub-urban villages included in the study. these findings are consistent with a world bank report citing that more isolated communities with limited access to road networks have less access to health services, other institutions, and economic opportunities.13 malnutrition was significantly correlated with lower self-rated health scores for adults, while 20 and 21 participants reported obesity and chronic illness as personal health problems, respectively. asthma and allergies were also the third and fourth most commonly reported personal health problems. community leaders cited poor health habits coupled with malnutrition and infectious disease as a challenge for their resource-limited communities. these finding are consistent with the growing trends in developing countries where increasing rates of non-communicable diseases such as obesity and chronic respiratory disease are coupled with existing burdens of malnutrition and infectious disease in resource poor areas.14 in addition to malnutrition, dental problems and alcohol use also significantly predicted lower individual health scores for participants and should be considered by hol and non-profit programs as areas to target program efforts. nearly half of the participants with children or grandchildren under 18 reported that malnutrition affected their children or grandchildren, while over a quarter of participants reported that their children or grandchildren were overweight. similar to participants’ personal health problems reported, allergies and asthma were the 3rd and 4th most common children’s health problems reported, respectively. the second most common reported health problem for children was problems at birth, including low birth weight, premature birth, or complications with delivery. the hol sponsorship program provides nutritional support to children and families in their program in order to address malnutrition, but pre-natal care, health education, 18 bale dec 2020. christian journal for global health 7(5) and medical intervention may be future areas of intervention to consider. community leaders cited economic and institutional barriers in accessing healthcare and the ability to overcome health issues. all community leaders were in consensus that healthcare services and medication are often inaccessible. all community leaders responded that there were no health centers located near their communities, and travelling to the closest health center was difficult for most community members. participant 3, from the most rural village, specifically cited long transportation times that were very dangerous for women traveling to the nearest health center. the difficulty in accessing health services is consistent with survey data from the encuesta nacional de condiciones de vida (encovi 2014) that poorer guatemalans are more likely to not have access to health facilities and even when they do have access, these health centers are often understaffed and lack medication.15 community leaders reported that non-profit programs and aid from hol have been positive overall, but there is room for more projects, improvement in health education, and higher education opportunities. community leaders were eager to start health promotion and education initiatives. hol can capitalize on this enthusiasm of community leaders through fostering a collaborative, long-term relationship to guide health promotion and intervention design and implementation. this engagement can play an important role in including and empowering community members in improving health outcomes. the health needs identified here can serve as a baseline for further investigation into the health needs of impoverished eastern guatemalan villages served by hol and non-profit organizations to inform health promotion programs. future surveys and interviews can continue to conduct health needs assessments in these areas, getting further feedback from communities on how to properly address health concerns and design health promotion strategies engaging village communities. limitations this study faced several limitations, including a potential for response bias and limited generalizability. implicit bias due to the researcher being from a different culture as well as language and cultural barriers could all serve as further limitations to accurately collecting and analyzing the data in this study. the overall sample consisted mostly of women, and the survey sample size was small, specifically in village a. the interview sample size was small and lacked greater representation of all the community leaders in each village. this study served to identify perceived health problems and barriers in these communities and to get a glimpse of possible solutions specific to each villages’ needs. this study also does not assess the impact of specific programs hol already has in place. conclusion the results of this study identify the many unmet health needs, numerous socioeconomic barriers to accessing health services, and environmental factors impacting health that guatemalan village communities face. communities’ perspectives on their perceived health needs are an important tool to guide and educate hol and other non-profit programs to best meet the health needs of the various village communities served through maximizing the impact of non-profit interventions and aid. references 1. world bank. project appraisal document on a proposed loan in the amount of us$100 million to the republic of guatemala for a crecer sano: guatemala nutrition and health project [internet]. washington (dc): international bank for reconstruction and development; 2017 march. report no: pad1922. available from: http://documents.worldbank.org/curated/en/89573149 1232631449/pdf/guatemala-pad-main-03072017.pdf 2. guatemala ministry of health and social assistance, university of valle and division of reproductive about:blank about:blank 19 bale dec 2020. christian journal for global health 7(5) health-centers for disease control and prevention (cdc). atlanta, united states: centers for disease control and prevention (cdc); 2009. available from: http://ghdx.healthdata.org/record/guatemalareproductive-health-survey-2008-2009 3. braveman p, tarimo e. social inequalities in health within countries: not only an issue for affluent nations. soc sci med. 2002;54:1621–35. https://doi.org/10.1016/s0277-9536(01)00331-8 4. united nations development programme (undp). human development indices and indicators: statistical update [internet]. new york: undp; 2018. https://doi.org/10.18356/9a42b856-en 5. clarke m, ware, v. understanding faith-based organizations: how fbos are contrasted with ngos in international development literature. prog dev stud. 2015;15(1):37-48. https://doi.org/10.1177/1464993414546979 6. contraloría general de cuentas. informe de auditora financiera y de cumplimiento organización cristiana de beneficio social, esperanza de vida “ong”, 01 de enero al 31 de diciembre de 2018; [comptroller general of accounts. financial auditor report and compliance of christian social benefit organization, hope of life “ngo”, from 01 january to 31 december 2018]. 2019 may. available from: https://esvida.org/es/wpcontent/uploads/2019/07/informe-de-auditoria-cgc2018.pdf 7. hopeoflifeintl.org. hope of life international [internet]; cranston, ri. c2020 [cited 2020 sept 30]. available from: https://www.hopeoflifeintl.org/ 8. world help organization. village transformation in guatemala [internet]. forest, va. [cited on 2020 sept 30]. available from: https://worldhelp.net/transformation2/ 9. minkler m, wallerstein n, eds. community based participatory research for health: process to outcomes. [2nd ed.] san francisco, ca: jossey bass; 2008. https://doi.org/10.1177/1524839909335804 10. wallerstein n, duran b. using community-based participatory research to address health disparities. health promot practice. 2006 jul;7(3):312-23. https://doi.org/10.1177/1524839906289376 11. hernandez a, ruano a, hurtig a, goicolea i, sebastian m, flores w. pathways to accountability in rural guatemala: a qualitative comparative analysis of citizen-led initiatives for the right to health of indigenous populations. world dev. 2018 oct;113:392-401. https://doi.org/10.1016/j.worlddev.2018.09.020 12. john hopkins. 2018 community health needs assessment (chna) and implementation strategy for john hopkins bayview medical center [internet]. 2018; 1–116. available from: https://www.hopkinsmedicine.org/johns_hopkins_bay view/_docs/community_services/jhbmc-chnaimplementation-2018.pdf 13. world bank. poverty in guatemala. world bank country study. washington (dc): world bank; 2004. [license: cc by 3.0 igo]. https://doi.org/10.1596/08213-5552-x 14. misra a, khurana l. obesity and the metabolic syndrome in developing countries. j clin endocr metab. 2008;93(11_supplement_1): 9–30. https://doi.org/10.1210/jc.2008-1595 15. instituto nacional de estadística — guatemala. encuesta nacional sobre condiciones de vida encovi 2014: la pobreza en guatemala, principales resultados. [institute of national statistics— guatemala. national survey of living conditions, encovi 2014: the poor of guatemala, principle results] [internet]; 2015. available from: https://www.ine.gob.gt/sistema/uploads/2015/12/11/vj nvdb4izswoj0ztuivpicaaxet8lzqz.pdf peer reviewed: submitted 7 may 2020, accepted 5 oct 2020, published 15 dec 2020 competing interests: none declared. acknowledgements: my sincere thanks to dr. judyth twigg for mentorship and encouragement throughout this project; hope of life staff, world help organization staff, and william bale for about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank https://worldhelp.net/transformation2/ about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank about:blank 20 bale dec 2020. christian journal for global health 7(5) assistance in data collection and thoughtful discussion; david benusa for assistance in data analysis; viviana bermudez for spanish translation assistance; and the david baldacci experiential learning endowment fund for financial support. correspondence: claudia bale, virginia commonwealth university, richmond, va, usa. baleca@vcu.edu cite this article as: bale c. identifying communities’ perspectives on their health needs in impoverished villages in guatemala. christian journal for global health. december 2020; 7(5):9-20. https://doi.org/10.15566/cjgh.v7i5.391 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org about:blank https://doi.org/10.15566/cjgh.v7i5.391 about:blank introduction methods results results of interviews discussion limitations conclusion references short communication internally displaced iraqi people in kurdistan urgently need global heath action: an opportunity in crisis maha ashama a md,mph,global health consultant some faced jeers and floggings while still others were chained and put in prison for their faith. they were stoned; they were sawed into two; they were put to death by the sword. they went about in sheepskins and goatskins, destitute, persecuted and mistreated. the world was not worthy of them. they wandered in deserts and mountains, and in caves and holes in the ground. these were all commended for their faith yet none of them received what had been promised. god had planned something better for us so that only together with us would they be made perfect. (hebrews 11:36-40 niv) in january 2014, the islamic state of iraq and the levant (isil) gave christians and minority yazidies, kakais, and shabaks, in the areas of iraq they controlled, an ultimatum: convert to islam, pay tax when isil confiscated their assets, or be killed.1 consequently, massive numbers of people were displaced, more than 2.5 million iraqis. this included an estimated 500,000 who fled mosul on june 10 alone.2 these internally displaced people (idp) were distributed into 2,857 informal sites, including 32 camps across iraq. these events created the most rapidly unfolding humanitarian crisis in the world.1,2,3 more than 800,000 iraqis sought refuge in the kurdistan region of northern iraq, sheltering at first on bare ground, under bushes and bridges, and then moving to makeshift shelters, abandoned construction sites, and, in some cases, homes of family and friends.2 continuing insurgent violence threatens the displacement of 400,000 more by december 2015.4 iraqis displaced prior to the isil crisis and 235,563 syrian refugees in 11 camps, 97% of whom are in kurdistan, bring the humanitarian caseload to 5.2 million people.4 the chaldean diocese in erbil, with only two priests and less than a dozen volunteers, rushed to aid tens of thousands of the displaced iraqis flooding the city one june night in 2014, opening its sanctuary and premises. today, the church is a lead humanitarian aid provider in and around erbil, having established and maintained 26 idp centers and other locations on ad hoc basis.5 decades of war along with political and social unrest since the 1990s have impaired the infrastructure and health systems of security-compromised iraq. today, since isil militants closed on a large area of central iraq, including anbar, ninewa, salah aldein, and diyala provinces, the provision of health care has diminished due to the destruction of facilities and a shortage of medical personnel and supplies.2 the discontinuation of electricity and water supply, the shortages in fuel supply and the problems faced in procuring all these items cause a delay in treatment and halt vaccination campaigns.6,7 humanitarian relief is blocked from civilians — trapped in brutal sieges — further jeopardizing their health and life.2,7 while international humanitarian assistance has since made its way to the region, idp who reach relatively safe areas are largely neglected.2,3,4,8 the provision of essential public health services has sharply deteriorated.2 health care and humanitarian relief in the region face three important but hidden challenges. historically, challenges have been confined to the health issues of overcrowded refugee camps. contemporary wars have expanded the scope of conflict, adding the devastating impact of violence targeting civilians and stretching the limited capacity of fragile local health systems.9 isil crimes of beheading, crucifixion, rape, human trafficking, modern slave trade, and sexual violence are committed against iraqis, especially christians and yazidies1,10 (personal communication with anonymous yazidie internally displaced leader in kurdistan, march 2015). these atrocities overwhelm unassessed and unaided idp, creating mental health and psychological issues. persecuted iraqi christians bring hebrews 11 alive. a recent study identified trauma as a key influence on the mental and physical health of iraqi refugees in sacramento, california.11 post-traumatic stress disorder (ptsd), anxiety, and depression were documented mental health issues.7 iraqis are often reluctant to disclose mental illness, which is stigmatized in middle eastern cultures.11 secondly, the mental health of displaced iraqis who witnessed or were subject to atrocities, particularly adolescents and children who escaped isil captivity, is not formally assessed. rather, this is documented by sporadic anecdotal reports that have low visibility. expert mental and psychological care is lacking, or interventions are left to intermittent short term medical missions and poorly trained, or untrained, local volunteers (chaldean diocese staff, september, 2014 and march, 2015). violent deaths, kidnapping, and assaults against iraqi doctors have been documented, leading to a sharp decline in specialists and lack of specialist care.12 more than 50% of specialists have left isil controlled regions.2 thirdly, victims of violence who are idps in kurdistan are largely neglected. the lancet study of the performance of humanitarian aid agencies may shed light on this deplorable negligence. humanitarian agencies may deviate from humanitarian core values and instead give priority to competitive agendas, with little collaboration between each other, while small charities provide immediate emergency relief.13 the chaldean church, though unprepared as a humanitarian agency, nevertheless, has stepped in to provide caring for the influx of idps in erbil, dahuk, and zakhou territories, doing it with humility, compassion, and love. the genocide and displacement of iraqis – christians in particular – captured only minimal global attention. a data driven situation analysis is non-existent in the 26 church-run centers. perhaps main stream media has been neglecting the state of persecuted christians in iraq by deciding human worth is based on religion, ethnicity, and politics. 13 perhaps there are parallels to international aid abandoning civilian somalis trapped in violent fighting or the disregard of health care in haitian slums until the 2010 earthquake brought humanitarian aid organizations to the scene for relief and the opportunity to make major news headlines.2 global health actors have an awesome responsibility. decisive and immediate actions are needed to proactively engage with state leaders, economists, politicians, and religious leaders to end isil brutality and crimes against humanity. lead research institutions are called urgently to establish and communicate evidence-based data on the magnitude and consequences of crimes committed against iraqi idp, not ignoring persecuted christians, with the hope of motivating global health policy makers and state governments to take appropriate actions. international relief organizations must uphold impartial core humanitarian values focusing on relief activities, including neglected iraqi christians in their reporting systems. we must strengthen the over-stretched health care system in kurdistan, technically and operationally, identifying and addressing service access barriers for idp. we have a responsibility to actively engage members of displaced communities – in particular the wealth of unemployed health care professionals – in health care training, delivery, administration, and management. we must ensure the security and safety of the health care workforce and international aid personnel. we need to educate main stream media on human equality and worth according to god’s design, his having created man and woman equal in his sight and in his image (gen 11:27). the suffering 5.3 million internally displaced people in iraq can no longer endure just being fodder for the media. they deserve honest, competent advocates and players to bring their situation alive to the world. god empowers and calls the christian global health and medical community to respond (2cor 1:7-11). references williams s. inside the refugee camps of northern iraq. united kingdom: the telegraph [internet] [updated 2014 november 2; cited 2015 march 20]. available from: http://www.telegraph.co.uk/news/worldnews/islamic-state/11260461/exclusive-inside-the-refugee-camps-of-northern-iraq.html world health organization [internet]. geneva: conflict and humanitarian crisis in iraq: public health risk assessment and interventions. 2014 october 24. available from: http://who.int/hac/crises/irq/iraq_phra_24october2014.pdf world health organization [internet] geneva: crisis in iraq update funding request. [updated feb 2015; cited 2015 mar 20). available from: http://www.who.int/hac/crises/irq/iraq_country_update_funding_request_22february2015.pdf united nations high commissioner for refugees. [internet] geneva: iraq situation emergency response. [internet]. [updated 2015 march 17; cited 2015 march 25]. available from: http://www.unhcr.org/54f8592ef93.html bazi d. our future is in our children. let’s save them. [update 2014 september 19; cited 2015 march 20]. in: baghdadhope. christians in erbil [internet]. baghdad: available from: http://baghdadhope.blogspot.com/2014/09/christians-in-erbil-father-douglas-bazi.html lipshultz e. securing health in war zones [updated 2013 january 29; cited 2015 march 20]. in: harvard college global health review [internet] united states of america: available from: http://www.hcs.harvard.edu/hghr/online/securing-health-care-in-war-zones/ elsayed a, galea s. the health of arab americans living in the united states: a systematic review of the literature. bmc public health. 2009;9:272-80.: http://dx.doi.org/10.1186/1471-2458-9-272 medecins sans frontieres. [internet]. geneva: iraq: thousands of displaced in kirkuk lack essential aid. 2014 dec 4 [cited 2015 march 20]. available from: http://www.msf.org/article/iraq-thousands-displaced-kirkuk-lacking-essential-aid spigel p, chechi f, columbo s, paik e. health care needs of people affected by conflict: future trends and changing framework. lancet. 2010; 375(9711):341-5. http://dx.doi.org/10.1016/s0140-6736(09)61873-0 batha e. iraqi women are trafficked into sexual slavery rights group: reuters [internet] [updated 2015 february 17; cited 2015 april 20]. available from: http://www.reuters.com/article/2015/02/17/us-iraq-trafficking-women-iduskbn0ll1u220150217 ziegahn l, ibrahim s, al-ansari b, mahmood m, tawffeq r, mughir m, et al. the mental and physical health of recent iraqi refugees in sacramento, california. university of california, davis clinical and translational science center, sacramento, cal. [internet] 2013. available from: https://www.ucdmc.ucdavis.edu/crhd/pdfs/iraqi_refugee_health_2013.pdf al-kindi s. violence against doctors in iraq. lancet.2014;384(9947):954-5. http://dx.doi.org/10.1016/s0140-6736(14)61627-5 growth of aid and the decline of humanitarianism. the lancet. 2010;375(7911):253. http://dx.doi.org/10.1016/s0140-6736(10)60110-9 competing interests: none declared. acknowledgements: this article is inspired by a small egyptian interchurch team, a small group of christians who were nudged by the holy spirit to visit kurdistan in september, 2014 and march, 2015 for assessment and relief missions hosted by the chaldean diocese in erbil. correspondence: dr maha asham mahaasham10@gmail.com cite this article as: asham, m. internally displaced iraqi people in kurdistan urgently need global heath action: an opportunity in crisis. christian journal for global health (may 2014), 2(1):59-62. © asham, m. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ conference report spiritual dimensions of illness and healing: the 4th annual medicine and religion conference daniel w. o’neilla a md, matsc, assistant professor of family medicine, university of connecticut school of medicine, usa the fourth annual conference on medicine and religion was held in cambridge, ma, usa march 6-8, 2015. in western culture, there continues to be a divide between care for the body (by healthcare) and care for the soul (by religious communities). this dualism and reductionism may have led to clinical advances, but has resulted in increased mechanization of care, dehumanization of the patient experience, and isolation in the experience of illness and dying. this conference was a forum for health care practitioners, scholars, religious leaders, chaplains, and students from various religious traditions, predominantly the monotheistic abrahamic religions including christianity, to address these issues and interact toward a more integrated approach to health care. in the first plenary session, a case study was presented of an african-american woman diagnosed with advanced cervical cancer who attributed her disease to her sins and challenged the objectivity of her “non-religious” treating physician.1 the multidisciplinary panel reflected on an approach to integrating her belief systems into her clinical care. harold koenig, md (duke university’s center for spirituality, theology and health) discussed the two paradigms at work – the clinician’s and the patient’s, and the need to communicate with her in her own christian paradigm, to embrace prayer for healing as synergistic with the chemotherapy and radiation, and to affirm her understanding of her disease viewed as the consequence of her sins and her desire to be forgiven and recover for her future ministry purposes. rev. gloria white-hammond, md (bethel ame church, boston) encouraged building trust, involving her faith community, evaluating her understanding of disease, sin, penance, and atonement, as well as what god was saying to her in her circumstances. linda barnes, phd (medical anthropologist, boston university) highlighted the socio-economic framework needed to consider clinical care among the working poor, the racial divide and possible fatalism associated with it, the tension of authority between medical/scientific reality and spiritual truths, with a need to develop “meaning-centered explanations” including a paradigm of ultimate healing. heather curtis, ma, thd (historian, tufts university) related the long christian tradition of suffering as a spiritual experience, exemplified by jesus christ. curtis identified the protestant view of illness and pain helpful for the purification of the flesh and the greater spiritual purposes in suffering and that she retained a priority for spiritual growth over her freedom from disease. in her paradigm, even the healthy (i.e., her physician) needed to prioritize relationship with god. george handzo, mdiv (healthcare chaplaincy network of new york city) noted the absence of a critical spiritual history in the clinical encounter, the delay in involving a “spiritual care professional”(i.e., chaplain) from the beginning, and addressing the affective as well as the cognitive aspects of care. this may take the form of “spiritual care teams”as practiced with adventist health care2 and allowing space and presence in order for the suffering to create meaning in the face of illness.3 in the second plenary session entitled in what sense is illness a spiritual and/or religious experience?, rabbi saul berman, jd (yeshiva university), representing a jewish perspective, proposed that spirituality in the face of illness gives an awareness of the presence of god, highlights the ultimate set of values and virtues over which humans govern their lives, and gives opportunity to experience the effects of sin and, in healing or comfort, the experience of divine love –the way things ought to be. ahsan m. arozullah, md, mph (astellas pharma & darul qasim), representing a muslim perspective, highlighted the divine will in cause of both illness and cure, but that the cause and effect for particular cases remains indefinable. margaret mohrmann, md, phd (university of virginia), representing a christian perspective, spoke of jesus christ as revealing the necessity of death, and the possibility of life, and the need to ask and account for how the afflicted person understands their world with cultural humility (more than just cultural competency), and by providing a narrative of hope and “ldordered love” (augustine) that challenges the existing order of despair. in the third plenary session by the same panel entitled how should particular spiritual and religious needs of patients be addressed and by whom?, rabbi berman highlighted the universal call to do no harm, the scripture–informed duty to rescue those nearby, seeing them through their faith community which shapes who they are and recognizing the imago dei in them. this requires all health workers to ask them about their spiritual needs and then listen. dr. arozullah proposed divisions of labor – only those trained and qualified to address spiritual needs. professor mohrmann cautioned that we can easily draw conclusions or categorize before allowing the person space to open up regarding spiritual matters. she noted the need to be sensitive to power and authority differentials, to be open to silence in the patient encounter, to understand other traditions, and practice loving chastisement when appropriate. in the keynote address entitled cares, taking care and caregiving: the vital nexus between religion and medicine, arthur kleinman, md, ma (harvard university) spoke of the time-compressed, technology-driven contemporary health systems that have depersonalized and diminished the value of shared responsibility of basic care–giving in communities. what is needed is affirmation of the person (not just the disease or problem) and moral solidarity as a critical component – what he describes as “presence” which has roots in religion. this calls for clinical pastoral education. he recognized that global health care has unquestionable religious roots with social networks and moral experience formative for health, with trans-local aspirations and essential strategies for enduring illness and improving care. as a non–theist, he noted the increase in atheism in the west and a “robust plurality” in culture, but he recognized religion as a key source for revitalizing caregiving. he notes the examples of james grant of unicef and hafden maller of who as well as clara barton who drew from their christian missionary backgrounds as “crucial motivation,” but recognized the hesitancy on the part of secular society to see religion as a global asset in the health domain. though current health systems are “systematically disabling students from the human side of care,” his solution was a caregiving movement from the bottom up. in the third and final plenary, the same panel of three addressed the question: what is at stake and what is experienced, spiritually, among those who care for patients? reflecting on several case presentations, rabbi berman noted that we need to move from personal awareness of spirituality to the level of holiness –to the actualization of values in the caregiver’s daily life. this is accomplished by a deeper understanding of the character of god found in exodus 34:6-7, of which justice is central to transform the health of our society. dr. arozullah pointed out the pitfalls of misplaced intentions (pleasing god, pleasing the patient, or getting the best outcome), the “god complex,” or the mistake of serving the means or the ends instead of the person. prof. mohrmann extoled the value of endurance, grace, and generosity, even on the worst of days – that we will receive what we need when doing what we must. the dehumanization of medicine is a human decision, and to dehumanize is to desacralize and miss the opportunity to re–wright meaning by engaging in the life narrative of the afflicted, sharing our own narratives, and proclaiming anew realities which reveal that a spiritual community is a healing community. there were many papers and posters presented on the interface of religion and health care, including one by ashley moyse, phd, defining life from a christian perspective: bounded by and inclusive of death and made hopeful by practicing availability and fidelity in caregiving through joy and sorrow and treating the afflicted as a subject, not an object –embodying valid hope toward a reconciled future. elizabeth marshall, md, mat discussed job and the value of lament as a means to hope and healing, and a paper on the life of renown vascular surgeon alexis carrel’s discovery that the mystical state of union with christ surpassed cognition and reason, so that at the end of his life he could write that he felt like a “small child before god.” there were many other topics such as the importance of recovering a transcendent dimension of health care and a “hidden curriculum” in training which provides mentors who model compassion and empathy. though the conference was quite diverse in its various theistic views and traditions, the christian perspective was well–represented, and it created space for dialogue with other faiths. there was a gallery of art work related to christian contexts of health care, and a group of african-american gospel singers created an uplifting backdrop during the banquet. there was not a strong application for global health contexts, but many of the principles shared have valuable application for international health care, education, and community development, some of which have been shared in this brief report. references an interdisciplinary case discussion on “i was bleeding for my sins” [available at http://www.medicineandreligion.com/an-interdisciplinary-case-discussion-on-i-was-bleeding-for-my-sins.html ] koenig h g. the spiritual care team: enabling the practice of whole person medicine, religions 2014, 5(4), 1161-1174. http://dx.doi.org/10.3390/rel5041161 park c l, & george l s (2013). assessing meaning and meaning making in the context of stressful life events: measurement tools and approaches. journal of positive psychology, 8, 483-504. http://dx.doi.org/10.1080/17439760.2013.830762 competing interests: none declared. correspondence: daniel w. o’neill, university of connecticut school of medicine, dwoneill@cjgh.org cite this article as: o’neill, dw. spiritual dimensions of illness and healing: the 4th annual medicine and religion conference. christian journal for global health (may 2015), 2(1): 80-83. ©o’neill, dw. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ case study july 2021. christian journal for global health 8(1) the faith-based advantage: a case study on the adventist development & relief agency’s response to humanitarian impacts of covid-19 as a faith-based organization emily hirataa, michael peachb, sharon tobingc a mph, technical advisor for health & nutrition, adra international b mpa, global emergency coordinator, adra international c mph, senior technical advisor for health, adra international abstract large-scale health emergencies like covid-19 oftentimes result in widespread humanitarian impacts. due to their long-standing relationships and involvement within local communities, along with extensive networks and support from faithaffiliated institutions, faith-based ngos carry a unique advantage in reaching the most vulnerable during such crises. the adventist development & relief agency’s (adra) experience during its global covid-19 response showcases how keeping a local presence in-country and fostering partnerships with affiliated faith institutions and constituents can result in a wide reach of programming. by providing dedicated personnel and small seed-funding, developing a flexible global strategy involving strong business continuity plans and emphasis on its faith base, and supporting the sharing of information and lessons learned among local offices, faith-based ngos are capable of quickly delivering life-saving interventions to vulnerable communities. adra and the affiliated seventh-day adventist church have proved during the first year of covid-19 that they are stronger together, highlighting the importance of utilizing a faith base when implementing humanitarian interventions. key words: faith-based organizations, global health, humanitarian response, covid-19, seventh-day adventist introduction large-scale health emergencies such as epidemics and pandemics can result in widespread humanitarian need for vulnerable populations. while already at heightened risk of poorer health outcomes directly related to the health emergency at hand, vulnerable populations are also disproportionately at risk of suffering secondary humanitarian impacts as well.1-3 secondary impacts seen during covid-19 and other major outbreaks include economic instability and livelihood disruptions, food insecurity and malnutrition, health system stress/collapse, expanded need for psychosocial support, educational delays, increased child labor, hindered access to basic services, and the rise of violence and abuse.2-14 25 hirata, peach & tobing july 2021. christian journal for global health 8(1) faith-based non-governmental organizations (ngos) have the potential to leverage mobilization for humanitarian response to reach the needs of vulnerable communities that may otherwise be overlooked during large-scale health emergencies. oftentimes, faith-based ngos have long-standing relationships and involvement within local communities, are trusted more than local secular institutions, and frequently have the ability to provide services of better quality than counterpart government and non-government organizations.15-18 moreover, faith-based ngos often have extensive networks with other faith and development institutions, creating a unique position from which to form collaborations and deliver support in times of humanitarian crisis.18 the charter for faith-based humanitarian action, endorsed in istanbul during the world humanitarian summit, has recognized this ‘unique position and comparative advantage’ of local faith actors in humanitarian settings, particularly given they are embedded in society, before, during, and long after crises occur.19 the adventist development and relief agency (adra) is one such faith-based ngo that has been providing humanitarian support during the covid-19 pandemic. adra is the official humanitarian branch of the global seventh-day adventist (sda) church and comprises a network of locally-registered offices in 118 countries, delivering assistance through localized on-the-ground approaches within the communities in which these offices are based.20 seasoned in emergency response and capitalizing on its faith-based structure, the network of adra country offices banded together at the onset of the covid-19 outbreak to develop and implement the “stronger together” global covid-19 response, successfully supporting millions of pandemic-affected people across the globe. methods previous to the covid-19 pandemic, adra interventions did not operate under one single overarching action plan to address humanitarian crises. yet, with the scale and extent to which covid-19 was impacting the globe, adra’s network of local country offices joined together as one body to implement its “stronger together” global response. this joint global response consisted of four key elements: 1) creation of a global covid19 taskforce; 2) development of adra’s “stronger together” covid-19 framework and response strategy; 3) provision of seed funding to kickstart projects under the response strategy; and 4) creation of the covid-19 technical interest group to provide supplementary technical knowledge and materials to country offices. data on each of the four key elements was collected through analyzing adra’s global response reports and meeting minutes, studying existing strategic documents for the global response, and analyzing transcripts from an interview conducted with adra’s global emergency coordinator. further information was collected to make comparisons to pre-pandemic performance, as well as to the general state of other organizations in the sector during the first year of pandemic, through review of annual reports and news articles. covid-19 taskforce during march 2020, adra established a covid-19 taskforce to organize and manage its global response. the taskforce was comprised of key leadership within adra at the international vice president level along with experienced program management professionals from across the global adra network of country offices. the taskforce prioritized strengthening operational capacity, promoting staff wellbeing, adapting to new ways of working, supporting local sda churches, capturing lessons learned, and leveraging funds. for the first several weeks after its establishment, the covid-19 taskforce met daily over virtual online platforms to collaborate and develop adra’s global response strategy. 26 hirata, peach & tobing july 2021. christian journal for global health 8(1) figure 1: adra's "stronger together" global covid-19 strategy “stronger together” covid-19 framework and response strategy given adra’s presence in a wide variety of contexts, rather than a one-size-fits-all approach, adra created a flexible strategy (figure 1) based on a framework of four simple pillars (table 1) developed specifically for the covid-19 crisis, which could be applied in any local office: 1. know your reality: adra realized the agency’s impact could only be effective if its staff, volunteers, and partners understood their own risks and took the appropriate measures to mitigate and address them. at an organizational level, adra offices also needed to understand the disruptions the pandemic would bring to their current operations and pivot existing projects where necessary to address covid-19. 2. love your neighbor: while adhering to social responsibility, valuing and providing protection, and in consideration of pandemic restrictions, adra was intentional in strengthening connections with the sda church and other entities to further extend its reach to the most vulnerable. 3. grow local: adra enabled local networks and leadership, as well as fostered economic recovery and resilience. offices were advised to “think outside the box” of external funding, highlighting the focus on providing local solutions to local problems. this meant being intentional about mapping assets and understanding how to leverage existing resources through local partnerships. 4. think global: understanding that adra’s global network of offices would be “stronger together,” this fourth pillar built common purpose in adra’s worldwide office network for a global covid-19 response. the sda church and adra hold a presence in 118 countries, with a global church membership of 22 million people, and this advantage was to be explored to leverage greater impact and develop innovative solutions that could be shared and adapted based on local contexts. 27 hirata, peach & tobing july 2021. christian journal for global health 8(1) table 1. adra “stronger together” covid-19 global strategy framework know your reality understand personal and professional risk pursue new business opportunities love your neighbor build connections with the community support the most vulnerable activities to include: ● undertaking risk assessments ● developing business continuity plans ● updating safety and security plans ● undertaking training needs analysis for staff ● participating in relevant covid-19 online learning forums ● agreeing what successful response looks like with staff and other stakeholders ● undertaking regular needs assessments ● engaging and sharing information with government and coordination bodies ● influencing donors and supporters with regular communication activities to include: ● developing implementation strategies aligned with adra’s priority sectors ● exploring technology and innovations to enhance program delivery ● explore partnerships with the sda church and other faith communities ● mainstream accountability and safeguarding in all project activities ● promoting the application of humanitarian standards ● adopting simple but scalable approaches to response plans ● partnering with church and commercial media channels to disseminate information materials promoted by the world health organization and other health authorities ● prioritizing the physical and mental wellbeing of staff and volunteers grow local enable local networks and leadership foster economic recovery and resilience think global build common purpose in the adra office network for a global covid-19 response advocate to think global, but act local activities to include: ● building and maintaining a volunteer capability ● establishing domestic surge capacity for disaster response ● developing early recovery plans for local offices and partner communities ● exploring local and sustainable fundraising opportunities ● developing a return-to-work strategy for staff and volunteers ● partnering with local civil society organizations and the sda church and other faith communities to coordinate planning and implementation ● exploring opportunities to shift resources and decisionmaking to indigenous local civil society organizations and governments ● exploring technology to foster social enterprise and cash transfers to support economic recovery ● encouraging effective performance through simple monitoring, evaluation, accountability, and learning (meal) frameworks activities to include: ● using the global footprint of adra and the sda church to advocate for the most vulnerable ● aligning with sda church strategies for community service and outreach ● contributing local data to adra headquarters to demonstrate global impact ● actively promoting adra’s global marketing and development campaigns to encourage efficient local fundraising ● utilizing the adra technical learning labs for resources and support ● representing adra on national and international platforms ● regularly reviewing adra structures to ensure agile and effective response ● leveraging coordination mechanisms available through un agencies to share information and seek funding opportunities. foundational to this framework were three precepts by which adra was to function within each pillar: 1. workforce resilience. adra recognized its own staff needed to be cared for so they could care for others. using a multi-layered support structure, workforce resilience was promoted by compassionate leadership to provide for the basic safety, security, and wellbeing of adra’s staff; deliver a safe, productive, and flexible work environment; and build a stronger workplace culture that prioritizes psychological safety in light of covid-19 stressors. practical tools were also developed and disseminated to the adra country office network to facilitate business continuity planning and flexible workforce employment strategies. 2. building organizational capacity. adra’s management and leadership at the country, 28 hirata, peach & tobing july 2021. christian journal for global health 8(1) regional, and global levels were considered vital to navigating the numerous issues resulting from covid-19. this provided the opportunity to confer with the broader adra workforce to ensure a team approach to meet the immediate and future needs of each office. 3. stretching leadership. adra believes that every leader in the agency has the opportunity to lead with courage during uncertain times. as the pandemic has changed the way humanitarian interventions can be implemented, leadership has also needed to evolve. the changing needs and expectations of leadership during the covid-19 crisis necessitated clear and courageous plans for competency alignment and development. as the length of how long the pandemic would last was unknown at the time of development, the strategy was set to expire in march 2021, with plans to develop a revised strategy if needs were to continue. given the pandemic’s ongoing impacts, a revised strategy has been established, building on the previous pillars and precepts, while adding more intentional focus on health, education, and livelihoods sectors. seed funding to kickstart the global strategy developed by the covid-19 taskforce, adra’s headquarters provided $2.5 million to support the process and get projects running within one month of establishment – by april 2020. country offices submitted proposals to the taskforce for small funding. proposals were vetted to ensure quality design and capacity before receiving approval for funding. this funding was conditional on the country office identifying opportunities to ‘grow local’ by building local partnerships and leveraging additional funds from other donors for increased impact. covid-19 technical interest group concurrent to adra’s global covid-19 strategy was the development of a global covid-19 technical interest group (tig), established in march 2020. the tig’s membership consisted of adra staff with clinical, public health, wash, social behavior change, and other relevant technical experience. the tig regularly discussed technical matters relating to covid-19 and provided supplementary technical materials and advice to the adra network. the tig was housed within adra’s existing health technical learning lab, which serves to promote technical learning and dialogue on various health topics within adra’s global office network. because of the well-regarded reputation of the health technical learning lab, this provided a strong foundation for the tig to develop credibility and equipped it with established communication channels through which covid-19 technical information and materials could easily be shared. for the first month of operation, as knowledge about covid-19 was rapidly changing, the tig met weekly through virtual online platforms. in april 2020, meeting frequency was revised to every two weeks, followed by quarterly frequency in 2021. results by march 2021, adra had implemented 422 projects in 96 countries as a global response to the covid-19 pandemic across adra’s nine global regions, impacting nearly 20 million beneficiaries (see table 2). table 2. number of covid-19 responses and beneficiaries by region region # of projects # of beneficiaries africa 47 16,015,531 asia 75 1,900,000 central america/caribbean 10 54,178 eastern europe/central asia 12 94,613 europe 32 42,000 middle east and north africa 27 260,375 29 hirata, peach & tobing july 2021. christian journal for global health 8(1) north america 69 713,826 south america 101 763,659 south pacific 49 124,938 total 422 19,969,120 compared with programming from the previous five years leading up to the pandemic, adra’s covid-19 global response reached a greater number of beneficiaries despite fewer number of projects and smaller budget size (table 3). table 3: comparison of number of responses, beneficiaries, and budget size with previous years program period # of projects # beneficiaries programming budget (usd) 2015 1306 18,503,456 $190 million 2016 1197 15,700,923 $186 million 2017 721 11,028,011 $219 million 2018 1043 16,255,597 $270 million 2019 1181 13,940,984 $324 million 2020* 1372 20,789,281 $329 million global covid-19 response† 422 19,969,120 $26 million *based on unofficial preliminary data only; 2020 figures are currently under analysis and have not yet been published through an annual report. †global covid-19 response figures include all covid-19 programming data in 2020 through march 2021. a range of humanitarian needs were met as a result of adra’s response to the pandemic. the largest need adra addressed was food insecurity with 129 projects (33% of total); followed by health (103 projects, 24%); water and sanitation (89 projects, 21%); psychosocial support (58 projects, 14%); health/hygiene awareness and promotion (20 projects, 5%); and livelihoods (4 projects, 1%); with nine other projects (2%) falling under other various categories. nearly 70% of projects in adra’s global covid-19 response were in partnership with sda church institutions. as a result, every $1 usd invested by adra was leveraged through these partnerships with $7 usd in outside funding. other faith institutions such as latter-day saint charities also collaborated to increase coverage and impact. the overall budget for adra’s global covid-19 response equaled just under $26 million usd. to supplement adra’s global response, adra’s covid-19 technical interest group provided various technical resources to country offices to complement project implementation and ensure safety and technical accuracy. resources included health advisories, reference documents, and adra-tailored webinars (see table 4). table 4: adra covid-19 technical interest group resources. resource type resource title date of publication webinar planning a promotion-based response to covid-19 16 march 2020 health advisory novel coronavirus (covid-19) health advisory 24 march 2020 reference document non-personal communication channels for responding to covid-19 24 march 2020 webinar covid-19: respiratory protection 13 april 2020 reference document role of religious institutions and faith leaders in the covid-19 response 14 april 2020 30 hirata, peach & tobing july 2021. christian journal for global health 8(1) webinar mental health & psychosocial support during covid-19 4 may 2020 repository workplace key message materials 22 may 2020 online forum conversations on principles of closing and opening adra offices 25 june 2020 reference document involving faith communities in covid-19 response and recovery: an overview 22 july 2020 online survey covid-19 survey: vaccine questions/concerns 21 september 2020 webinar covid-19, one health, and adra: preventing future pandemics at the human-animalenvironment interface 27 october 2020 webinar covid-19 and gender in wash and cash transfers 17 november 2020 webinar vaccine campaigns: lessons learned from adra polio vaccination campaigns and their application for covid-19 vaccine rollout 17 february 2021 discussion while global job loss was rampant and many organizations and institutions struggled to stay afloat during the first year of the covid-19 pandemic,20 adra not only survived without losing staff or downsizing operations, but thrived. during previous years leading up to the pandemic, between 20152019, adra reached an average of 15.1 million beneficiaries through a range of 721-1306 projects each year.22-26 yet with covid-19 projects, adra unexpectedly reached nearly 20 million beneficiaries through 422 projects in response just to the pandemic alone, not counting other operations (which seemed largely unaffected by the additional programming27). by implementing a global strategy that covered adra’s entire network of offices instead of executing separate individual responses through a fragmented approach, adra met and surpassed its record of beneficiaries reached in a given year, providing humanitarian relief to a greater number of vulnerable people than thought possible with the initial seed funding of merely $2.5 million. adra’s faith base opened the door for much of its success. given its relationship with the sda church, which carries a footprint in over 200 countries and boasts over 102,000 affiliated institutions worldwide,28,29 adra’s potential for greater impact than the agency alone could accomplish was vast. a core element throughout the entire strategy was the focus of leveraging relationships with the sda church and other faith communities to capitalize on local trust, volunteer resources, public relations, and existing outreach efforts. while adra is affiliated with the sda church, partnering to conduct humanitarian interventions is not typical in many settings. yet as a result of adra’s intentionality to grow locally and minimize this gap within the “stronger together” strategy, nearly 70% of adra’s global covid-19 response projects were conducted in partnership with the sda church. the breadth of this global response, with such a relatively small overall budget, would not have been achievable without these partnerships. this indicates that capitalizing on a faith-based ngo’s own faith constituents and emphasizing partnerships with affiliated institutions can have considerable effect on implementation. adra’s ‘stronger together’ approach also provided a common framework for the sda church to be relevant in the communities they serve during these unprecedented times. the expansive global footprint established with the sda church was instrumental in reaching the “last mile.” adra was able to help identify the most vulnerable people in remote and hard-hit areas and deliver support quickly to those that needed it most. adra’s partnerships with local sda churches, their members, and their resources for implementation intensified adra’s potential for humanitarian reach and scale. 31 hirata, peach & tobing july 2021. christian journal for global health 8(1) adra’s global covid-19 response was not without challenges. with so many country offices involved, capturing metrics proved difficult. various software and dashboards used to track and record project data were not automatically translated into one centralized system. another difficulty was determining what recovery and resilience look like, given the wide set of contexts through which adra was working. while adra is well-versed in emergency response, covid-19 has presented complicated layers in which recovery and resilience cannot be measured in a straightforward way. additionally, due to the scale of the pandemic’s reach, it was not possible to fund programs through each of adra’s country offices within its global network. with additional seed funds, even more adra offices could have been included to provide humanitarian assistance to those most in need within the respective countries. in addition to acknowledging these difficulties, it is also important to consider this case study’s limitations. firstly, this study did not directly compare outcomes or outputs to secular ngos, government programs, or other counterpart intuitions. further studies could be designed to make such comparisons of programming outcomes with secular organizations to further understand the faithbased advantage. secondly, this study does not include official data for adra’s additional operations unrelated to covid-19 programming in 2020, due to the delayed release of adra’s full 2020 annual statistics. future studies could be designed to include full and finalized data on all of adra’s operations (beyond covid-19 alone) for the given year under study to better understand how typical programming expenditures and beneficiary reach were impacted due to covid-19 programming. nevertheless, the successes adra experienced with its overall response to the covid19 pandemic provide lessons for faith-based ngos to address future pandemics and other large-scale emergencies. by creating simple and flexible strategies that encourage local growth and partnerships, encouraging the sharing of lessons learned and other technical information among offices, and by capitalizing on collaborations with affiliated faith institutions and constituents that are already part of local communities, faith-based ngos have a potential advantage over their secular counterparts in serving multitudes of vulnerable people. conclusion faith-based ngos can play an essential role in response to humanitarian impacts that result from large-scale health emergencies. adra’s experience during covid-19 showcases how keeping a local presence in-country and fostering partnerships with affiliated faith institutions and constituents can result in a wide reach of programming, even with few funds. by providing dedicated personnel and small seed-funding, developing a flexible global strategy involving strong business continuity plans and emphasis on its faith base, and supporting the sharing of information and lessons learned among local offices, faith-based ngos are capable of quickly delivering life-saving interventions to vulnerable communities that may otherwise not be reached. adra and the sda church have proved during the first year of covid-19 that they are stronger together. the challenge will be to continue to leverage the global footprint to build back better, to be more resilient to future shocks, and to apply the valuable learnings that have permanently shifted humanitarian response. references 1. sokat yk, altay n. serving vulnerable populations under the threat of epidemics and pandemics. journal of humanitarian logistics and supply chain management. 2021. https://doi.org/10.1108/jhlscm08-2020-0070 2. rohwerder b. secondary impacts of major disease outbreaks in lowand middle-income countries. k4d helpdesk report 756. institute of development studies; 2020. available from: https://opendocs.ids.ac.uk/opendocs/bitstream/handle/ https://doi.org/10.1108/jhlscm-08-2020-0070 https://doi.org/10.1108/jhlscm-08-2020-0070 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innocenti; 2020. available from: https://euagenda.eu/upload/publications/wp-2020-05working-paper-impacts-pandemics-childprotection.pdf.pdf 5. wenham c, smith j, davies se, feng h, grépin ka, harman s, herten-crabb a, morgan r. women are most affected by pandemics – lessons from past outbreaks. nature. 2020;583(7815):194-8. https://doi.org/10.1038/d41586-020-02006-z 6. norouzi n, zarazua de rubens g, choupanpiesheh s, enevoldsen p. when pandemics impact economies and climate change: exploring the impacts of covid-19 on oil and electricity demand in china. energy research & social science. 2020;64:101654. https://doi.org/10.1016/j.erss.2020.101654 7. jena pk. impact of pandemic covid-19 on education in india. international journal of current research. 2020;12(7):12582-6. https://doi.org/10.24941/ijcr.39209.07.2020 8. hallgarten j. evidence on efforts to mitigate the negative educational impact of past disease outbreaks [internet]. k4d helpdesk report 793. education development trust; 2020. available from: https://opendocs.ids.ac.uk/opendocs/bitstream/handle/ 20.500.12413/15202/793_mitigating_education_effect s_of_disease_outbreaks.pdf?sequence=6&isallowed= y 9. mobula lm, samaha h, yao m, gueye as, diallo b, umutoni c, anoko j, lokonga jp, minikulu l, mossoko m, bruni e, carter s, jombart t, fall is, ahuka-mundeke s. recommendations for the covid-19 response at the national level based on lessons learned from the ebola virus disease outbreak in the democratic republic of the congo. the american journal of tropical medicine and hygiene. 2020;103(1):12-17. https://doi.org/10.4269/ajtmh.200256 10. rafaeli t, hutchinson g. the secondary impacts of covid-19 on women and girls in sub-saharan africa [internet]. k4d helpdesk report 830. institute of development studies; 2020. available from: https://opendocs.ids.ac.uk/opendocs/bitstream/handle/ 20.500.12413/15408/830_covid19_girls_and_wom en_ssa.pdf?sequence=1&isallowed=y 11. leddy am, weiser sd, palar k, seligman h. a conceptual model for understanding the rapid covid-19-related increase in food insecurity and its impact on health and healthcare. the american journal of clinical nutrition. 2020;112(5):1162-9. https://doi.org/10.1093/ajcn/nqaa226 12. wolfson ja, leung cw. food insecurity and covid-19: disparities in early effects for us adults. nutrients. 2020;12(6):1648. https://doi.org/10.3390/nu12061648 13. pérez-escamilla r, cunningham k, moran vh. covid-19 and maternal and child food and nutrition insecurity: a complex syndemic. maternal & child nutrition. 2020;16(3). https://doi.org/10.1111/mcn.13036 14. barello s, falcó-pegueroles a, rosa d, tolotti a, graffigna g, bonetti l. the psychosocial impact of flu influenza pandemics on healthcare workers and lessons learnt for the covid-19 emergency: a rapid review. international journal of public health. 2020;65(7):1205-16. https://doi.org/10.1007/s00038020-01463-7 15. goldsmith s, eimicke wb, pineda c. faith-based organizations versus their secular counterparts: a primer for local officials [internet]. ash institute for democratic governance and innovation, harvard university; 2006. available from: https://www.innovations.harvard.edu/sites/default/file s/11120.pdf 16. widmer m, betran ap, merialdi m, requejo j, karpf t. the role of faith-based organizations in maternal and newborn health care in africa. international journal of gynecology & obstetrics. 2011;114(3):218-22. https://doi.org/10.1016/j.ijgo.2011.03.015 https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/15129/756_secondary_impacts_of_major_disease_outbreak_%20in_low_income_countries.pdf?sequence=81&isallowed=y https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/15129/756_secondary_impacts_of_major_disease_outbreak_%20in_low_income_countries.pdf?sequence=81&isallowed=y https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/15129/756_secondary_impacts_of_major_disease_outbreak_%20in_low_income_countries.pdf?sequence=81&isallowed=y 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job losses accelerate in development sector, survey results say [internet]. devex; 2020. available from https://www.devex.com/news/covid-19-job-lossesaccelerate-in-development-sector-survey-results-say97946 21. adra international [internet]. silver spring. our story. [updated 2020; cited 2021 mar 25]. available from: https://adra.org/about-adra 22. adra international. 2015 annual report [internet]. adra international; 2016. available from: https://adra.org/wp-content/uploads/2020/02/2015adra-annual-report.pdf 23. adra international. 2016 annual report [internet]. adra international; 2017. available from: https://adra.org/wp-content/uploads/2020/02/2016adra-annual-report.pdf 24. adra international. 2017 annual report [internet]. adra international; 2018. available from: https://adra.org/wp-content/uploads/2020/02/2017adra-annual-report.pdf 25. adra international. 2018 annual report [internet]. adra international; 2019. available from: https://adra.org/wp-content/uploads/2019/10/annualreport-2018.pdf 26. adra international. annual report 2019 [internet]. adra international; 2020. available from: https://adra.org/wp-content/uploads/2020/10/adraannual-report-2019.pdf 27. adra international. pbi dashboard: 2020. [internal database]. unpublished data. 28. world council of churches [internet]. geneva. seventh-day adventist church. [updated 2021; cited 2021 mar 25]. available from: https://www.oikoumene.org/churchfamilies/seventh-day-adventist-church 29. seventh-day adventist church. 2020 annual statistical report [internet]. office of archives, statistics, and research; 2020. available from: https://documents.adventistarchives.org/statistics/a sr/asr2020a.pdf peer reviewed: submitted 28 april 2021, accepted 2 june 2021, published 30 july 2021 competing interests: none declared. correspondence: emily hirata, adra international, silver spring, md, usa. emily.hirata@adra.org cite this article as: hirata e, peach m, tobing s. the faith-based advantage: a case study on the adventist development & relief agency’s response to humanitarian impacts of covid-19 as a faith-based organization. christ j global health. july 2021; 8(1):24-33. https://doi.org/10.15566/cjgh.v8i1.541 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://doi.org/10.1002/j.1839-4655.2012.tb00254.x https://doi.org/10.1002/j.1839-4655.2012.tb00254.x https://doi.org/10.3390/rel7030019 https://agendaforhumanity.org/sites/default/files/charter%20for%20faith-based%20humanitarian%20action.pdf https://agendaforhumanity.org/sites/default/files/charter%20for%20faith-based%20humanitarian%20action.pdf https://agendaforhumanity.org/sites/default/files/charter%20for%20faith-based%20humanitarian%20action.pdf https://www.devex.com/news/covid-19-job-losses-accelerate-in-development-sector-survey-results-say-97946 https://www.devex.com/news/covid-19-job-losses-accelerate-in-development-sector-survey-results-say-97946 https://www.devex.com/news/covid-19-job-losses-accelerate-in-development-sector-survey-results-say-97946 https://adra.org/about-adra 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mailto:emily.hirata@adra.org https://doi.org/10.15566/cjgh.v8i1.541 about:blank abstract introduction methods results discussion references short communication practical advice for effective healthcare delivery: three principles to promote quality child healthcare globally elvira g beracocheaa amd, mph, president of realizing global health introduction sadly, child health is one of the areas lagging behind when it comes to achieving the 2015 targets of the millennium development goals.1 the saddest part is that in spite of having the medical knowledge and technology to save millions of lives, mdg4 will not be achieved by many countries at this time in history. countries will have to implement more effective strategies and renew their efforts to accelerate achieving this goal. in fact, in 2004, schellenberg and others demonstrated the effectiveness of using integrated management of childhood illnesses program (imci) as a strategy to deliver life-saving medical care for the most prevalent causes of child mortality: malaria, pneumonia, diarrhea, and dehydration and malnutrition.2 along with adequate nutrition and vaccinations, the world could save millions of lives if only the world had focus and leadership. that is where you and i come in, to help get focus and support country leaders to implement imci and an effective child health program. if you are a healthcare or development professional working in an organization that wants to improve the child health program in any country quickly and dramatically, this article will help make a bigger and lasting impact by focusing on improving consistent growth monitoring, nutrition, immunizations, malaria prevention, and imci in every facility you can reach. there are three principles you must implement to ensure that what you do improves not only your organization and its projects but also the whole country’s child health program; because in this way, you help fulfill the right of every child to receive quality healthcare and to live a healthy life.3 before i tell you the three principles, i would like to ask you to think bigger and aim at improving the health system as a whole to deliver sustainable improved child health results. you are not there just to deliver health services or manage a clinic or a project. your work can also impact the country’s child health program and the health system in the part of the country where you work. remember the “global health impact sequence” projects – programs – systems donor–funded projects must improve the country’s programs so that the country’s health system delivers better quality services to every child everywhere every day. prevention, education and early detection the three principles that you have to strengthen in your country’s child health program are: prevention, educationandearly detection. these principles will ensure that the country’s child health program is able to prevent the most prevalent child conditions, educate mothers to provide appropriate nutrition and care, and support community health workers to do early detection of child health problems. early detection is essential to save lives: a child that is not breastfed or gaining weight, who does not sleep under a mosquito net, to whom parents do not show emotional attachment, or who is raised by siblings is at risk of health problems. most health workers know the warning signs that a child may be at risk. we must empower chw to detect and use all resources available to respond and save lives. the best place to start applying these principles is with infants, children from birth to 11 months of age. mortality is high in this group. let’s look at ways your organization or project can improve the country’s infant health program (ihp). begin by asking yourself and encourage health providers you work with to ask themselves these questions: is there an up-to-date infant health policy that guides the ihp?     yes, no     do not know if yes, do you have a copy and have you read it? if no, what can you do now to help create one or update the existing one? do my team and i apply the 3 principles every time we meet a mother with a well or sick child?     yes   no   do not know if your country has an ihp, get a copy, read it, and discuss it with your team to find ways you can apply it. use it to assess how well you are doing. if not, do not wait to get started to improve quality and coverage of infant healthcare. while you help create the ihp or the whole child health policy, you can use the infant quality health care checklist below (table 1), a simplified version of the prevention, education, and early detection principles and imci competencies that are required to deliver quality child healthcare. having clear responsibilities and accountability for results achieves better and sustainable results because when everyone knows what to do, how, and when, services will work even if you are not there to supervise all the time.4 table 1.infant quality health care checklist assessment questions yes no has the infant’s mother received at least 4 antenatal care visits? was the infant delivered by a trained attendant? is the infant’s immunization schedule up-to-date? has this infant received its dose of vitamin a? is this infant being breastfeed? does the mother wash her hands before feeding the infant? is the infant’s growth what is expected for his or her age? are the infant’s parents spacing the birth of the next child? does the infant sleep under an insecticide-impregnated mosquito net? are the infant’s parents hiv/aids negative and know about prevention? does the mother know when and how to start complementary feeding? does the mother know about how to clean the infant’s mouth and teeth? is the infant cared for by a responsible adult at home all the time? do the mother and father know how to play with, discipline, and stimulate the infant? does the mother know how to detect diarrhea and prevent dehydration? does the mother know how to prepare ors (oral rehydration salt)? does the mother know how to detect rapid breathing and other danger signs of pneumonia? total if you answered yes to every question, then you are providing adequate primary infant health care. congratulations! you should strive for a full score of 17 for every infant. if not, then you now know what to work on to help infants and their parents and improve your program. discuss the checklist with your team and partners, and agree on ways to turn nos into yes. think of the simplest and easiest steps you can all apply right away first, and take action to correct any departure from the checklist. for example, one simple step is to consistently smile, make eye contact, and use the mother’s name to establish rapport, so she can feel comfortable and ask questions about nutrition, vaccines, prevention, home treatments, etc. the applications of these three principles and the infant quality health care checklist above have been proven to prevent disease and mortality (who). you can use the checklist to monitor yourself, your team, and your partners to ensure you consistently apply the three principles when treating or caring for every child everywhere every day. after analyzing the quality of care infants are receiving, you can use these same principles in the provision of health care for children 1-5 years of age. with the exception of breastfeeding, which usually has been discontinued by the child’s second birthday, all the other questions in the checklist still apply. for this age group, additional areas you might add to monitor are the child’s speech and motor development, as well as detection of signs of child abuse, particularly if the child is an orphan. i believe god wants us to think big and do our best in 2015. god knows every child deserves to go beyond their 5th birthday and celebrate their 85th birthday or more! we need to design and manage an effective child health program that goes beyond child survival and consistently improve the quality of children’s healthcare and fulfill the right to health of every child (un 1989). email me your success stories and challenges to strengthen your country’s ihp. i will be happy to help you figure out the best way you can achieve lasting impact this year. let’s all work together. let’s focus on improving child health and finish the unfinished agenda of mdg 4 and end preventable child and infant deaths. references united nations [internet]. new york: millennium development goals report; 2014 [cited 2015 jan 23]. available from: http://www.un.org/millenniumgoals/2014%20mdg%20report/mdg%202014%20english%20web.pdf schellenberg jrma, adam t, mshinda h, masanja h, kabad, g, mukasa o, et al. effectiveness and cost of facility-based integrated management of childhood illness (imci) in tanzania. lancet. 2004;364(9445) :1583–94.http://dx.doi.org/10.1016/s0140-6736(04)17311-x united nations [internet]. new york: convention of the rights of the child (crc); 1989 [cited 2015 jan 23]. available from: http://www.ohchr.org/en/professionalinterest/pages/crc.aspx williams b, morrissey b, goenka a, magnus d, allen s. global child health competencies for paediatricians. lancet. 2004;384(9952):1403–5. http://dx.doi.org/10.1016/s0140-6736(14)61128-4 resources imci site http://www.who.int/maternal_child_adolescent/topics/child/imci/en/ imci chart booklet http://www.who.int/maternal_child_adolescent/documents/imci_chartbooklet/en/ caring for newborns and children in the community, adaptation for high hiv or tb settings http://www.who.int/maternal_child_adolescent/documents/newborn-child-community-care/en/ competing interests: none declared. correspondence: : elvira beracochea, realizing global health | 4710 olley lane, fairfax va 22032 | ph: 703-978-3331 | www.realizingglobalhealth.com elvira@realizingglobalhealth.com cite this article as: beracochea eg. practical advice for effective healthcare delivery: three principles to promote quality child healthcare globally. christian journal for global health (april 2014), 2(1):66-69. © beracochea eg. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ short communication july 2021. christian journal for global health 8(1) the church, food culture, and ecotheology: an ongoing church effort in reducing bushmeat eating in minahasa, indonesia alva supita,d, agusteivie telewb,d, nancy bawilingc,d a md, msc, pgdipclinres, phd student in biomedical sciences, city university of hong kong, hong kong b md, msc c md, msc, budi setia hospital langowan, minahasa, indonesia d public health department, manado state university, indonesia abstract minahasa is a christian-majority region in the muslim-majority country of indonesia. most of the minahasan people are meat consumers, with an increased consumption rate during festive seasons. unfortunately, during these seasons, the consumption of non-cattle animals such as wild animals also increases. this eating style was reported to be related to the high prevalence of metabolic diseases in this area. in this paper, we report the effort of the largest church organization in minahasa to promote healthy eating habits among its congregation, which comprises the majority of the society of the region. more recently, the church has also been incorporating the values of wild animal conservation in its programs in collaboration with a local non-government organization. this ongoing unique phenomenon might serve as a unique example of how a church organization can be involved in public and planetary health as a part of its mission to preach the gospel to every creature. key words: ecotheology, minahasa, wild animals, eating habits, covid-19 introduction minahasa is a district region in the northern peninsula of sulawesi island, indonesia. thanks to the efforts of the netherlands missionary society (nederlandsch zendelinggenootschap) ministry— among others—in the 19th century, minahasa had become a christian-majority area in the muslimmajority country of indonesia. currently, there are on average 4.13 church buildings in every minahasan village from various denominations (table 1). the largest denomination is the minahasa evangelical christian church (gereja masehi injili di minahasa, gmim), possessing 998 out of 3,586 protestant church buildings/sites in minahasa. . 65 supit, telew, bawiling july 2021. christian journal for global health 8(1) table 1. the descriptive statistics of churches in minahasa compared to the christian and total population and the number of villages districts population (all religions) protestant population catholic population number of villages protestant churches catholic churches minahasa, central 347,290 290,447 27,486 270 1,016 69 south minahasa 236,463 214,010 7,671 178 514 22 north minahasa 268,935 209,983 20,784 131 478 51 southeast minahasa 116,323 95,527 1,424 144 306 14 manado city 451,916 306,262 27,211 87 717 28 bitung city 225,134 95,035 7,068 69 452 23 tomohon city 100,587 72,931 23,147 44 103 24 total 1,702,706 1,284,195 114,791 923 3,586 231 note: by indonesian law, protestant and catholic are separated into two different religions. data source: ministry of religious affairs1, north sulawesi statistic bureau2 food is a marker of social status in various civilizations around the world, including minahasa.3 while the muslim-majority indonesian people have a restricted meat diet, minahasan people have been known to eat almost all animals, which can be partially attributed to their non-food-restricting belief in christianity. local phrases circulating among minahasans state that, “even the devil, after cooked in chili, is our food,” as well as “if adam and eve were minahasans, humans would never need to fall into sin because they would eat the snake instead of the forbidden fruit.” these jests were not invented by minahasans, as people from other areas have also claimed these jokes as their own. however, minahasan people are proud of being the subject of these, at least when chatting among themselves. it is not common for a protestant church organization to intervene in what its congregation should or should not eat.4 however, in the last few decades, when the protections to endangered animals have been reinforced by the indonesian law, the church has also been called upon to support the government efforts. it has revived its ecotheological function, as stated by the edenic charge to humans: to work the earth and take care of it—which also means to keep, maintain, and cultivate (genesis 2:15, various translations). the recently emerging covid-19 pandemic has reinforced the function of the church in maintaining the relationship of its people with the wild animals; not eating them can prevent zoonotic transmission of animal pathogens into humans. in this paper, we report how local churches have been involved in advising healthy consumption of animal meat, especially during the festival seasons (e.g., christmas and new year). this is embedded within the sermons at the discretion of the priest of the village-level congregations. more recently, on the synodal level, formal memorandums of understanding were established, including an agreement with a local pro-environment, nongovernment organization to protect wild animals, particularly the local ape (yaki, macaca nigra) from being hunted for food. three factors form a related triangle of notions: the church, food culture, and conservation. these will be the foci of discussion in this report. the excessive and exotic eating habit of minahasan people during the festivals in minahasa, christmas is the most celebrated festival of the year, followed by the harvest thanksgiving period from june to august. while the 66 supit, telew, bawiling july 2021. christian journal for global health 8(1) congregations celebrate christmas day by attending the services in the church, the feast usually continues for the following week until the new year on the 1st of january. during this period, special foods are prepared, mostly high in fat content. the main domesticated animals to be slaughtered are pigs, chickens, ducks, followed by cows. unfortunately, it has been a tradition that the consumption of noncattle, wild animals also increased during the festival, including dogs, bats, snakes, turtles, and even some monkey species (ref. 1 and 2 in mandias, 20195). the consumption of these exotic animals is rather cultural than nutritional, merely for celebration purposes. the church has been advising a reduction in this practice by incorporating health advice into the sermons around the christmas season. it is not uncommon for the priests to preach about healthy eating during the season, mostly quoting that, “our body is the temple of god, therefore we need to take care of the food intake to prevent diseases,” “christ was born into humbleness, not feast,” as well as incorporating some satires about rational feastings, such as, “don’t insist to eat brenebon (=red bean meat soup, a delicacy) in december, and pay the bon (=debt) for the whole following year.” approaches, however, were mostly—if not always—persuasive, not restrictive. it is noteworthy that minahasa has the secondhighest prevalence of diabetes mellitus type 2 in indonesia.6 the incidence of acute gout is also among the highest in indonesia, which is likely to be related to the high-purine intake, including from wild and exotic animal meat.5 it is the authors’ observation as practicing physicians in this area that there is an increase of acute gout incidence in january compared to other months. no randomized controlled study, however, has shown whether more aggressive contextual preaching during the festival season could reduce the incidence of acute gout or diabetes in the long term. also, there seems to be no direct scriptural prohibition against the habit of eating wild animals. therefore, other approaches to the congregation are necessary, most likely at the level of the church organizational policy. green gospel, food culture, and pandemic in 2019, the synodal board of gmim signed an agreement with yayasan selamatkan yaki (ysy, safe ape foundation) to incorporate the value of ecological conservation of wild animals into the curriculum of gmim sunday school. the syllabus contained nine chapters about forest, fauna, marine, waste management, and others.7 while the foundation has expertise in this conservation area, the church leaders identified and shared the scriptures concerning the environment, e.g., genesis 2:15 and the story of noah’s ark. this can be considered as the initial formal agreement of the church with an external organization, mutually reaching out for a common aim of wildlife conservation. in fact, ecological themes have appeared in gmim’s vision statements and themes, most notably in 2014: “ . . . to overcome poverty, injustice, radicalism, and environmental destruction.” the 2019 pact with ysy can therefore be considered a manifestation of the vision statement. encouragement from the pulpit was also given, asking the congregation, specifically, not to consume protected wild animals during the festivals. nevertheless, due to the novelty of the program, it might be too early to observe the effect of the agreement. the covid-19 pandemic in the year following 2019 affected the implementation of the agenda. on the other hand, the year 2020 has added another set of reasonings for advocating wildlife animal conservation. the sars-cov2 virus is believed to be originated from bats, mainly because it shares homology sequences with bat coronaviruses.8 although an exact incidence of zoonotic transmission has not yet been established, the imminent danger of the bat-to-human transmission of coronaviruses was predicted before it emerged.9 thus, humans need to keep away from the wild 67 supit, telew, bawiling july 2021. christian journal for global health 8(1) pathogen and, hence, to the carriers—in covid-19 context, the bats. many minahasan people are proud bat-eaters. the church, therefore, in addition to actively promoting healthy lifestyle behavior through the sermons, also acts as a provider of effective social control against wild animal consumption by reflecting on the ongoing pandemic and providing authoritative advice to avoid wild animal consumption. conclusion as the largest christian church organization in minahasa, gmim has been actively promoting healthy eating habits, and more recently, started to embrace a commitment against wild animal consumption. however, the parameters for evaluating these commitments have not been well developed. therefore, as the process of fulfilling the calling for ecological preservation is ongoing, it is suggested that other collaborations, perhaps with the academia or public health agencies, can be made to systematically analyze the impact of christian ecotheology application within gmim on the health of the planet. the green gospel should embrace the conservation of yaki, other wild animals, the environment, and the individual churches themselves as the body of christ—the center of creation. references 1. ministry of religious affairs of north sulawesi indonesia. data tempat ibadah di sulut tahun 2019 [internet]. manado, indonesia; 2019. available from: https://sulut.kemenag.go.id/data_umat/4/datatempat-peribadatan-di-sulut-tahun-2019 2. north sulawesi statistic bureau. provinsi sulawesi utara dalam angka 2021 [internet]. manado, indonesia; 2020. available from: https://sulut.bps.go.id/publication/2021/02/26/ef5603f cc2c336b42cc0e4a5/provinsi-sulawesi-utara-dalamangka-2021.html 3. weichart g. makan dan minum bersama: feasting commensality in minahasa, indonesia. anthropol food. 2001 mar 21;s3:s3-8. https://doi.org/10.4000/aof.2212 4. resane kt. “and they shall make you eat grass like oxen”(daniel 4: 24): reflections on recent practices in some new charismatic churches [internet]. pharos j theol. 2017;98(1):1–17. available from: https://www.pharosjot.com/uploads/7/1/6/3/7163688/ article_10__vol_98_2017.pdf 5. mandias r. the relationship between eating wild animal meat with the level of uric acid in langowan minahasa, indonesia. kne life sci. 2019;4(13):64–9. https://doi.org/10.18502/kls.v4i13.5226 6. utomo h, wungow n, marunduh s. kadar hba1c pada pasien diabetes melitus tipe 2 di puskesmas bahu kecamatan malalayang kota manado. ebiomedik. 2015;3(1). https://doi.org/10.35790/ebm.3.1.2015.6620 7. selamatkan yaki. gmim church supports yaki conservation – selamatkan yaki [internet]. 2019 [cited 2021 apr 2]. available from: https://www.selamatkanyaki.ngo/2019/06/19/1417/ 8. fang g, song q. legislation advancement of one health in china in the context of the covid-19 pandemic: from the perspective of the wild animal conservation law. one heal. 2021;12:100195. https://doi.org/10.1016/j.onehlt.2020.100195 9. fan y, zhao k, shi z-l, zhou p. bat coronaviruses in china. viruses. 2019 mar;11(3). https://doi.org/10.3390/v11030210 peer reviewed: submitted 1 april 2021, accepted 3 may 2021, published 30 july 2021 competing interests: none declared. correspondence: alva supit, manado state university, indonesia. alva.supit@unima.ac.id https://sulut.kemenag.go.id/data_umat/4/data-tempat-peribadatan-di-sulut-tahun-2019 https://sulut.kemenag.go.id/data_umat/4/data-tempat-peribadatan-di-sulut-tahun-2019 https://sulut.bps.go.id/publication/2021/02/26/ef5603fcc2c336b42cc0e4a5/provinsi-sulawesi-utara-dalam-angka-2021.html https://sulut.bps.go.id/publication/2021/02/26/ef5603fcc2c336b42cc0e4a5/provinsi-sulawesi-utara-dalam-angka-2021.html https://sulut.bps.go.id/publication/2021/02/26/ef5603fcc2c336b42cc0e4a5/provinsi-sulawesi-utara-dalam-angka-2021.html https://doi.org/10.4000/aof.2212 https://www.pharosjot.com/uploads/7/1/6/3/7163688/article_10__vol_98_2017.pdf https://www.pharosjot.com/uploads/7/1/6/3/7163688/article_10__vol_98_2017.pdf https://doi.org/10.18502/kls.v4i13.5226 https://doi.org/10.35790/ebm.3.1.2015.6620 https://www.selamatkanyaki.ngo/2019/06/19/1417/ https://doi.org/10.1016/j.onehlt.2020.100195 https://doi.org/10.3390/v11030210 mailto:alva.supit@unima.ac.id 68 supit, telew, bawiling july 2021. christian journal for global health 8(1) cite this article as: supit a, telew a, bawiling n. the church, food culture, and ecotheology: an ongoing church effort to reduce bushmeat eating in minahasa, indonesia. christ j global health. july 2021; 8(1):64-68. https://doi.org/10.15566/cjgh.v8i1.537 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ cjgh.org https://doi.org/10.15566/cjgh.v8i1.537 about:blank introduction references editorial may 2023. christian journal for global health 10(1) building evidence in diverse places where healing is needed most this year the journal completes a decade of publishing christian perspectives on global health. in an accompanying editorial on research, reflection, and writing for global health, daniel o’neill and nathan grills review the case of why the journal exists and why it is both right to publish such perspectives and how such publishing can be helpful to the church and our neighbors around the world. their argument is comprehensive, scripture-informed at multiple points and very well worth your attention. multiple submissions in this issue testify to the breadth of the global reach and interest of the journal. covid-19 continues to be with us in terms of understanding its associated complications even when active infection is on the wane. margarita portilla diaz and her colleagues inquired into musculoskeletal complications engendered in university professors in colombia by remote working conditions, finding substantial health effects. seyed reza hosseini and his coworkers surveyed sleep quality and associated factors in elderly persons living in a community in iran. the editors value informed discussion of differing points of view and offer the category of commentary to further that aim. drs. nicholson, dahlman and carlough provide a perspective on the ongoing relevance of the medical missionary enterprise that is balanced, but illustrative of its virtues in meeting needs and sustainability in ways and in locations government and secular initiatives fail to serve. dr. volodymyr shablystyi and colleagues describe the roles several nongovernmental organizations (ngos) doctors without borders, the international committee of the red cross and oxfam – have played during the war in ukraine. their account does not mention faith-based organizations which have also contributed in major ways to the ongoing humanitarian effort there, but the lessons learned from their analysis of the relationship of government under martial law with ngos can inform fbo action and democratize aid. two field reports inform us regarding faith-based global health interventions in two low-income countries: supit, mautang and pangemanan report on a collaboration between school and university to benefit school health in indonesia, and daring, ten broek and colleagues show evidence on outcomes in a program to bolster adolescent appreciation of gender equality in bangladesh. an additional reflection by m. shawn morehead in the form of a meditation on dust inspired by personal experience in afghanistan speaks of our common humanity and common need. in a letter-to-the-editor william cayley responds to james harries’ article biomedical services’ fit amongst people with relational worldviews, and a ‘middle road’ published in the previous issue. he offers the biblical story of daniel and his colleagues as captors in babylon, suggesting an ancient and god-ordained precedent for clinical trials, which he argues are not beyond comprehension for people who hold indigenous or relational world views. harries’ response highlights the global variations which exist in the interpretation of both the biblical story line and health-related observations in nature. our editors’ response contributes to the debate. finally, jessica culver poetically prays for grace in the suffering and inconvenience occasioned by an injury, and the doxological hope that emerges from the christian faith in the god who suffered and heals. . https://journal.cjgh.org/index.php/cjgh/article/view/757 https://journal.cjgh.org/index.php/cjgh/article/view/757 https://journal.cjgh.org/index.php/cjgh/article/view/747 https://journal.cjgh.org/index.php/cjgh/article/view/659 https://journal.cjgh.org/index.php/cjgh/article/view/751 https://journal.cjgh.org/index.php/cjgh/article/view/751 https://journal.cjgh.org/index.php/cjgh/article/view/749 https://journal.cjgh.org/index.php/cjgh/article/view/749 https://journal.cjgh.org/index.php/cjgh/article/view/761 https://journal.cjgh.org/index.php/cjgh/article/view/741 https://journal.cjgh.org/index.php/cjgh/article/view/741 https://journal.cjgh.org/index.php/cjgh/article/view/767 https://journal.cjgh.org/index.php/cjgh/article/view/767 https://journal.cjgh.org/index.php/cjgh/article/view/745 https://journal.cjgh.org/index.php/cjgh/article/view/759 field report nov 2015. christian journal for global health 2(2): 69-71. learning to see jessica merrill paulraj a a bsn, nurse educator in northeast india i moved to india with eyes wide open, or so i thought. i came with a nursing degree, some tropical medicine training, and passion for the “outcast”. however, i defined “outcast” according to my own perspective. and through that defining, ironically, i cast others out. i came with a desire to serve young girls without a family. i loved them as my own and made a life with them. however, when that season came to a close and abba god brought a little boy disfigured beyond imagination into my arms, i could have never imagined that this is why he called me. allow me to explain with a bit of background. i first came to india in 2006 and moved here permanently in 2009. i was working with at-risk children in delhi until 2011 when i got married and joined my husband who was working as a psychiatrist in assam, india. we both had dreams (which i now call “delusions of grandeur”) to change the world. my husband dreamed of bringing change through revolutionizing mental healthcare across north india. i had worked as an obstetrics nurse and had dreams of seeing radical changes in women’s health across india. these career plans did not include children for “at least 5 years.” however, the night before our six-month anniversary, a little boy was born in the hospital in which we were working. at birth, he did not have eyelids nor a fully formed mouth. he had an absent palate, no fingers, and his legs were fused together. this was due to a genetic condition called bartsocas papas popliteal pterygium syndrome. his birth family was overwhelmed with grief at his condition, and due to the heavy shame that their community placed on them, they abandoned him at the hospital. my husband and i met this little boy and were overcome with a desire to see someone care for him. however, we did not think we were at all a part of that plan. i would go to bathe him each day and we would play relaxing piano music for him in order to soothe him when he was upset. we prayed and asked hundreds around the world to pray for his life and that god would provide a home for him. meanwhile, my husband and i had been doing a bible study on the book of romans. before this little baby was born, we had read romans 8:15 that says, “we no longer have a spirit of fear but of sonship, by which we cry out ‘abba! father!’” this verse really impacted us as we realized the fact that god, in his great love and perfection, loved us (broken people) so much that he found a way to adopt us into his family. he did not leave us as orphans but made a way for us to come to him. my husband was reminded of this verse a few days after this little baby was born and came home exclaiming, “jessica, we were that baby. in our spiritual state, before jesus rescued us. . . we were just like this baby. we were orphans, we were disfigured by our sin, and we had no hope, but god in his great love adopted us and made us his children. how can we look at this little boy and deny him the incredible love that god provided for us?” this truth is what led us to adopt this little boy and name him adam. we named him adam after the first man, created in god’s image, because even though his body is broken and unformed, we believe god still had created him and had a beautiful purpose for his life. psalm 139:16 says, “your eyes saw my unformed body.” we may 70 paulraj nov 2015. christian journal for global health 2(2): 69-71. not understand why adam has to suffer with such a disfigured body on this side of eternity, but we can rest assured that god saw his unformed body, and god gave him life. one question that was on my heart and mind a lot before we officially adopted adam was, “can i raise a dying child?” the doctors who diagnosed his condition said he had only 2 months to live. could i raise a child knowing that he was dying? i felt as though the lord responded to that question with, “jessica, you too are dying.” “. . . your husband, he is dying.” “. . . each of your future children. . . once they enter the world, their days are counted, and you do not know what tomorrow holds for you or anyone you love.” i do not say this in a pessimistic, foreboding way, but with the scriptural understanding of reality that all flesh is like grass, here today and gone tomorrow. just because adam has a medical condition that labels him more “fragile” than others, he is no less deserving of life, love, or a family. to make a long story short, adam has far surpassed initial estimations and prognoses. he passed 2 months and is now an active 4yearold boy. he has two little brothers and amazes us daily with all that he can understand and do despite the limitations his body places on him. he has had a total of 15 surgeries in the us, thus far, and we anticipate a few more surgeries and years of therapies. adam has learned how to crawl and walk in order to get around. his malformed legs do not hold him back by any means. his absent fingers have never interfered with him picking up anything. he loves to sit in my lap and flip pages in books while i read out loud to him. he plays peek-a-boo and loves to find his shadow. he has two little brothers who tend to drive him crazy, but he is starting to show more affection towards them as time passes. adam has brought change across india and the world. his life has spoken to millions of people, even though he has never spoken a word. his story has traveled across nations, even though he has no feet. we have been amazed at the way that god can take one little life initially seen as a curse and make such a beautiful story. my husband and i never imagined that we had a role in the disability community; but, god has shown us that we all have a role in it because there is no such thing as a disability community. we are all in this journey, called life, together. there is no “us” and “them.” no matter what our mind or body is capable, we have been called to care for one another. we serve a god who can make beauty from ashes and who takes the foolish things of the world to shame the wise. he is in the business of restoring broken things, and we are the ones blessed enough to be on the journey with this great god. although these years have been wrought with tears, fears, and exhaustion, they have been hemmed in with beauty unimaginable to our mortal eyes. god has used our adam to take our eyes off what is possible with man, and he has fixed our gaze heavenwards onto what is only possible by a mighty god who sees brokenness as beautiful. i never imagined having a child on whose behalf i would conduct research and find places that could accommodate him. before adam, i would talk all day about advocacy but not advocacy for people who had different abilities or for those with physical, emotional, developmental, or neurological limitations. i was blind to that community of individuals. disability scared me, and it did not seem exciting. then adam entered my life, and i cannot imagine a more worthy life than as a momma or friend or nurse, advocating for all needs of the differently-abled because jesus advocates for me. 71 paulraj nov 2015. christian journal for global health 2(2): 69-71. competing interests: none declared. correspondence: jessica merrill paulraj. jessica.merrill.cooksey@gmail.com cite this article as: paulraj, jm. learning to see. christian journal for global health (nov 2015), 2(2): 69-71. ©paulraj, jm. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:jessica.merrill.cooksey@gmail.com http://creativecommons.org/licenses/by/3.0/ field reports christian healthcare in medically underserved north philadelphia amanda martineza a ms, fourth-year medical student at ohio university heritage college of osteopathic medicine in athens, ohio abstract with an unfortunate number of underserved communities throughout the world, it would be remiss to overlook the prevalence of ones located right in the backyards of america. most residents of these communities suffer disproportionately from health disparities. they are often lower income, non-white residents of dense and diverse urban neighborhoods, like ones located in north philadelphia. since 1989, a health center, esperanza, has been dedicated to serving the members of the north philadelphia community through an intentional and faith-based approach. today, its director, susan post, has continued to carry out the mission of esperanza through efforts that highlight purposeful proximity. key words: underserved, philadelphia, health, healthcare, faith-based, christianity, urban, esperanza introduction most of the residents of north philadelphia lack basic health care services, live in households with incomes at or below 200% of the poverty level, and nearly one-in-five people lack health insurance, resulting in communities that are designated as federal medically underserved areas.2 after the migration of puerto ricans to philadelphia grew substantially from the 1940s to the 1970s following the city’s economic decline, several blocks around north fifth street known as “el centro de oro” or “center of gold” became philadelphia’s growing latino community.3 carolyn klaus, an internist, and other concerned health professionals realized the great unmet need for affordable primary health care in north philadelphia, and on june 15th, 1989 esperanza health center opened its doors on fifth street in “el centro de oro.”4 this health center and its current executive director, susan post, continue to serve the residents of north philadelphia through a wholistic and intentional approach to healthcare. dr. klaus described susan as “a small women with a big vision and an impressive grasp of the complexities of modern healthcare.”5 through an interview with esperanza’s director, susan post, we will present more insight on the mission of esperanza and its director of 17 years; the following text contains her responses to the interview. interview the mission of esperanza at esperanza, we are hoping to reach those in our community with fullness of health. health is a word that incorporates a lot, and we are serving a community that has many factors that go against health. so, we start by having enough medical clinicians and sites to try martinez 112 june 2022. christian journal for global health 9(1) to allow each person in our community to have a primary care clinician, and to provide primary care services such as mental and dental healthcare in addition to medical care. however, we are also trying to address our goal of improving the overall health of the community. a good deal of that has to do with what happens outside the exam room—how we eat, how we exercise, how we connect with others. so, we are developing our care to include intentional connection with people in the context of their lives— senior programs, prenatal groups, or parenting circles, for example. these are programs that our community has suggested and that make a difference in their lives. we are learning from our community, and we hope to keep moving forward with healthy initiatives in the years to come. the meaning of healthcare at esperanza as i have been at esperanza and living in my community, my idea of what healthcare means has changed a great deal. i typically thought it was physical, how our body is doing, though i also always knew that poor health can be hard on our mind and spirit. now, though, i see so much more about how relationships and community play a part in health and health care. our system in america is sometimes typically that the doctor has all the education and information, and they tell the patient what to do. that might work on one level, but overall ongoing health is about our lifestyle—what we eat, how we sleep, who we love, how we connect, what we hope for, how we manage when in pain or disability. these things are so much greater than what a doctor tells us in the 10 minutes we hear from him or her in the exam room. healthy lifestyle is important and, maybe, it’s preventative health that needs to be addressed first, for sure. and when someone does get sick or has a medical issue, that’s when deep caring and community is even more important, and i don’t think we consider that enough in our modern health care system. so, at esperanza we can’t be all that to our patients, but we can be a conduit to that. we can talk to our patients about the assets in their lives and the relationships of people who can help them if they are sick, we can encourage and make space for preventative care and activities that engage people with those around them. we have a program for seniors, and many of those seniors live around me in my neighborhood. they are the ones who help me with my health—inviting me to a healthy life through friendships, walks, sharing life together, hoping for each other. they enrich my life and for that i am extremely grateful. so, it’s not so much what is esperanza doing but what are we doing with our community together? the call to the underserved for me, there was a spiritual component to it. i felt drawn to see the world from god’s perspective, from what i know it to be through the bible. that means seeing people with their godgiven dignity and value. it means seeing where god is taking the world in his process of redemption. but whether one is moved by spirituality or not, i think a big part of deciding to put your life into this is the product of proximity, being close to the community. that might be from growing up here yourself, or from having a friend from this community, or 113 martinez june 2022. christian journal for global health 9(1) from going to church here, as i originally did, or just being close enough to see, really see the community and its needs, its inherent beauty and value, and wanting to see that beauty have its full effect on the lives of people who live here. for me, that’s a god thing. i want to be doing things that god had in mind when he made each person who lives here. i guess the motivation can come from different places, but ultimately it is a desire to see this place become what it was meant to be. living in intentional proximity from my studies, i saw the benefit of people who are different socioeconomically, living in proximity to each other. beneficial for all involved. but it was when that moved from book knowledge to transformation of my heart to want to know and understand this community and myself; and for me, with a desire to have god’s heart, i sensed it would be good to move here. once i decided to move, i sensed a commitment and a connection with the people who were to be my neighbors. i am grateful for the time i have had living within my community—it has been life-changing to me, life-bringing, and there is no better way to grow with others than to be identified with them in community. empowerment through collaboration listening to my community has been life-changing to me. it has allowed me to question assumptions and preconceived notions that i lived with my whole life from the perspective of my growing up world. but there is a much bigger perspective and picture for me than that, and it starts with listening to my community. i’m not quite sure how much listening has empowered my community but likely it has. mainly it has helped me to grow in my perspective and that larger perspective has affected all that i do at esperanza. there is a tendency for people like me to come into a community and try to change it with the expectation that i might know more of what the community needs than they do, because i am educated, etc. but that’s not true. the community knows their needs and they need me to listen and identify with them so with this combined bigger perspective, we can make our community a better place. the community’s impact it’s funny, people often say that i have made an impact, or maybe ask me how the community has changed since i’ve been here, but what is on my mind usually is how the community has made an impact on me. it has changed so much about me. it has shown me aspects of joy i hadn’t known in my own culture. what it means to celebrate even while suffering. it has shown me a bigger picture of god. i have learned about connectedness, that i belong to them and they belong to me, and it is meant to be that way but somehow in my world i haven’t understood the importance of community. we are built for it, we need it, grow from it, it is vital, but we sometimes live so individualistically and alone, it can be sad to think about sometimes. i have seen how health care is tied into relationships with others: your family, your community, helping you know how to be healthy. martinez 114 june 2022. christian journal for global health 9(1) discussion proximity since its founding in 1989, esperanza has done just what its english translation suggests, give hope to its community. its mission is “to not only provide excellent, compassionate care in jesus’ name for all patients, but also to reach outside of the exam room walls for a healthier community.”4 after 30 years, esperanza now has three sites: kensington, hunting park, and fifth street, allowing clinicians to practice “neighborhood-engaged care” with the central goal of mitigating disparities.1 with over 215 employees, it prides itself on employing individuals who are committed to advancing their mission. a large percentage of esperanza’s current staff members have taken personal stake in the development of the neighborhood they serve because they themselves are north philadelphia residents, who are proud to call this community their home. this includes its own executive director of 17 years, susan post. the teachings of john perkins, an evangelist and civil rights activist, reiterates that living out the gospel means bettering the quality of other people’s lives spiritually, physically, socially, and emotionally as one betters one’s own.6 this viewpoint embodies how christian community development is committed to listening to the community residents and hearing their dreams, ideas, and thoughts, and is important, as the people of the community are the vested treasures of the future.7 as a federally qualified health center (fqhc), esperanza ensures that care is available and affordable to all, regardless of economic or social status. with thousands of patients being either uninsured or underinsured, no patient is turned away because of the inability to pay, and patients are also offered payment on a sliding scale based on income.8 esperanza additionally operates under a governing board where the majority of members receive care as patients at esperanza. with board members being residents and patients of the community, this aspect of proximity has greatly assisted esperanza’s implementation of efforts that aim to address the specific needs of the community. relocation results in transforming “you, them, and theirs” to “we, us, and ours” and this is reflected in numerous ways. the proximity and voices that the board allows patients to have has been essential, as according to research by virginia commonwealth university’s center on society and health, the overall life expectancy in esperanza’s communities of service is 10 to 17 years shorter than life in philadelphia’s more prosperous neighborhoods.2 this glaring difference is the result of the cumulative effects of deep poverty, high crime, repeated trauma, and lack of access to affordable, quality healthcare that directly impacts residents.2 with this unfortunate reality, the access to quality healthcare and diverse resources that esperanza provides north philadelphia are efforts that aim to address these unfortunate disparities. spirituality the spiritual component that esperanza has embodied since its inception brings patients and employees in proximity in intangible but significant ways. to some, medicine and religion may be opposites, but a holistic approach to medicine has increased greatly throughout the recent decades. although spiritual well-being may be regularly inquired about during medical assessments, esperanza continues to meet the spiritual needs of patients in one space.9 esperanza partners with patients, the church, and local organizations to bring healing and wholeness to their community. at esperanza, praying for or with a patient is just as common as taking their blood pressure, something not commonly seen throughout the traditional healthcare system. with significant research indicating a strong linkage between a patient’s spiritual care and their overall well-being, since its founding, esperanza aimed to meet the needs of their patients beyond their physical health. their patients frequently express the desire to discuss spiritual concerns or to pray with someone during their visit.9 115 martinez june 2022. christian journal for global health 9(1) spanish language proficiency the spiritual foundation that sets esperanza apart is only as successful as it is because of another aspect of proximity that the health center has incorporated since day one; cohesive and intentional proficiency of the spanish language. this proximity component of communication is crucial in settings like north philadelphia, where individuals may solely speak and understand the spanish language. esperanza has responded to the overwhelming need for spanish-speaking services in their community, as its primary medical care providers and clinical support staff are competent in english and spanish.2 in 2018, esperanza provided bilingual primary healthcare services for over 14,000 patients of all ages through over 64,500 patient visits.2 the health center has made effective and comfortable communication with their patients a priority, since language barriers can be an obstacle that prevents many from obtaining basic healthcare services. information can be lost in translation, which unfortunately can result in a misunderstanding of patient concerns and information conveyed by healthcare providers. the intentionality of bilingual proficiency that allows for a proximal connection between healthcare providers and patients is another stride that esperanza makes to break down potential barriers to accommodate their patients to the best of their abilities. conclusion through its leadership and mission, esperanza continues to work towards a society that reflects true equity. the dedication esperanza and susan post have shown to their north philadelphia community is reflected by them continuing to embody “we” and “ours” instead of “them” and “theirs” by attributing their work to something much deeper than themselves. susan, herself, describes her work to be that of what resembles the execution of the love that jesus has for everyone no matter their zip code or identifying demographics. the efforts of esperanza began in 1989, and today the health center and its director continue to bring a new meaning to the definition of the city of brotherly love. go to the people, live among them, learn from them, love them. start with what they know, build on what they have: but of the best leaders, when their task is done, the people will remark, “we have done it ourselves.” -lau tzu10 references 1. alicea-alvarez n, reeves k, lucas ms, huang d, ortiz m, burroughs t, et al. impacting health disparities in urban communities: preparing future healthcare providers for “neighborhood-engaged care” through a community engagement course intervention. j urban health bull n y acad med. 2016;93(4):732-43. https://doi.org/10.1007/s11524016-0057-6 2. our impact | esperanza health center [internet]. 2021 [cited 2021 feb 3] available from: https://esperanzahealth.com/about/impact/ 3. our community | esperanza health center [internet]. 2021 [cited 2021 feb 3] available from: https://esperanzahealth.com/about/community/ 4. our history | esperanza health center. [internet]. 2021 [cited 2021 jan 3] available from: https://esperanzahealth.com/about/history/ 5. klaus c. prescription for hope. bristol, indiana: restoration press; 2008. 6. perkins, john. christianitytoday.com [internet]. 2021 [cited 2021 feb 23]. available from: https://www.christianitytoday.com/ct/people/p/johnperkins/ 7. ccda philosophy. into the neighborhood [internet]. 2013 oct 1 [cited 2021 jan 16]. available from: https://intotheneighborhood.org/about-intothe-hood/ccda-philosophy/ 8. payment and insurance | esperanza health center [internet]. 2021 [cited 2021 feb 3]. available from: https://esperanzahealth.com/patients/payment/ https://doi.org/10.1007/s11524-016-0057-6 https://doi.org/10.1007/s11524-016-0057-6 https://esperanzahealth.com/about/impact/ https://esperanzahealth.com/about/community/ https://esperanzahealth.com/about/history/ https://www.christianitytoday.com/ct/people/p/john-perkins/ https://www.christianitytoday.com/ct/people/p/john-perkins/ https://intotheneighborhood.org/about-into-the-hood/ccda-philosophy/ https://intotheneighborhood.org/about-into-the-hood/ccda-philosophy/ https://esperanzahealth.com/patients/payment/ martinez 116 june 2022. christian journal for global health 9(1) 9. spiritual care | esperanza health center. [internet]. 2021 [cited 2021 feb 3]. available from: https://esperanzahealth.com/services/spiritual-care/ 10. ccd philosophy » christian community development association. christian community development association [internet]. 2021 [cited 2021 feb 2]. available from: https://ccda.org/about/philosophy/ peer reviewed: submitted 22 feb 2021, accepted 14 jun 2022, published 20 jun 2022 competing interests: none declared. correspondence: amanda martinez, philadelphia, pa, usa am467317@ohio.edu cite this article as: martinez a. christian healthcare in medically underserved north philadelphia. christ j global health. june 2022; 9(1):111-116. https://doi.org/10.15566/cjgh.v9i1.633 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ www.cjgh.org https://esperanzahealth.com/services/spiritual-care/ https://ccda.org/about/philosophy/ mailto:am467317@ohio.edu https://doi.org/10.15566/cjgh.v9i1.633 about:blank abstract introduction references original article dec 2022. christian journal for global health 9(2) redeeming gender imbalances: how biblical interpretations effect women’s health in indonesia fotarisman zaluchua a mph, phd, lecturer, universitas sumatra utara, indonesia abstract several health indicators suggest that the level of women's health globally remains poor. indicators such as maternal mortality, domestic violence, and stunting, particularly in africa and asia, are also linked to poor women's health. there is evidence that the poor quality of women's health parallels the prevalence of gender imbalance. one system supporting gender imbalance is the subjective interpretation of normative gender relations. to address this issue, this qualitative study makes use of the approach developed by joan w. scott covering four dimensions of analysis: symbols for both sexes in a culture, normative conceptions that follow these symbols, gender division, and subjective identity. this subjective research took place in the island of nias, indonesia where christianity is the primary religion. the result of this study shows that certain interpretations of biblical verses have negatively impacted women, such as women being considered inferior to men, experiencing loss of opportunity to maintain health due to excessive work responsibilities, and risking mental and physical violence. certain interpretations of biblical verses are believed and accepted as an absolute and fixed self-identity for christians. an analysis of gender roles using an approach offered by an historian like joan w. scott accurately explains the power of religion-based symbols and norms in maintaining gender imbalance, which in turn, affect women’s health. a way forward is suggested to expand biblical interpretations which could increase equality and improve women’s health. key words: women’s health, gender imbalance, symbols, norms, bible, rural introduction maternal mortality, poor health of women, and domestic violence against women remain complex global health issues for humanity. another issue closely related to pregnancy and women's health is childhood stunting. these problems are suspected to be inextricably intertwined with gender inequality.1-6 the issues of women's health are not equally distributed worldwide. after africa, maternal mortality is concentrated in the eastern region, especially asia.7 indonesia is among the countries with the highest rate of maternal mortality in asia with the latest data showing 305 deaths per 100,000 live births.8 in addition, the status of women is also closely related to the health status of children under five years. the asian region contributed as many zaluchu 12 dec 2022. christian journal for global health 9(2) as 53 percent of global stunting cases in 2020.9 meanwhile, in southeast asia, three countries are the ones with high cases of stunting, and indonesia sits highest on the list.10 up to the end of 2021, an official publication by the government revealed that stunting in indonesia had reached 24.4 percent.11 likewise, violence against women occurs on a massive scale with a much higher prevalence in african and asian regions.12 the government officially reported that gender-based violence in indonesia reached 338,000 cases in 2021 alone.13 the conditions mentioned above reflect the unsettling realities of women's health status, which might be magnified by norms embraced by a particular society. the norms are perceived as social values that should be maintained. religion is one among other sources of societal norms. unfortunately, religion has been proven to maintain and support gender imbalance in society.14-16 these roles are hardly unchallenged since religion is believed to represent a sacred power. although gender imbalance is not the direct teaching of the church, the perceptions of some church congregations, derived from the bible, have been their life inspiration for years.17 like a template, the holy bible is a life reference of believers' behavior, which butler called "performativity."18 joan w. scott offers a theoretical framework to understand gender-based imbalance and analyze its religious dimensions.19 joan w. scott argues that gender norms are firmly established in christianity employing religious symbols. scott's analysis brings a new perspective on gender analysis, not only on the theoretical level, which was developed after the publication of her essay,20 but also on the praxis level, something that will also be demonstrated in this paper. women cannot break the glass ceiling of gender imbalance because the existing power sources do not take sides with them.21 in addition, religion provides dead, fixed, and solid norms which reject changes. systematic examinations of gender imbalance have indeed been done extensively. however, studies to understand gender imbalance in its subjective biblical interpretation in local contexts remain limited, especially if such a study is linked to women’s contemporary issues. experts tend to understand gender imbalance situations from a general point of view. interventions based on this generic outlook are often non-parallel to local communities’ understanding. as a result, such an approach is most likely to reach a dead end. gender imbalance analysis must not be detached from people’s daily activities.22 therefore, gender imbalance formation should be understood according to its locus,23 and by doing so, one can comprehend it more accurately and then can offer more contextual changes in the future. the ultimate goal is, of course, to improve women’s health. as far as the author is concerned, scott's concept has contributed to the interrogation of gender imbalance in the western culture, while in the context of eastern culture, especially indonesia, it has never been used. this article attempts to explain religious influence on gender imbalance in the eastern context, especially in an indonesian rural area with a majority christian faith. this paper attempts to explain how limited interpretations of biblical teachings could contribute to women’s health issues in regions with highly complex global health problems like in asia and, especially, indonesia. main concept gender imbalance has created inequality and inequity.24 instead of creating an understanding of the roles of men and women which should be complementary to each other,25-26 inaccuracy in understanding the meaning of the bible has ironically strengthened gender imbalance.14 further, as stated by hwa yung (2015), church communities in asia are often only nominal, but lacking in true understanding of the bible.27 13 zaluchu dec 2022. christian journal for global health 9(2) gender imbalance generally occurs through social processes in society.28 the social process is formed by various channels, from the birth of a social agent to the end of his or her life. in his book, bourdieu adds a remark on this by pointing out that the binary system has placed males and females in a vast gap of positions and roles. men were symbolized by "dry," where their primary activities are outside the house (i.e., in the fields, meeting place, and market) whereas women were symbolized by "wet" (suggesting that they work in gloomy locations and are mostly engaged in housework, yard work, and woodworking).29 in this paper, i use a concept proposed by joan w. scott. she put forth her important idea in her essay entitled gender: a useful category of historical analysis.19 scott defines gender in historical context. her first assumption is that “gender is a constitutive element of social relationships based on perceived differences between the sexes.”19 she claims that the primary mechanism for encoding and maintaining power relations is gender. based on these assumptions, scott creates a "template" in which she adds four crucial characteristics related to gender. the institutionalization of gender differences, symbols for both sexes in a culture, normative conceptions that follow these symbols, and subjective identity are among these aspects. no one of these four components operates without others due to their interdependence. scott maintains that these very four aspects build the power interactions that create, sustain, and extend gender disparities. scott centered her attention on images like "eve and mary" in the western christian tradition. an effective and efficient system of control is needed to maintain the gender roles so that men and women behave in accordance with their respective roles. these gender roles function more effectively when the instruments of control are normative. thus, the binary, which separates the duties of men and women, is justified by social conventions and backed by religious values. then the division of labour is formed based on the sexual binary. the development of a subjective identity based on sex differences and implemented in daily activities will lead to the subjective self-perceptions of women (and of men as well). according to scott, the formation occurs through a long process, a personal life history, where women and men both meet what is expected of them within the social system they reside. in line with scott, i argue that gender imbalance is manufactured and each culture contains the four aspects proposed by scott. in this paper, scott's template is useful in assisting gender research since it explains how gender disparities persist in a given culture in addition to demonstrating the presence of gender inequalities within this society. making use of the four aspects developed by scott enables us “to discover the nature of the debate or repression that leads to the appearance of timeless permanence in binary gender representation.”19 materials and methods this qualitative research was conducted in nias island, where about 92 percent of the people live in rural areas. nias island is dominated by the nias ethnic group, and the majority are considered christian.30 christian missions entered nias island in 1832 and reached their peak with the formation of the local church in the 1930s.31 more than 95 percent of all people on the island are members of christian local churches. therefore, a localized christian viewpoint will represent the informant’s perspective of this study. in-depth interviews were conducted by the author in 2014 with 25 married husband and wife couples, all of whom claimed to be christian. to provide additional information, the researcher also conducted in-depth interviews with the couple’s mothers-in-law. interviews with the wife, husband, or mother-in-law were conducted in separate places to avoid bias, even though they were still at the informant's house. interviews were conducted at the same time or differently zaluchu 14 dec 2022. christian journal for global health 9(2) depending on the informants' availability of time. interviews were conducted in the nias language. data were collected using open-ended unstructured questions. the questions were oriented to four fundamental questions as in scott's concept, namely a) how men and women are symbolized; b) what norms are attached to the symbol; c) what kind of division of labour conforms to the norm for men and women; and d) how women internalize these norms. see the guided questions in appendix a. each informant was informed about the research objectives and given a verbal explanation of the research procedure. because informants’ educational background was not supportive, verbal consent was obtained. for field research, an ethical permit was issued by health research ethical committee of medical faculty, nommensen hkbp university, medan, indonesia. informants were de-identified by the use of pseudonyms. when carrying out the research, there was no access to electricity due to limited resources from the government in the research location. responses were recorded through mobile electronic mp3 devices. research data were manually analysed for practical purposes in the field since research activities took place in different locations. after thoroughly listening to the interview recordings, the next step was to code the informants' answers. the final step was to categorize the coded information under the themes of the research goals. most of the data collected for this paper come particularly from one of the chapters of the author’s phd dissertation at the university of amsterdam. the dissertation has been published under the title gender inequality behind maternal mortality in nias island, north sumatra, indonesia, towards a gender audit.32 results in the following sections, the research result regarding the four dimensions proposed by scott will be presented systematically. the dimensions cover the symbols used to divide gender, the norms represented, and practical implications of the symbols and perceptions of gender roles. symbol to better grasp the correlation between biblical interpretations and the gender imbalance in the given society, the author interviewed both husband and wife to find out how they perceive themselves. their answers varied, yet they explicitly revealed gender role differences (table 1). table 1. men and women respondents’ viewpoints on self-representing symbol for male gender role for female gender role högö (head) to be praised gi’o (tail) to follow kafalo (leader) si so föna (at the front) to lead solo’ö (follower) si so furi (at the back) to follow ga’a (older) to be served akhi (younger) to serve the symbolic representations mentioned by the respondents above clearly give contrasting perceptions about men and women. in essence, male and female were represented as dichotomous, binary oppositions. male was symbolized by something which is “up there,” “in front of,” or “which comes first.” in contrast, female was marked by something “at the rear.” högö, kafalo, and si so föna are symbolic ideologies colouring niasan daily life. for instance, the head (högö) represents a husband because he is pictured as sitting higher up or in the front, whereas the tail (gi'o) represents his wife since she is pictured as sitting lower down or in the back. animal heads, 15 zaluchu dec 2022. christian journal for global health 9(2) particularly pig heads, are immensely significant to niasan culture. högö is always given to the esteemed person at nias weddings. boiling pig heads (högö), which are regarded as the most important and honourable parts of the animal, are always offered during wedding meals. different home functions were cited as another description of this symbol. in an interview with a wife, ina grace (a pseudonym), she stated that her husband was referred to as a leader (kafalo), the one who had greater responsibility for making decisions, and his wife was a follower (solo'ö), the one who carried out her leader's decisions. as a result, a wife will occasionally assert that she was just hiding in plain sight in a given circumstance, si so furi, while her husband was out in the open, si so föna. the kafalo, who had greater privilege than the other members of the community, was considered to be the highest hierarchical position in the society historically. a kafalo was seen as having greater skills or abilities than common people because they were the focal point of the town. without the kafalo presence, it was impossible to start a communal gathering or function. the kafalo was recognized for always sitting at the front portion (föna) and in his allotted higher position. biological metaphors were cited by some respondents as a way to emphasize gender differences. for instance, a wife, who was born later, was seen as the younger (akhi), but her husband, the firstborn, was seen as the older (ga'a). a girl’s duty at home, as "an akhi," was to constantly treat her brother with respect and provide the finest service possible. again, the older brother (ga'a) had the decision-making authority first, followed by the sisters. ga'a had the right to take over his parents' role in decision-making as well. on critical examination of the terms högö, kafalo, si so föna, and ga’a representing male, one can see that they are identical to biblical symbols. these symbolic representations share the idea that male is associated with the head, just like jesus christ as the head of the church or king/leader. in addition, the old testament explicitly narrates adam, a male, as the first human being created (si so föna, ga’a), while female is created afterward. the symbolization reflects an ideology on the importance of male status, i.e., the husband. he is as significant as christ himself (a view implied by one informant’s response). it is true that the respondents interviewed did not talk about biblical symbols. the juxtaposition of male and christ can be seen in the poetry of the nias ethnic group stating that woman as the second creation. 33 the poetry said that in the beginning, was the creator. the creator then created woman and made her quite pretty and perfect. a man then took the woman away because he was created earlier than her. the symbol and the poetry are parallel in keeping an ideology that the position of man is higher than that of woman for the latter is merely gi’o, solo’ö, si so furi, and akhi. therefore, it is clear from the beginning there had already been a cultural belief in the distinctive positions between man and woman, husband and wife before the advent of christianity. for the people on the island of nias, symbols for women had not refered to their status higher than or equal to men. this might explain some of the health issues women experience, as will be discussed in the following section. normative scott places emphasis on the use of symbols having consequences for normative roles. the existing norms ensure that both sexes adjust to the symbols representing their existence. in her narrative, ina gayusu (pseudonym) shared her belief as follows: submissive. everything we say should be followed. undeniable. more importantly, if a husband likes to drink and his wife likes to argue [about her husband’s habit], then the household will be chaotic. it could not be like that...it has zaluchu 16 dec 2022. christian journal for global health 9(2) been written in the bible that the head of men is christ, and the head of women is men. that is what we follow. if we do not follow bible’s commands, we will be lost…just follow it. in line with the previous statement, ina gayusu firmly believed in what the symbols revealed to her. for her, the bible was a life guide to follow without reserve. she was left with no choice but to obediently uphold this bible-derived principle because it "has been written in the bible". ina gayusu accepted the notion that men were superior to women as true. indeed, the respondents in this research often referred to what is written in 1 corinthians 11: 3. ina gayusu insisted that the bible's contents had major repercussions in addition to stating her firm religious belief that it was an authoritative source. if a wife does not follow it, she will be a lost soul (elungu). according to ina gayusu, this position was not something she had declared, but rather was what god wanted her to be. her adherence to god's commands was voluntary rather than forced. field observations confirm that it had become normative for women to bear physical and nonphysical burdens. for a husband, his wife was "a worker," as she was supposed to be. a woman who refused to follow the directions of her husband, and even worse with any public display of resistance, was deemed to be disobeying biblical teachings. a husband once said that a wife's refusal to obey her husband as "… being inappropriate. i have the right not to feed her. and if she keeps on misbehaving, i will give her one beating. it [the beating] is to discipline her." the more we examine gender division in the light of scott's approach, the more we find out its connection with issues of women's health. the following section shows how symbols and norms are manifested in work division. institution the third dimension proposed by scott is the implications of symbols and norms. the implications are generally manifested in the division of labour. in this section, only interviews with wives are present to determine the types of work they perceived as women’s jobs, and to discover the coverage of work they had to handle. the results are shown in table 2. table 2. women’s duties from the wives’ perspective women duties reasons • clothes washing • fulfilling husband’s needs • working in in the paddy field • keeping the home clean • taking care of children • fetching water from wells • cooking food and boiling water • feeding pigs • collecting rubber • collecting cassava leaf • collecting firewood • food preparation and serving for husband • it is wife’s duty to fulfill family members needs • family members needs demands for woman’s work • a wife cannot humiliate her husband by allowing him to do women’s jobs, e.g. fetching water • it is the nature of woman to deal with household work, and it is the nature of man to be “the leader” • it is wife duty to serve all her family members, including her husband original article dec 2022. christian journal for global health 9(2) field observations show that wives fully accept their positions. this collective, absolute obedience is perceived as “normal” and “an identity” that is in line with biblical teachings. in this situation, it is difficult for any member of society to challenge the truth of biblical interpretations and teachings by disobeying their “role.” the life experiences shared, especially by ina mika, are powerful examples in understanding the subjective identity in scott's concept. ina mika demonstrated how pervasive and intransigent the grasp of subjective identity construction and how it affects women. their subjective perception of the gender-based symbols—that "men's position is higher than women's"—remains fostered and reinforced throughout their lives. discussion this current research shows that scott's concept is very useful as a framework in explaining the interpretation of verses in the bible which play a role in shaping and maintaining a gender imbalance in the eastern tradition. the symbols regarding "who is a man" and "who is a woman" clearly reveal that the gender imbalance is supported by the informants' inaccurate understanding of the bible (see also the questions in appendix a). it should be recognized that quotes and figures of speech used to represent the husband—and the local people in the research location—as if they are directly derived from biblical teachings are highly questionable. the teachings of jesus christ are not meant to create a hierarchy among human beings but that we must love one another indiscriminately. god makes men and women complete and helps each of them to fulfill god's call. no one holds the authority over another (gen. 1:27, 5:2) since god is the one who possesses the highest and most absolute authority. however, social realities in this population studied treated biblical interpretations as inflexible truths. those who adhere to christianity believed that obedience to gender norms, though the norms bear inequity, is being faithful to their religion. in this light, gender imbalance is more than just a concept; it is a manifestation of the identity of obedient adherents to christianity. as a result, the demarcation line between men and women and between husbands and wives must be continuously maintained, because that is perceived as the best way to comply with biblical teachings. though the biblical interpretation is not comprehensively done, the informant’s view (table 1) that the symbol of jesus as the head of the church is immediately synonymous with the husband as the head of the household (högö, kafalo), on a practical level, supports the existence of hierarchy in the relationship between men and women and between husband and wife.14 thus, what is taking place right now is a tradition justified through symbols, norms and gender divisions, and self-identity formation. the process operates non-physically. those who undergo the process are not supposed to ask questions; they obediently take it as an undeniable truth. in other words, everyone will assume their given identity because the gender norms are already provided to each one. gender norms govern not only the mind but also behavior. this internalization process naturally takes place for generations. each one only plays his or her predetermined role.18 to ensure the successful operation of the normative regulation, gender norms do provide two things to every social agent. first, important guidelines for behavior so that they continue to carry out existing norms, and second, at the same time, imposing sanctions on those who try to behave outside of these norms.34 wives who behave differently will get social sanctions in the form of being called "dishonorable" as informed by ina gayusu. she insisted that women’s failure to follow biblical teachings meant their denial of christian virtue, in which one might end up in a zaluchu 18 dec 2022. christian journal for global health 9(2) “chaotic” situation. for ina gayusu, the morality of woman is measured with how obedient a wife is to her husband which she believed was explicitly stated in the bible. there is no wonder if the jobs that wives should deal with (see table 2) are more than just daily activities. they are proof of their obedience to the bible. in this study, a wife was "configured" inflexibly to perform daily work from simple to complex tasks. a wife was expected to prepare and serve meals for the entire home while also being worn out from working in the field. she was also expected to participate in social gatherings like wedding receptions. as mentioned by moser, women in developing countries like indonesia hold the triple burden of the productive, reproductive, and social sectors.35 this division of duties between husband and wife is also supported by interpretations that again come from the bible. one husband said that “women are able to do all things” (interview, 6 augustus 2014). another husband explained that “women are born with more additional strength than men, and this enables them to handle any kind of works” (interview, 2 september 2014). these statements are conveyed when interpreting subjectively the meaning of diligent work as written in romans 12:11, and especially, titus 2:5, which subjectively was considered only to be done by women. in fact, this subjective view was often used by men to refuse to take part in jobs labelled as women's duties. when a husband handled a woman's perceived designated chores such as washing clothes or cooking, he would be teased by his peers as "a savuyu of his wife." savuyu, meaning "slave," is someone follows only his master's instructions and orders. this word, although it has some connection with practices in the past, also refers to the jews who were slaves in the land of egypt. so, if a husband helps his wife by doing the work that his wife does daily, he would be humiliated because christian believers must not be under the concept of savuyu anymore. husbands who perform "women's jobs" were usually teased by other men. it is true that these rural men must perform energy-intensive jobs, like clearing trees from a plot of land or working in the family rice crop or garden. however, some men still found time to unwind while working hard. a husband was not instantly given domestic responsibilities, and more importantly, he was not subject to the same types of norm and social expectations as women. these men lived in a system that was more favourable to them.29 when work divisions are based on gender and there is no option for exchanging roles, especially if supported by religious-based symbols, social agents will accept them as a normative regulation. this rule has been constantly imposed, passed down through the centuries and recognized as normal by social actors. given that both sexes have a thorough understanding of the range of their respective duties, it makes sense for women (and men) to simply conform to gender roles—a template—created for them. butler says, “gender is the repeated stylization of the body, a set of repeated acts within a highly rigid regulatory frame that congeal over time to produce the appearance of substance, of a natural sort of being.”18 what is being measured and discussed in this paper cannot be used to establish the direct cause of poor health of women. however, gender imbalance norms can be social determinants of disproportionately poor women's health. being invisible and difficult to revise, the gender norms play a significant role in maintaining gender imbalance between men and women. gender norms have become an inseparable part of the existing body of the social agents in the fields of social science and linguistics.35 the norms are even planted on a solid base, for they contain religious identity wholeheartedly embraced by the religious adherents in this study. the members of society have made their interpretations and lived accordingly for a long period of time. as a result, these biblical interpretations are not questioned. 19 zaluchu dec 2022. christian journal for global health 9(2) the gender division has been accepted as an identity and used to build what is perceived as a well-managed life. in a normal situation, efforts to change gender norms will encounter a "patriarchal bargain,"37 not only from men but also from women themselves. resistance is even greater when gender norms are attached to religion. the above series of processes is the social landscape behind the poor quality of women's health in various parts of the world, especially in the eastern region. gender norm-based identities are forcibly distributed to women, and as a result, they lose their autonomy. on physical and mental levels, many women have no chance to take care of their pregnancy, consume nutritious food, and manage pregnancy spacing. after giving birth, a woman cannot fully focus on providing healthy food for her baby. women are loaded with so many other jobs that they have no room to fulfill their maternal responsibilities. husbands may impose more burdens by committing violence against their wives. to sum up, the approach offered by joan w. scott helps to investigate a particular social phenomenon, namely, the presence of gender imbalances which lead to injustices behind the poorer conditions of women's health. this investigation hopefully offers new insight into women's health interventions in the future. conclusion and recommendation the gender imbalance still survives so strongly because it supports the social agent's interpretation of the meaning of the bible. with these interpretations, symbols, norms, division of work, and subjective identity are maintained in society, and women, including pregnant women, women with babies, and even children, pay the price for this practice. this social conditioning must be overcome because it is very detrimental to women’s health. first, the local church should give more accurate interpretations of the relationship between men and women. instead of using only biblical verses that favor men, the church should offer holistic, balanced biblical interpretations. the church must highlight the importance of a husband's love and sacrifice to his own wife (ephesians 5:25-33), in the same way jesus christ sacrificed and emptied himself to redeem god's chosen people. this message should be routinely delivered to the congregation in religious activities, such as sunday services in church, weekly activities, and especially home worship activities. for the church leaders in the eastern hemisphere, where gender norms still favor men over women, they need to initiate a dialogue to shed light on the interpretations of pertinent biblical verses. through dialogue, church leaders may be able to correct the personal biblical interpretations that may cause gender injustices, especially the ones against women. given the fact that women's health is related to long-held traditions, the church is required to develop teachings that argue that jesus christ does not only sacrifice himself to redeem human beings from their sins but also save them from any oppressive or harmful traditions. the blood of christ should also redeem every deep cultural practice which promotes gender injustices. a redeemed cultural practice encourages the congregation to love and serve one another (mark 9:35), create reciprocity, and submit to one another as redeemed people (ephesians 5:21). the church should play an active role in fostering a healing community as a manifestation of her responsibility in this world.38 allowing gender injustices to happen means paving the way for human tragedy to occur before the church's eyes. it should be recognized that many churches are insensitive to gender injustice. in these circumstances, activists, health practitioners, and health researchers need to urge church leaders to scrutinize whether their church plays direct or indirect roles in encouraging gender inequalities that cause negative consequences to women’s health. church leaders in nias island may show resistance, but if logical explanations of zaluchu 20 dec 2022. christian journal for global health 9(2) gender inequality offered by scott's concept are given, they could join hands to address gender inequality which has disadvantaged women for so long. future studies could be in the form of action research aimed to understand the possible changes as an effect of people's education, and of course, by using social channels suitable to the people. this research was conducted on nias island with only individual members of several congregations. the results therefore may not reflect the views of other church members or the synod leaders. in addition, there may have been different dynamics if it was carried out in urban areas. though gender differences can be accepted as a gift of god, unjust gender imbalances remain a challenge to be resolved because of the global health problems they produce in god's creation. as a man, i see so many things that should be fixed in this very patriarchal culture, but would encourage a better understanding of the justice and human dignity expressed as truths written in the bible. references 1. hamal m, dieleman m, de brouwere v, de cock buning t. social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in india. public health rev. 2020;41. https://doi.org/10.1186/s40985-020-00125-6 2. fathalla mf. human rights 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hj. gender inequality: the problem of harmful, patriarchal, traditional and cultural gender practices in the church. hts teol stud / theol stud. 2019;75(1):a5177. https://doi.org/10.4102/hts.v75i1.5177 17. woodhead l. les différences de genre dans la pratique et la signification de la religion. trav genre soc. 2012;27(1):33-54. https://doi.org/10.3917/tgs.027.0033 18. butler j. gender trouble. routledge; 2010. 19. scott jw. gender: a useful category of historical analysis. am hist rev. 1986;91(5):1053-1075. 20. whitney sb. history through the lens of gender. j womens hist. 1999;11(1):193-202. https://doi.org/10.1353/jowh.2003.0105 21. isenberg n. second thoughts on gender and women’s history. am stud. 1995;36(1):93-103. https://www.jstor.org/stable/40643733 22. nyhagen l, halsaa b. religion, gender and citizenship. palgrave macmillan; 2016. 23. davis k, evans m, lorber j. handboook of gender and women’s studies. sage publication; 2006. 24. crompton r. the future of gender. in: j. 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[thesis, fully internal, universiteit van amsterdam]. 2018. available from: https://pure.uva.nl/ws/files/22548046/thesis.pdf 33. zebua, s. sejarah kebudayaan ono niha. lembaga budaya nias; 1995. 34. wieringa se. passionate aesthetics and symbolic subversion: heteronormativity in india and indonesia. asian stud rev. 2012;36(4):515-530. https://doi.org/10.1080/10357823.2012.739997 35. bourdieu, p. language and symbolic power. polity press; 1991. 36. moser con. gender planning and development: theory, practice and trainning. routledge; 1993. 37. kandiyoti d. the social construction of gender. in: lorber j, farell sa, eds. sage publication; 1991:104-118. 38. o’neill dw. theological foundations for an effective christian response to the global disease burden in resource-constrained regions. christ j glob heal. 2016;3(may):3-10. https://doi.org/10.15566/cjgh.v3i1.112 peer reviewed: submitted 5 may 2022, revised 1 nov 2022, accepted 23 nov 2022, published 20 dec 2022 competing interests: none declared. acknowledgements: the author expresses sincere gratitude to indonesia endowment fund for education (lpdp) for the scholarship provided for this research, and the head of district health office in nias, west nias and south nias for supporting this research by giving access to local health personnel and maternal and child health information. https://doi.org/10.4102/hts.v75i1.5177 https://doi.org/10.3917/tgs.027.0033 https://doi.org/10.1353/jowh.2003.0105 https://www.jstor.org/stable/40643733 https://doi.org/10.1017/cbo9780511619205.011 https://www.christianitytoday.com/ct/2018/august-web-only/complementarian-egalitarian-debate-gender-roles-explainer.html https://www.christianitytoday.com/ct/2018/august-web-only/complementarian-egalitarian-debate-gender-roles-explainer.html https://www.christianitytoday.com/ct/2018/august-web-only/complementarian-egalitarian-debate-gender-roles-explainer.html http://www.jstor.org/stable/25002517 https://sumut.bps.go.id/indicator/12/70/1/jumlah-penduduk-daerah-perkotaan-dan-perdesaan-menurut-kabupaten-kota.html https://sumut.bps.go.id/indicator/12/70/1/jumlah-penduduk-daerah-perkotaan-dan-perdesaan-menurut-kabupaten-kota.html https://sumut.bps.go.id/indicator/12/70/1/jumlah-penduduk-daerah-perkotaan-dan-perdesaan-menurut-kabupaten-kota.html https://pure.uva.nl/ws/files/22548046/thesis.pdf https://doi.org/10.1080/10357823.2012.739997 https://doi.org/10.15566/cjgh.v3i1.112 zaluchu 22 dec 2022. christian journal for global health 9(2) correspondence: dr. fotarisman zaluchu, indonesia fotarisman.zaluchu@usu.ac.id cite this article as: zaluchu f. redeeming gender imbalances: how biblical interpretations effect women’s health in indonesia. christ j glob health. dec 2022; 9(2):11-22. https://doi.org/10.15566/cjgh.v9i2.651 © author. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ appendix a. guided questions 1. in your community, is there any symbol to represent males and females? what are the symbols for men used in contexts of daily life, social interactions, and customary occasions? how about the symbols for women; how are they symbolically represented? and in what contexts? 2. how do those symbols exist? are those symbols related to gender roles? what are the gender roles? how are the symbols related to gender roles? 3. is there any evidence to support those symbols? is there any symbol derived from the bible? could you show me the biblical source? is your understanding of the biblical verses based on your own interpretation, or do your church leaders tell you so? 4. are the male and female symbols rigidly used in society? how does the symbol work? 5. what happens if someone violates gender norms? if there is any sanction, do males and females receive different treatments? who creates and enforces the sanctions? 6. in your opinion, what are the criteria of an ideal man? what are the criteria of an ideal woman? what are the characteristics of an ideal man and an ideal woman? why are these ideal characteristics important? 7. as a man, what do you usually do in daily life, customary activities, and in church concerning the implementation of gender norms? 8. as a woman, what do you usually do in daily life, customary activities, and church concerning the implementation of gender norms? 9. how are gender norms regulated? who is in charge of supervision? who is in charge of giving directions? 10. what is man’s work pattern? please tell me a man’s work pattern from time to time in a single day. 11. what is a woman’s work pattern? please tell me a woman’s work pattern from time to time in a single day. 12. which part of the bible supporting the practices of gender division? why do you have such a conclusion? 13. how are male norms taught in the family circle? how are female norms taught in the family circle? who plays a significant role in teaching the norms? are there any biblical verses justifying the norms? 14. what is your own experience in fulfilling the roles? do you have any experience outside your community? mailto:fotarisman.zaluchu@usu.ac.id https://doi.org/10.15566/cjgh.v9i2.651 about:blank abstract key words: women’s health, gender imbalance, symbols, norms, bible, rural introduction references commentary nov 2015. christian journal for global health, 2(2):61-63. a call to the church: embrace children with disabilities natalie ann flickner a a ba, ma, writer, crisis care training international in the world today, two-thirds of the world’s children are either children at risk or children in crisis. among that number are children with disabilities. these children have been abused, abandoned, neglected, and exploited. crisis care training international (ccti’s), for whom i work, has developed resources and curriculum focused on healing children of trauma, child soldiers, children with hiv/aids, orphans, street children and children with disabilities across the globe. in 2013, the ccti founder, dr. kilbourn, published a book, “let all the children come,” written about children with disabilities. now, i am writing the ccti curriculum to help christian workers, like missionaries, to understand the multi-faceted needs of children with disabilities, not only to understand children with disabilities, but also to learn how to build ministries to share the love of jesus with them. before i share more about why the worldwide church needs to increase its value of and missional action toward children with disabilities, i want to share with you one reason god has called me to write on behalf of children with disabilities — i was one myself. the night i was born, a newborn had already died in the hospital. my mom had a quick delivery, and i was pronounced a 10 on the apgar scale. that’s a perfect score by the way. but thirty minutes after birth, i was found by a nurse black and blue in my crib. i had stopped breathing, and within critical minutes, my brain was starved of oxygen resulting in mild cerebral palsy. i know, without a shadow of a doubt, that almighty god was with me in those very moments. at age two, i still was not speaking. my parents took me to a speech therapist named carol, and she became a central part of my life. in fact, one of my earliest memories is with carol, probably around age three. my memory is that i could not pucker to make the “sh” sound, like in “shoe” or “show.” so carol was trying to motivate me to pucker in a fun way by putting lipstick on me. i saw carol two to three days a week for thirty minutes at a time for the next ten years of my life. however, at age 12, i told my parents “no more!” i was the first child in my school district to be mainstreamed with multiple physical needs. my parents, along with carol, had to strongly advocate for my needs in school. the school provided speech, occupational, and physical therapy. but my greatest difficulty in school was handwriting. i had a black typewriter that followed me from 3rd grade until 12th; but not everything in school can be done by typewriter. kids were very cruel. i was called retard or cripple. kids mimicked the way i talked and walked. my mom asked a girl scout leader if i could join her troop. it was a troop that most girls from my grade attended. the leader told my mom, “no, because the girls need a break from natalie.” one year, i won first place in the science fair. kids destroyed parts of my project. even in youth group at church, a boy mimicked the way i ran in a game. i frequently cried at school. i always was deeply embarrassed about crying at school, none of the other kids ever did. but as i look back, i realize that i was often physically overwhelmed, bleeding inside from being different and reeling from painful rejection. but when jesus came into my life at age 11, my physical struggles did not end. he came to walk with me in my struggles. he changed my heart forever by giving me joy and hope. he has never left me through depression, nor through having a genetic form of arthritis as an adult, nor 62 flickner nov 2015. christian journal for global health, 2(2):61-63. through eye problems resulting in glaucoma. he is my strength and my hope. there are estimated 95 million to 150 million children in the world who have disabilities. when i say children with disabilities, i am talking about children with spina bifida, down syndrome, autism, cerebral palsy, or any other condition at birth. i am also talking about children who have fought as child soldiers, children who were exposed to war, or child laborers who have lost arms, legs, or eyes. similarly, children who have had accidents in life that left them paralyzed or injured. like me, they desperately need the lord jesus christ as their savior from sin and his radical promise of eternal life. god wants these children, the least of the least, to hear his good news and taste the sweetness of a relationship with him. why are these 95 million children the least of the least? let me tell you. as unicef states, “they are one of the most in need, most vulnerable, and most marginalized groups of children in the world.”  they are often declined needed healthcare and basic education.  they tend to be impoverished throughout their entire lives.  they endure lives of prejudice, discrimination, and social exclusion.  they are extremely vulnerable to abuse and exploitation. i had excellent therapy which allowed me to do my best in life. they don’t. without needed therapy, they can’t gain skills like walking, talking, and feeding themselves. in my research, i have read and seen countless stories of children spending their lives in bed or on the floor without the ability to walk, go outside, play, or interact with others. one video tells the story of a boy with polio in a crowded camp in africa crawling on his hands and knees through muck to visit the latrine before receiving a bucket for personal use. can you imagine being that boy? i had a great education. they don’t. millions are never allowed to go to school. authorities don’t want them in school because they think children with disabilities will not go far in education, so why bother? do you know, that through the un, over 100 countries signed and passed laws in 2006 for all children with disabilities to be allowed to go to school? but since that law, little to nothing has really changed for children with disabilities. although seculars see and acknowledge the problem, i believe the only true hope for children with disabilities is through the hope and love of jesus through the worldwide church. but has the worldwide church acknowledged the dire need of children with disabilities? i had kids make fun of me. around the world, whole societies shun children with disabilities. in fact, some parents are so ashamed of having a child with a disability, they never register the child with the government. many never leave the house. and when they do, not only do children reject them, but also adults. of course the societal rejection that children with disabilities face is not a direct consequence of disability but rather the society’s inability to adapt. god’s people should be leading the charge against cultural norms and modeling acceptance of children with disabilities. i was heartbroken as a child. they are too. i grieved my physical losses. they do too. in fact, children with disabilities have a higher risk than other children for emotional difficulties like depression and anxiety. this fact should cause the church to recognize that childhood disabilities affect the whole child, not just the physical. therefore, ministries should not only help children physically but also help them thrive socially, emotionally, and educationally. they should be seen as children who have the potential to powerfully affect their homes, communities, and even the world. i heard the name of jesus and responded. do they? churches overseas often see children with disabilities as demon-possessed or results of sin. 63 flickner nov 2015. christian journal for global health, 2(2):61-63. because of wrong theology, these children are often forgotten by the church of jesus christ. but, jesus himself has not forgotten them. listen to isaiah 61:1-4: the spirit of the sovereign lord is on me, because the lord has anointed me to proclaim good news to the poor. he has sent me to bind up the brokenhearted, to proclaim freedom for the captives and release from darkness for the prisoners, to proclaim the year of the lord’s favor and the day of vengeance of our god, to comfort all who mourn, and provide for those who grieve in zion — to bestow on them a crown of beauty instead of ashes, the oil of joy instead of mourning, and a garment of praise instead of a spirit of despair. they will be called oaks of righteousness, a planting of the lord for the display of his splendor. children with disabilities are often poor and the broken hearted. but jesus came to free them. he yearns to give them strength and hope in this world. with jesus in their lives, children with disabilities transform from being labeled as weak to becoming strong in faith and unwavering instruments of love. i see endless opportunity for god to change this world not only for children with disabilities but also through children with disabilities. most likely, there are more organizations in the world today that holistically engage children with disabilities than ever before. some of these organizations are compassion international, world vision, and joni and friends. regarding children with disabilities, world vision’s director of education and life skills, linda hiebert, said, “can we ever truly make up for the time we’ve already lost with the world’s most vulnerable children? the answer has to be yes, but it will require everything we’ve got.” i propose that “everything we’ve got” includes both additional organizations and every individual church throughout the world. individual churches need to acknowledge the vast needs of children with disabilities, be willing to welcome them, and be a creative bridge between them and the world. church, look into the horizon. imagine all children with disabilities all over the world physically strengthened, included in education, valued in society, emotionally encouraged, and spiritually vibrant! children with disabilities are worthy as god’s children to be equipped to reach their potential and to be celebrated as indispensable contributors to the world-wide church. peer reviewed competing interests: none declared. correspondence: natalie ann flickner, crisis care training international. natalieflickner@gmail.com cite this article as: flickner na. a call to the church: embrace children with disabilities. christian journal for global health (nov 2015), 2(2): 61-63. © flickner na this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:natalieflickner@gmail.com http://creativecommons.org/licenses/by/3.0/ editorial nov 2015. christian journal for global health, 2(2):1-4. interdependence: a new model for the global approach to disability nathan grills a a mbbs, mph, dphil, associate editor, cjgh; nossal institute of global health, university of melbourne, australia disability affects over one billion people worldwide. the world health organization (who) estimates that over 80% of individuals with disability live in low and middle income countries, where access to health and social services to respond to disability are “limited for all citizens.” 1 disability is a growing area of importance in global health, which was demonstrated by the development and adoption of the un convention on the rights of persons with disabilities 2006 (crpd). 2 addressing disability is becoming more widely recognized as critical to promoting global health and development in low resource settings. to achieve many of the sustainable development goals (2015), the international community will need to improve their response to disability and more effectively include people with disabilities. 3 the church and christians working in global health can play an important role and are increasingly doing just this. a number of examples of recent national and global christian disability movements are described in this journal. 4 field reports by foxell, flickner, and paulraj demonstrate how short and long term disability ministries can be effective. there are also increasingly more courses available such as what hall describes in uganda to teach those christians in global health how to be disability inclusive. 5 the who defines disability as “the interaction between a person’s impairments and the attitudinal and environmental barriers that hinder their full and effective participation in society on an equal basis with others.” 2 this definition of disability highlights the challenge to the global health community and helps us understand the evolution of various paradigms or models of disability. this definition goes beyond mere healing or the medical model whereby the disability is seen in medical terms as something undesirable to be fixed or minimized. 6 it also goes further than the charitable model, whereby people with disabilities are merely an object of help, an approach that the church has perhaps championed with the best intentions and often with a positive impact. 7 the who definition promotes a social model. that is one which requires societal attitudinal change and modification of disabling environments in order to facilitate those with disability to be independent and empowered. the social model of inclusion is helpful, but i think it is inadequate and based on the western collectivist idea of promoting independence and autonomy as the ultimate endpoint within a society. we as christians should go further. sandin in this issue describes how explanatory models of disability and societal position can be thought of along the individualist-collectivist axis. he muses that “the ninth beatitude might have been blessed are those that do for themselves, for . . . ” because the dominant western individualist approach to disability has led to services that elevate independence and autonomy as the ultimate endpoint. however, such a paradigm is incongruent in a more collectivist society, which is what exists in most low and middle income countries (lmics). i believe that the social model of understanding disability is also inadequate for a biblically informed community. at its best, a collectivist approach to disability would not so much fear dependence but acknowledge it as a normal part of life and something that can bring value and respect to the individual. for example, we recently undertook a disability measurement study in india — a http://journal.cjgh.org/index.php/cjgh/article/view/84 http://journal.cjgh.org/index.php/cjgh/article/view/76 http://journal.cjgh.org/index.php/cjgh/article/view/87 http://journal.cjgh.org/index.php/cjgh/article/view/80 http://journal.cjgh.org/index.php/cjgh/article/view/66 2 grills nov 2015. christian journal for global health, 2(2):1-4. country that can be described as collectivist. it involved asking key informants from the community to identify those with disability. we then used our own self-assessment disability measurement tool. many of those identified as disabled through key informants, especially the elderly, did not have a disability when they assessed themselves. this was because their functioning in society was not impaired by their old age loss of physical function, but was instead accommodated by family and the community. a friend from the field commented insightfully that for many indians the “endpoint of striving for independence and autonomy is actually loneliness!” vanier would go even further, concluding that “isolated we die.” he says: but of course people cannot live in isolation and in such extreme individualism. everybody needs friends or companions. a certain togetherness or belonging…..is an integral part of the human nature. 8 dependence on each other, that is interdependence, can build community, increase social interactions, and, therefore, can promote emotional wellbeing. i have recently proposed that a new model needs to be considered. 9 it is a model which goes beyond the medical, charitable, or social frameworks and which views community and friendship as essential to both the provision of services and to the ultimate wellbeing of those with disability. this model, which i have named the interdependence model, values community and inter-reliance as a goal of disability work. such an alternative perspective challenges the underpinnings of disability care in the west; i believe it should challenge the way we as christians interact with disability in the global disability sector. for those who work in disability and rehabilitation, this model should change how we think about our interventions, service delivery, and program goals. such interdependence, which gives this model its name, is not merely functional interdependence, but also the interdependence that exists between friends. in support of this model of disability, the lausanne movement cape town commitment captures the importance of going beyond a merely social model and encourages friendship: “. . . both in society and in the church. god calls us to mutual friendship, respect, love, and justice.” 10 this is what jeff mcnair touches upon in his article in this edition entitled “disability and human supports” where he explains that government social services, where workers are paid to be caring, can never be defined as friendship. friendship cannot be defined as charitable acts where we associate with a person with disability in response to their need. that is not friendship but charity. friendship by definition is bi-directional and interdependent. the interdependence model privileges the idea that a person with disability exists in a community to which they contribute and from which they receive assistance. without this community and without including the vulnerable we hurt ourselves and our community. we all lose. typically, the dependence of those with disability is often physical, and perhaps the dependence of those without disability might be more emotional or spiritual. for example, my five year old daughter abby has a profound intellectual and physical disability, and she is entirely dependent on my wife and me and on medical interventions to survive. however, in terms of my spiritual and emotional growth over the past five years, i think i have been more dependent on her than any other person or thing in my life. that is, my daughter and i are truly interdependent. i would not be the person i am and not fulfill my potential without her ministering to me. and for the church, the “seemingly weaker parts are indispensable” (1 corinthians 12:22, niv), and these make the church a “place of belonging; it is a place of love and acceptance; it is a place of caring; it is a place of growth in love” whereas “individualism and materialism lead to rivalry, competition and the rejection of the weak.” 8 perhaps our focus on promoting autonomy ultimately devalues and decreases the wellbeing of a person with disability or may even lead to rejection. http://journal.cjgh.org/index.php/cjgh/article/view/86 3 grills nov 2015. christian journal for global health, 2(2):1-4. from a christian or biblical perspective, i believe that the ultimate endpoint in disability care is more aligned with that of a non-western collectivist perspective. the body of christ is one that is interdependent. a biblical model needs to go beyond just changing society to accommodate for people with disabilities: it needs to move towards acknowledging that they play an important part in our community and indeed in our church. the interdependence model is a picture of a healthy church. we each rely on each other. there is love and friendship between all parts. we build each other up. we live together and care together. we work together and are ultimately more effective in our mission. all of us, with and without disabilities, need the love, care, and acceptance of others in the community of christ. this community is vividly described in the bible in 1 corinthians 12:12-28. when each part plays its role and depends on each other, we are a truly healthy, a more biblical and a better society. the cape town commitment supports paul’s imagery in 1 corinthians by means of the following: we encourage church and mission leaders to think not only of mission among those with a disability, but to recognize, affirm and facilitate the missional calling of believers with disabilities themselves as part of the body of christ. 10 in terms of church inclusion this is the ultimate endpoint that i think we should aim for in our health programs and churches. our mission and the mission of the church is not primarily to provide comfort or good teaching, although this is important, but it is to be outwardly focused, to be reaching out with the love of christ as in luke 14:13. if we are to be effective in that mission then we need to allow every part of the body to contribute. those with disability have a calling as part of this body. this interdependence model could be easily rolled out through churches across lmics to promote wellbeing and spiritual health. high cost technological and medical approaches to disability compounded by poverty are often expensive and out of reach of many with disability. yet, the interdependence model – which can be undertaken at low cost by all christians, can be easily adopted by church congregations and health missions. this model accepts that people with disability can be healthily dependent upon family, community, and church. whilst this must not be used as a relativist justification to deprive people of expensive aids and appliances, it does not make these items indispensable for wellbeing. similarly, i acknowledge the importance of autonomy for a person with disability and the useful aids and procedures to promote it. however, for any of us, independence is not healthy when it impedes our interdependence within the body and our dependence on christ. independence is not the ultimate aim or endpoint for us who believe in the body of christ on this earth. in a world with increasing numbers of people with disability and incurable diseases, and where those with disability are increasingly from low resource settings, churches and christians in global health need to not only provide services but also reach out and include those with disability. we need to promote the dignity and value of those with disability as created in god’s image and ultimately a mutuality and friendship between every part of the body of christ. that is the interdependence model. yet, such an approach could be costly, as it challenges existing structures, biases, and traditional roles in the modern church and our christian global health organizations. it may turn the church upside down, whereby the seemingly weaker and foolish things (“thing that are not”) shame the wise (“things that are”) (1corinthians 1:27-28, niv). yet, i believe that diversity and interdependence in our church and our global health movement is a foretaste of heaven. it’s a picture of the great banquet (luke 14). references 1. who. who director general’s message on the international day of persons with disabilities. 2014 [idpd, 2014] 2015 [ [cited 2015 aug 26]. available from: http://www.who.int/disabilities/en/ http://www.who.int/disabilities/en/ 4 grills nov 2015. christian journal for global health, 2(2):1-4. 2. un. convention on the rights of persons with disabilities. 2006 [cited 2015 aug 26]. available from: http://www.un.org/disabilities/convention/conventio nfull.shtml 3. united nations. transforming our world: the 2030 agenda for sustainable development. a/res/70/1. 2015. available from: https://sustainabledevelopment.un.org/post2015/tran sformingourworld 4. james sn, grills n, and varghese j. engage disability conference report. christian journal for global health. may 2015;2(1):75-9. summary available at https://www.youtube.com/watch?v=wudvkse2o5a 5. joni & friends international disability center. beyond suffering advanced studies: a christian view on disability and healthcare. available from: http://www.joniandfriends.org/bys/ 6. drum c. models and approaches to disability. in: drum ce, krahn gl, bersani h editor. disability and public health. washington dc: apha; 2009. p. 29. 7. the moral model, referred to by mcnair in his article in this issue, is one that is seen rarely in modern western societies, but it still plays a role in non-western societies and is one that the church needs to fight to overcome. 8. vanier j. community and growth: st paul’s press; 1991. 9. grills n, in preparation. 10. birdsall d, brown l. the cape town commitment: a confession of faith and a call to action. [movement l, editor]. : hendrickson publishers; 2011. p.44 competing interests: none declared. dr. grills is associate editor of cjgh correspondence: nathan grills, university of melbourne, australia. nathangrills@gmail.com cite this article as: grills n. interdependence: a new model for the global approach to disability. christian journal for global health (nov 2015), 2(2): 1-4. © grills n this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.un.org/disabilities/convention/conventionfull.shtml http://www.un.org/disabilities/convention/conventionfull.shtml https://sustainabledevelopment.un.org/post2015/transformingourworld https://sustainabledevelopment.un.org/post2015/transformingourworld https://www.youtube.com/watch?v=wudvkse2o5a http://www.joniandfriends.org/bys/ mailto:nathangrills@gmail.com http://creativecommons.org/licenses/by/3.0/ original article widows’ self-help groups in north india: a tool for financial and social improvement arun sharmaa, nicole bishopb, nathan grillsc a bbiomed, md, melbourne school of population and global health, university of melbourne, australia b b.app.sci, miph, research fellow, nossal institute for global health, melbourne school of population and global health, university of melbourne, australia c mbbs, mph, dphil, professor, nossal institute for global health, university of melbourne, australia; senior research advisor, australia india institute abstract background and aims: widows in india face immense challenges through enduring abuse, discrimination, and poor financial opportunities. whilst there are many nongovernmental organisations (ngos) undertaking women’s empowerment programs, there is a paucity of literature reviewing their impact. project sampan, located in uttarakhand, india, started by helping widows form self-help groups and provides financial education and agricultural skills training as well as group and private counselling. this study aims to evaluate the experiences of participants in the sampan widows’ empowerment program. methods: this qualitative study involved conducting seventeen semi-structured interviews between february to march of 2021; fifteen with participant widows and two with program facilitators. widows who were minimum of 18 years of age and had 18 months of involvement were included. participants were recruited through convenience sampling. thematic analysis was undertaken to generate common themes relating to the impact of sampan on the widows, and triangulation of this data was also conducted with observation diaries kept by program facilitators. results: the evaluation revealed four key themes. firstly, it was found that the agricultural education sampan provides changed widows’ daily practices, leading to improved produce as well as corresponding sales and an increased opportunity to partake in community business. this has helped improve widows’ confidence, agency, and independence. furthermore, the microfinancing component of the sampan program was consistently found to be a strength of the project, providing widows with financial security. their improved productivity and contribution to their communities has led to increased recognition by society, helping to mitigate some of the social stigma surrounding widowhood. the sampan program has also strengthened solidarity among widows through opportunities to socialise together. conclusions: this evaluation describes the plight of widows in uttarakhand, who have been historically excluded and financially vulnerable, but are growing in confidence and emancipation though their involvement in sampan. this study serves to underscore the existing literature about the discrimination indian widows face and demonstrate the value of self-help groups in empowering widows. 3 sharma, bishop & grills dec 2022. christian journal for global health 9(2) key words: widows, empowerment, india, stigma, financial independence background and aims estimates indicated that there were at least 55 million widows in india in 2017, thus greater in number today.1 whilst traditional practices such as sati (widow burning) are illegal,2 many widows face what has been referred to as “social death.” widows continue to be victims of abuse by family or community members.3 this is compounded by a lack of public concern for the deprivations experienced by indian widows.4 they often experience economic discrimination, alienation, exclusion from social functions, and feelings of hopelessness.4,5 in north india particularly, widows face immense difficulties in seeking gainful employment and receive little social support, culminating in poorer health and higher mortality levels than the general population.4 there is only a small body of literature pertaining to the impact of widows’ empowerment projects in india, despite many ngos and the government undertaking widows’ empowerment activities. empowerment has been defined as a multi-dimensional process through which a widow improves her wellbeing and standing within society.6 the term “empowerment” itself has been criticised at times, however, for creating ineffective programs that ignore material needs of the women and instead aim for a “blanket form of empowerment for all.”7 many existing widows’ programs in india focus on financial and economic empowerment, particularly through self-help groups (shgs). shgs were promoted by the reserve bank of india in the early 1990s and involved community members co-investing into savings and credit groups. subsequently, a microfinance movement was birthed,8 propelled by a belief that economic resourcefulness was an effective way of ensuring social protection.9 evidence shows that the most effective component of women’s empowerment efforts is economic (defined through a widow’s income, primary activity, independent savings, investment in home improvements, confidence to meet financial crisis and arranging of credit) and is twice as effective as developing a woman’s autonomy (independent management and decision making).10 project sampan is located in rural north india, and adopts something akin to a “microfinance-plus” approach to empowering widows, wherein “important inputs like literacy training, farming inputs or business development services” form part of the initiative.11 sampan has been running health and education programs in uttarakhand state since 2006 and began working with widows in 2016. the project started by providing informal financial literacy training to widows and helping them form shgs. now, it operates at four sites in the rural, mountainous regions of uttarakhand, running monthly meetings with training and follow-up support. led by two volunteers experienced in community development, the meetings had topics including agricultural skills, government financial schemes, and health issues and were responsive to the needs and opportunities arising. in addition to basic support for undertaking livelihoods activities, sampan offers informal private counselling where widows are able to debrief with their program facilitators, particularly around domestic stressors and their mental wellbeing. widows also pool funds for their shg when they gather and are able to take loans. to join the program, women’s financial status, home situation, and family support are assessed by program facilitators who prioritise those deemed to be in highest need, e.g., those with school-aged dependents or facing financial hardships. these eligibility factors are verified by panchayats (village governing body members), village pradhans (panchayat-elected leaders), and community health volunteers. the paucity of literature related to the effectiveness of widows’ empowerment projects beckons further research.12 this study evaluates the experiences of participants in the sampan widows’ empowerment program, assessing the kinds of sharma, bishop & grills 4 skills, attributes, and material gains resulting from their involvement. methods seventeen semi-structured interviews (ssis) were conducted in february to march of 2021 of which fifteen were with participant widows and two were with program facilitators using two separate ssi guides. the ssi guide for widows was pre-tested and subsequently updated. questions asked about widows’ experience with sampan, the nature and content of meetings, changes to widows’ livelihood since their involvement, and changes in community, social, and family relations. the interviews also gathered basic demographic data and explored information related to life goals and their perceptions of sampan and its work. for program facilitators, the questions additionally sought information about their perceptions of the impact of sampan’s activities, changes in widows’ attitudes, and areas for improvement. convenience sampling was used to recruit widows, according to the inclusion criteria of a minimum age of 18 years and a minimum of 18 months involvement in the program. widows agreed to participate after being informed about the nature of the evaluation. all three of the program facilitators participated in the interviews. interviews were conducted by ps who works for another local ngo and speaks fluent hindi, garhwali, and english. all interviews were audiorecorded, transcribed, and translated into english. one interview was stopped as the participant became emotional when discussing a personal situation, although her responses were included in analysis. a priori codes were applied to the interview transcripts, and thematic analysis generated common themes relating to the impact of sampan on the widows.13 sampan’s project manager corroborated the final themes.14,15 results participants generally reported a positive experience of being involved in sampan, emphasising various practical benefits (financial and educational initiatives) and social/emotional benefits (improved confidence, identity, and social standing). thematic analysis of the interviews revealed several themes, presented under a theory of change that suggests the knowledge and practices widows gained led to their empowerment and financial security, which helped improve their social standing and relationships. knowledge and practices training drives widows’ agricultural practices several interviews cited educational benefits of the intervention. the program coordinators emphasised the delivery of training in agricultural techniques, explaining that it had helped widows “grow and eat…nutritious food,” which is particularly important given many “suffer from deficiencies of vitamin a, iron, and other nutrients.”(f2) training improved agricultural practices and in turn improved produce quality and quantity and corresponding sales and income. participants cited some examples: “they taught us about fertiliser, how and when to sow the seeds and take care of them. they taught us a lot, and that benefitted us.”(w12) another participant mentioned, “there is a way to sow the seeds and spray the pesticide. we got information…we did not know anything earlier.” they went on to say that they now make their gardens with “proper gaps for maintenance and tilling” leading to a “good produce.”(w07) empowerment widows have gained confidence, agency, and independence involvement in the program has lifted widows’ self-esteem, given them confidence, and reduced their sensitivity to others’ opinions. one widow said, “i am not bothered by what other people think or say. i used to feel bad, but now i do not care about those people. it doesn’t affect me anymore.”(w04) many were afraid to be seen or to even speak in public, one saying, “when anyone said anything, i would be quiet.”(w07) one explained her increased ability to contribute to community discussions, saying she felt more confident and willing to speak up. another 5 sharma, bishop & grills dec 2022. christian journal for global health 9(2) demonstrated her growth in confidence in saying, “we women can do anything.”(w07) increased agency, being the ability to define one’s goals and act upon them16 was demonstrated by several respondents. one spoke of her newfound motivation, “when i got help from the group, i was motivated that i can do something. now i have courage.”(w07) similarly, another stated, “i feel good. [since] i joined this group, i am working and earning for myself. no one can say, ‘she can’t do anything.’”(w06) additionally, widows “now believe that they are capable of doing things for their families and are confident,” and they are “thinking for themselves.”(f2) one participant’s increasing independence was highlighted in her comment that, “i did not want to learn sewing when my husband was there, but now i have learned to sew and work in ‘rozgar guarantee’ [(national rural employment guarantee scheme)] so that i can run my family.”(w12) a program facilitator agreed that “most of them…have [begun] making decisions for themselves and their families.”(f2) financial security self-help groups pool funds, providing widows with financial security widows conveyed that the microfinancing component was one of the highlights of the program, and that it provided security, some respondents disclosing that they had accessed funds from their self-help group. participants said that having access to pooled funds assured them of financial security in case of future needs such as family weddings, house repairs, or children’s education. one summarised, it provides “surety...we have help in the future when we need it.”(w10) they noted the way the self-help group has prevented them from being reliant on others. “we do not have to go to others when we have a problem; we get help from our group.”(w07) “the women feel proud of themselves, that they were able to help another woman,” said a program facilitator.(f2) one respondent spoke of a situation where she had nothing to eat, and “had huge help from the group” who leant her rs 10,000.(w13) another widow had difficulties “bearing the expenses” after her son lost his employment, and “took a loan of rs 5,000 from the group…to [help meet] the other expenses of the house.”(w12) the value of this system of charitable loaning was particularly relevant to participants during the covid-19 pandemic, as families faced loss of employment and physical separation due to lockdowns. importantly, honing financial skills and gaining financial security provided opportunities for independence for widows facing a context of stigma and distrust. one respondent stated, “no one gives you money in the village; they question whether she will return it.”(w06) one woman turned rs 800-1,500 worth of seedlings into rs 10,000 worth of cucumbers and sold them at market, demonstrating that the sampan's material provisions (of seedlings, in this example) helped widows earn money to pay for household expenses and other necessities like school uniforms and books. social relations widows’ empowerment has helped address underlying social stigma around widowhood social stigma had been present within the marital family and in the community: • “[our marital families] thought of us as a burden. they thought that we depend on them.”(w07) • “[my family] did not allow [me to leave the home] because i was a widow and should not go anywhere.”(w05) • “they also used to taunt and say bad things about us.”(w13) one woman claimed that widows like herself were considered a “bad omen” by the community.(w04) however, widows reported decreasing stigma and increasing community acceptance and the program facilitators conveyed that villagers now took notice of the widows and their social and financial progression. participants generally attributed changes in social perception to the opportunities they had gained from involvement in community trade through sales of vegetables, sharma, bishop & grills 6 thanks to the provision of agricultural training/ education and goods. some alluded to new opportunities to participate in community and social events due to their improved economic engagement and improved public opinion. program facilitators cited the example of a “lower caste” widow whose contribution to the sampan program, “has made people realise her worth.” this has positively impacted her social life, and now, “she is invited and participates in all functions and events in the village, like weddings and so on.”(f2) widows have formed a sisterhood and gained valuable social connections sampan has created social networks for widows. in turn, they have gained a sense of belonging and camaraderie amongst themselves, which was reported by most participants as a major program benefit. several widows used the term “sisters”: “we come here and share like sisters,”(w07) while another mentioned that they “share our joys and sorrows with our sisters from different villages.”(w08) again, by contrast with their prior social exclusion, the program provided an opportunity for socialising: • “earlier i used to do only household chores. i used to feel lonely.”(w01) • “we used to live separately and had no social interactions.”(w13) moreover, widows reported being able to confide in one another, stating that they are, “able to listen to and share each other’s concerns.”(w04) one said, “the best part is that we meet sisters from all the villages and share about our difficulties and problems.”(w04) similarly, program facilitators commented, “women from different villages who wouldn’t have met otherwise, build friendship and [a] support network for each other. they laugh and share with each other, and we see the happiness on their faces. the coming together in groups has given women comfort and assurance that they are not alone.”(f2) widows have adopted the program’s culture of kindness within the practical skill-based teachings, sampan facilitators include value-based education. one coordinator said, “most of our teachings include how they can love and care for everyone.”(f2) women acknowledged this component of the gatherings, one participant saying, “i learned to pray for myself and others. to live with love.”(w12) this aspect of living in partnership was reflected in the comments of another participant who said, “we should not feel that we are from different villages. we should not discriminate. we think that we are from the same family.”(w06) they went on to say, “i learnt that we should not discriminate. everyone is equal. god created everyone equal, so we should not discriminate.”(w06) a program facilitator cited an example of a widow who previously had a very “self-centred approach.” he spoke of how she used to demand money for teaching other women about tailoring and stitching, but now offers free training.(f2) thus, group members have developed “mutual support and love.”(f2) discussion the themes raised in this study underscore existing evidence about the plight of widows in india, which is characterised by social stigma, marginalisation, and financial hardships.4,5,17,18 social stigma around indian widows is well documented, noting the “social death” that widows particularly in north india may face.17 it is accompanied by the attribution of discriminatory labels like “evil eyes” and by perceptions that widows carry “ill fortune,” creating significant barriers to their social inclusion.18 indeed, widows in our study frequently described their experiences of taking on an inauspicious status and being marginalised after the death of their husband. they reported being labelled as “omens,” being excluded from social celebrations, being verbally “taunted,” and having restrictions imposed on their physical movements. in stating that they feel they are a “burden” and of no worth to family members and the community, study participants effectively alluded 7 sharma, bishop & grills dec 2022. christian journal for global health 9(2) to their vulnerability, through marginalisation, to economic challenges. speaking of finances more than any other topic, our respondents also provided insights to support evidence that widows experience poverty more than the general population.12 they described their financial hardships principally in terms of pressures around meeting household expenses and in the form of crises precipitated by covid-19. conversely, they described the emancipation they felt from gaining access to finances via engagement in livelihood activities and/or self-help groups. additional evidence highlights that illiteracy is another barrier to financial security for widows in india,19 and sampan factored this into its planning through incorporating literacy activities to help with financial skills as well as linguistic competency. secondly, our findings demonstrated that social stigma and financial dependence co-exist with poor confidence and low levels of social engagement. participants spoke frequently of their poor self-esteem, defined by a fear of others, lack of courage, and the acceptance of a silent role in family and community discussions. sampan tackled these issues through accessible and tailored initiatives. the training in livelihood activities (i.e., agricultural techniques) and provision of agricultural goods and materials has created an avenue for widows to participate in community business and trades. taking up formal, structured employment can be difficult for widows, due to pressures to conform to strict social seclusion after the death of their husband.20 sampan’s livelihood programs provided widows an opportunity to engage in the local economy, primarily through sales of the produce from the seeds they were provided. this facilitated the widows forming livelihoods and developed a sense of connection and engagement with their community. therefore, achieving financial security granted widows a sense of independence, which has been accompanied by growth in confidence and agency. in our study, improved financial status has empowered widows to independently plan and aspire for their families. as a program facilitator stated, i believe that when a woman’s financial status improves, she gets visibility in her community…earlier people considered them worthless but now people buy the goats or other things from them. when a woman is able to sell a goat and earn money, she gains a rise in social status too.(f2) facilitators summarised the direct impact of basic livelihood activities such as selling goats or crops: “they now believe that they are capable of doing things for their families and are confident.”(f2) their improved financial situation has helped them overcome some of the ostracising effect of stigma around widowhood. as such, the microfinancing component (self-help groups) and the livelihood activities of sampan appeared to be the mechanism of change for the widows’ improvement in financial situation and confidence. participants in our study uniformly prioritised the financial benefits of the self-help groups when asked about their experience of the program. this underscores the evidence related to the centrality of economic factors in empowering women in shgs in india.10 it also highlights the importance and practical benefits of the microfinance movement in india. microfinancing provides women greater confidence to meet potential financial crises, without which they face challenges in obtaining a loan.20 importantly, this evaluation revealed that sampan is particularly effective in its adaptiveness as well as its human-centred approach to empowering widows. qualitative studies of widows’ experiences have highlighted the loss of emotional support—defined as availability of sympathy, affection, and the option of having someone with whom to share worries.3,21 whilst structured microcredit programs have been linked to emotional wellbeing among vulnerable women,5 the social aspect of sampan provided widows with an avenue to build strong relationships, share concerns, and resolve problems collectively. the structure of the sampan meetings—starting with prayer and then allowing women to share any matters of celebration/concern—was popular sharma, bishop & grills 8 among participants and demonstrates the compassionate, harmonious approach of the initiative. studies of mental health amongst indian widows have found that widowed older adults are 34% more likely to be depressed than currently married counterparts.22 on the background of emotional vulnerability and high risk for mental health issues, the informal counselling offered by sampan facilitators creates a unique, comfortable, and comforting environment for the widows. furthermore, the adaptability of the program was identified as a major “enabler” of participation. considering the covid-19 pandemic, the teachings on health and hygiene are demonstrative of sampan’s responsive, dynamic, and beneficiary-centred approach to empowering widows. widows alluded to their reciprocating of the kindness they have received, through passing on their learnings and endeavouring to care for one another. concerning lessons in hygiene, they said, “when we keep our surrounds clean, then our neighbours will too,” demonstrating the ripening of a community-oriented mindset.(w12) the study finds that the improvements in confidence, agency, and independence for the widows in sampan have been brought about primarily through microfinancing initiatives. empowering women through livelihood trades and self-help groups has provided them with new opportunities for societal participation, and all these gains are grounded in a human-centred approach. limitations our study may be limited by selection bias insofar as study participants volunteered and made themselves available for participation. while this may have excluded the experiences of other widows, responses allowed us to achieve data saturation. while there was a possibility of widow participants reporting largely positive aspects of sampan, the study undertook to overcome social desirability bias by interviewing program facilitators and triangulating data to confirm responses and themes. further, although widows provided anecdotal evidence of their lives before involvement in sampan, we did not have any data from interviews or sources prior to their participation. due to these limitations, causality between this study’s themes may be restricted. another potential limitation arose in translating interviews from garhwali/hindi into english for the purposes of coding and analysis. should there have been some mistranslations, the ultimate english interpretation may not have captured the nuances of a particular discussion. however, again, data consistency suggests that the translations did not stray from the intended responses. there is scope for future studies to specifically focus on the impacts of sampan on the widows’ development of agency, as this remains the primary focus of the facilitators. in particular, there is potential for studies to evaluate the impact of individual components of the program (e.g. charitable loaning/education programs) on the widows’ agency, to better assess causality. conclusion this qualitative evaluation describes the plight of widows in uttarakhand, as socially excluded and financially vulnerable yet empowered and emancipated through their involvement in sampan. through empathetic facilitation, otherwise marginalised and isolated widows have gained livelihood skills, knowledge, and a network of friendship and support. the project’s microfinancing initiatives have contributed to financial independence for widows, alongside which confidence, agency, and social standing have improved. whilst underscoring the literature concerning discrimination, ostracization, and financial hardship for widows in india, this study reinforces the value of self-help groups in improving the financial security of widows. future studies may aim to examine more closely the mechanisms for emancipation and development of agency amongst the widows involved in the program. references 1. chandrasekhar c, ghosh j. widowhood in india. business line. 2017 october 9 9 sharma, bishop & grills dec 2022. christian journal for global health 9(2) 2. bhugra d. sati: a type of nonpsychiatric suicide. crisis. 2005;26(2):73-7. https://doi.org/10.1027/0227-5910.26.2.73 3. houston kt, shrestha a, kafle hm, singh s, mullany l, thapa l, et al. social isolation and health in widowhood: a qualitative study of nepali widows' experiences. health care women in. 2016;37(12):1277-88. https://doi.org/10.1080/07399332.2016.1142546 4. chen m, dreze j. recent research on widows in india: workshop and conference report. econ polit weekly. 1995;30(39):2435-50. 5. lombe m, newransky c, kayser k, raj p. exploring barriers to inclusion of widowed and abandoned women through microcredit self-help groups: the case of rural south india. j sociol soc welfare. 2012;39:8. 6. swain rb, wallentin fy. does microfinance empower women? evidence from self‐help groups in india. int rev app econ. 2009;23(5):541-56. https://doi.org/10.1080/02692170903007540 7. mastey n. examining empowerment among indian widows: a qualitative study of the narratives of hindu widows in north indian ashrams. 2009;11:191-8. 8. saha s. expanding health coverage in india: role of microfinance-based self-help groups. global health action. 2017;10(1):1321272. https://doi.org/10.1080/16549716.2017.1321272 9. chen m, dreze j. widows and health in rural north india. econ polit weekly. 1992;27(43/44):ws81-ws92. 10. bali swain r, wallentin fy. factors empowering women in indian self-help group programs. int rev app econ. 2012;26(4):425-44. https://doi.org/10.1080/02692171.2011.595398 11. bali swain r, varghese a. being patient with microfinance: the impact of training on indian self help groups. working paper series, dept of economics, uppsala university. 2010. 12. dreze j, srinivasan pv. widowhood and poverty in rural india: some inferences from household survey data. j devel econ. 1997;54(2):217-34. https://doi.org/10.1016/s0304-3878(97)00041-2 13. braun v, clarke v. what can "thematic analysis" offer health and wellbeing researchers? int j qual stud heal. 2014;9:26152-. https://doi.org/10.3402/qhw.v9.26152 14. carter n, bryant-lukosius d, dicenso a, blythe j, neville aj. the use of triangulation in qualitative research. oncol nurs forum. 2014;41(5):545-7. https://doi.org/10.1188/14.onf.545-547 15. centers for disease control and prevention. framework for program evaluation in public health. mmwr 1999;48[no. rr-11] 16. kabeer n. resources, agency, achievements: reflections on the measurement of women's empowerment. 1999:435. https://doi.org/10.1111/1467-7660.00125 17. mohindra ks, haddad s, narayana d. debt, shame, and survival: becoming and living as widows in rural kerala, india. bmc international health and human rights. 2012;12:28-. https://doi.org/10.1186/1472-698x-12-28 18. trivedi jk, sareen h, dhyani m. psychological aspects of widowhood and divorce. mens sana monographs. 2009;7(1):37-49. https://doi.org/10.4103/0973-1229.40648 19. kayser k, lombe m, newransky c, tower g, raj pm. microcredit self-help groups for widowed and abandoned women in south india: do they help? j soc serv res. 010;36(1):12-23. https://doi.org/10.1080/01488370903333512 20. reed mn. the labor force participation of indian women before and after widowhood. demogr res. 2020;43:673-706. https://doi.org/10.4054/demres.2020.43.24 21. berkman l, glass t. social integration, social networks, social support, and health. soc epidemiol. 2000;1. 22. srivastava s, debnath p, shri n, muhammad t. the association of widowhood and living alone with depression among older adults in india. sci rep. 2021;11(1):21641. https://doi.org/10.1038/s41598-021-01238-x peer reviewed: submitted 19 jul 2022, revised 30 sept 2022, accepted 10 oct 2022, published 20 dec 2022 competing interests: none declared. correspondence: arun sharma, university of melbourne, australia arshar97@gmail.com https://doi.org/10.1027/0227-5910.26.2.73 https://doi.org/10.1080/07399332.2016.1142546 https://doi.org/10.1080/02692170903007540 https://doi.org/10.1080/16549716.2017.1321272 https://doi.org/10.1080/02692171.2011.595398 https://doi.org/10.1016/s0304-3878(97)00041-2 https://doi.org/10.3402/qhw.v9.26152 https://doi.org/10.1188/14.onf.545-547 https://doi.org/10.1111/1467-7660.00125 https://doi.org/10.1186/1472-698x-12-28 https://doi.org/10.4103/0973-1229.40648 https://doi.org/10.1080/01488370903333512 https://doi.org/10.4054/demres.2020.43.24 https://doi.org/10.1038/s41598-021-01238-x mailto:arshar97@gmail.com sharma, bishop & grills 10 cite this article as: sharma a, bishop n, grills n. widows’ self-help groups in north india: a tool for financial and social improvement. christ j global health. dec 2022; 9(2):2-10. https://doi.org/10.15566/cjgh.v9i2.699 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.15566/cjgh.v9i2.699 http://creativecommons.org/licenses/by/4.0/ abstract key words: widows, empowerment, india, stigma, financial independence background and aims methods discussion conclusion references commentary considering medical missions in all its different forms – a viewpoint from the asia-pacific region nyalpi nungaraia,b, matthew paula,b, nathan g johna,b, wei-leong goha a medical doctors from the asia-pacific region b pseudonyms used for security purposes abstract whereas some medical missionaries may already have moved away from “traditional” models of medical mission, in the experience of the authors from the asia-pacific region, many potential medical missionaries in the region still imagine a stereotypical generalist medical missionary who runs a mission hospital. the authors argue that with the economic and socio-political development of lowand middle-income countries (lmics) in recent decades, the landscape for medical missions has changed. hence, contemporary medical missionaries should be well-advised to have specialist qualifications and be more likely to teach, mentor, and do research rather than only doing hands-on clinical work. professionalism and quality, rather than “make-do,” should be the norm. there are more opportunities to partner with and strengthen existing local institutions rather than setting up a christian health service. furthermore, mission opportunities may be available in academia, government, or secular organisations, including places where christianity has a hostile reception. multi-disciplinary expertise and collaboration within health services are increasingly important and provide another opportunity for missions. medical missionaries may also come from other lmics, or from within the same country. jobsharing, self-funding, or fly-in-fly-out, may be a viable and legitimate means of sending more medical missionaries. these non-traditional models of medical mission that incorporate a diversity of approaches, but without sacrificing the “traditional” missional values and practices, should allow even more people to serve in medical missions. the purpose of this paper is to survey this topic in hope of stimulating discussions on non-traditional medical mission opportunities in the asia-pacific region and beyond. key words: christian mission, lowand middle-income countries, asia-pacific region, healthcare 43 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) introduction thinking about obstetrics fills me with dread, but how can i learn to do caesareans because i want to be a missionary doctor? i’m just a pharmacist, so i guess i need to go to medical school first before i can be useful on the mission field. i’m planning to go out into the mission field as a doctor as soon as i graduate, and i’ll figure it out when i get there. should i quit my job as a doctor and serve god full time? what’s the best specialty for me to choose if i want to be a medical missionary? why are all the speakers at yet another medical mission event all men, when more than half the audience are female medical students? these are comments and questions we have heard from committed christians in the asia-pacific region in recent years who are keen to serve the triune living god in a cross-cultural context. these comments and observations highlight for us that for many in our region, the term “missions” is still associated with a romantic and often outdated stereotype. the term “medical missionaries” may still conjure a mental image of white men as “jungle doctors” who joined mission agencies, were self-taught generalists, went to remote “third world” settings, made-do with whatever they had, single-handedly ran a missionhospital, worked all day and all night, learnt how to perform different surgeries (sometimes even from a textbook in the operating theatre), preached the gospel in all spare moments, rarely returned to their home countries, and had a supportive wife who home-schooled their children and quietly taught the bible to local women. this may sound antiquated to many readers in the north american context, which continues to send by far the largest numbers of missionaries.1 however, in our own experiences of exploring mission opportunities, being sent out, and talking with our juniors, we have found that this stereotype is often very much alive in the asia-pacific region. hence, when we suggest that it is possible to be a missionary in the form of an academic researcher, a government employee, an allied health professional, or a specialist in a particular field of health, we are often asked “how is that possible?” those roles may not fit with the traditional missionary stereotype in the minds of many. the purpose of this article is not to exhaustively review the many complex issues associated with health mission. rather, we intend to discuss issues that are relevant to christians in our region who are interested in missions. for each issue, we could give many more examples of people who are involved in non-traditional missions, but for security reasons, we have minimised personal anecdotes. a changed state of the world globalisation, industrialisation, migration, and urbanisation have rearranged human geographies and blurred traditional boundaries between missionary sending and receiving countries. this is evident in many of our settings in the asia-pacific where there is no longer an obvious axis from the “christian, developed west” to the “non-christian, underdeveloped third world.” many countries that traditionally received missionaries have undergone tremendous economic development, while countries that were historically christian are rapidly becoming more secular, with increasing socio-economic inequalities within highand middle-income countries. national healthcare systems have evolved, imposing stricter standards on all health professionals. global health continues to grow as a robust field with a corpus of knowledge and best practices. international travel was becoming easier until the pandemic hit, and internet communication 44 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) continues to be become more widespread and convenient. yet, half of the world’s 7.3 billion people continue to experience unmet health needs,2 and millions have yet to hear about the living triune god. non-traditional sources of medical missionaries as the “west” becomes increasingly postchristian, the centre of gravity of global christianity has moved to what were traditionally missionsreceiving countries.1,3 therefore, in many lowand middle-income countries (lmics), the increasing numbers of locally-trained health professionals are likely to be the best source of medical missionaries to the remote, under-developed, and underevangelised regions of the same country. compared to international missionaries, they have minimal visa requirements, a smaller cultural gap, possibly a smaller language gap, and therefore, may have fewer barriers and a higher probability of effectiveness. some of these job opportunities for medical missionaries in under-served areas of their own country may even be in government positions (see below). there are also many opportunities for migrants or children of migrants to return to the family’s country of origin, where the cultural and linguistic gap may also be smaller. indeed, in some parts of the world, national graduates of training programmes that were set up by international missionaries are already quietly but faithfully serving their own countries missionally.4 for example, south indians are the biggest source of missionaries to north india, and there are many indians with overseas citizenship who serve as missionaries in india.5 as lmics develop and churches in those countries mature, those countries will become not only the recipients of missionaries, but they are also likely to send missionaries to other lmics or even to high-income countries (hics).1 medical missions and missions in general are no longer characterised by the stereotypical fair-skinned person from a wealthy country serving a dark-skinned person in an impoverished country. accordingly, the medical missions discourse should revisit its frequent assumptions of what “sending” and “receiving” areas are, acknowledge the growing role of “nonwestern missionaries,” and attend to their needs.6 professionalism and quality in the past, when mission hospitals were often the only source of healthcare for large segments of a population, the focus was usually on providing basic and accessible healthcare. they were usually staffed and led by foreign missionaries who provided free or highly subsidized care. as the world has changed rapidly in recent decades, so has this model of traditional mission hospitals and medical missionaries. firstly, the model of mission hospitals in the “third world” financed by christian patrons in the “west” is now obsolete as many hospitals have nationalized their staffing and management and follow a local financing model.7 secondly, in the past, often the appropriate goal of missionaries was to provide some form of health service where there was none. they made-do with whatever resources were available, and in contemporary healthcare jargon, the focus was on accessibility and not necessarily on quality. in the current era, “making-do” should no longer be the goal when high-quality health services are becoming more common in lmics; even though such services may be out of reach for many people due to geography or finances, there is an awareness and hence desire for such health services. furthermore, research has shown that poor quality health services are now responsible for more mortality globally than the lack of access to health services;8 therefore, contemporary missions health facilities should not simply provide accessible health services, but they should also aim to provide high-quality health services supported by appropriate clinical 45 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) governance. establishing and strengthening quality systems is undoubtedly a longer and harder task than for an outsider just to jump in to provide a better service. thirdly, with advances in technology and changes in social and cultural values, society’s expectations of doctors everywhere are rising. hence, health systems and health professional education are also changing9 and aiming to reach higher standards.10 eight hundred new medical schools started worldwide between 2000 and 2014,11 family medicine is a growing medical speciality around the world,12,13,14 as are other specialties. improving the quality of healthcare is on the agenda,15 including striving to reach international accreditation standards,16 even in low-resource settings. with all these changes, lmics are justified in being selective about which outsiders they allow to help. in the past, the stereotypical missionary doctor was a “super-generalist” — a self-taught and competent physician, surgeon, obstetrician, anaesthetist, and paediatrician who treated all conditions while preventing diseases and injuries by running community health programs. however, given the rising patient expectations for specialised care, the rapid expansion of evidence-based medicine, and increased regulations, the self-taught generalist may now be the exception rather than the norm. it is, therefore, most likely that contemporary medical missionaries should expect to undergo standard specialist training in their home countries before going on the mission field, unlike in the past where many missionary doctors often had little more than a basic medical degree and a few years of basic hospital training in their home country. this would mean, for example, a radiation oncologist’s mission field would be in an urban teaching hospital, and a missionary with a higher degree in community health would work in a rural area or urban slum. as specialists, medical missionaries should be expected to maintain their skills and specialist licensing/registration in their home countries, which requires time and effort. when missionaries eventually return to their home countries for a longer period, up to date specialist licensing/registration should help ensure job prospects. hence, being on the mission field for many years without returning to the home country may not be viable, and other models of missions need to be considered (see below). even if there is an apparently desperate health need, missionaries should not be tempted to rush in to set up a health program without expertise. bringing in appropriately qualified and experienced personnel to conduct a needs analysis and engaging stakeholders may take longer, but it is now the norm; as is conducting monitoring and evaluation, and there are evidence-based guidelines published for this purpose.17 the established and growing discipline of global health18 has a corpus of knowledge and best practices. furthermore, with global information connectivity, the lack of technical soundness in the set-up and implementation of health programmes, and the lack of objective evaluation, even in resource-constrained settings, is no longer excusable. god is not glorified when missionaries have good intentions but bad practice, because this harms christian witness and may turn people away from jesus. the rt. rev. dr. rowan williams, when he was the archbishop of canterbury, provided a good summary: the poorest deserve the best […] they do not deserve what is left over when the more prosperous have had their fill, or what can be patched together on a minimal budget as some sort of damage limitation […] they deserve it simply because their need is what it is and because where human dignity is least obvious, it's most important to make a fuss about it.19 46 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) health system strengthening, not necessarily service delivery and substitution traditionally, medical missionaries have been on the front line providing clinical service. as rewarding and tangible as direct service delivery may be, there is always the risk that substituting local health professionals’ roles weakens rather than strengthens the long-term capacity of individuals and institutions. also, health professional licensing/ registration requirements are becoming more stringent in many lmics, such that foreign health professionals cannot expect just to walk in and do clinical work, and this should generally be seen as a positive phenomenon. with more medical education available in lmics,11 there is less need for foreign professionals to do the job that locals are now trained to do or at least could potentially do. the contribution of missionaries in the last two centuries who set up medical and nursing schools in “developing countries” or “the colonies” must be acknowledged here. some of them retain a strong christian and mission tradition but with minimal input from foreign missionaries (for example, the christian medical colleges of vellore20 and ludhiana21 in india), while others have been appropriately nationalised in other ways. while there may be rare opportunities for missionaries to help set up new teaching institutions in lmics in the contemporary era, there is an ongoing need for undergraduate and postgraduate health professionals in lmics to have supervision, training, and mentoring from qualified specialists, both at the undergraduate and post-graduate level. senior local professionals may not have sufficient capacity to provide the support required, but missionary health professionals may be in a position to offer such a “clinical co-presence.”22 to improve access and quality of healthcare, nurses are also becoming more specialised, even in lmics.23 therefore, nurses with specialised experience and/or qualifications are more likely to be needed as teachers, mentors, and consultants on the mission field than in direct clinical service. while lmics are rapidly strengthening their capabilities in the established medical specialities of internal medicine, surgery, paediatrics, anaesthetics, obstetrics, and gynaecology, there is an increasingly recognised global need for specialist multidisciplinary care in areas including mental health and psychiatry,24 disability and rehabilitation,25 and endof-life and palliative care.26 missionary doctors, nurses, and allied health professionals (physiotherapists, pharmacists, psychologists, occupational therapists, etc.) with appropriate advanced training and skills could, therefore, have important roles in teaching and mentoring in these sometimes “hidden” or “difficult” clinical specialities to serve some of the most vulnerable in a community. doctors, nurses, and allied health professionals alone cannot be expected to deliver high quality care. non-clinical professionals including managers, administrators, technicians, engineers, epidemiologists, experts in logistics, procurement, finance, human resources, data management and analysis, information and communication technologies, water and sanitation, and media and communications are also required. they all need to work to a high standard, and they may also have important roles in mentoring27 and training-the(local)-trainer28 rather than just doing hands-on work. other specialised skill competencies that lmics may require support from external sources include leadership, management, and governance,29 teamwork and communication,30 quality improvement,31 and training the trainer28 which are essential elements of modern health systems. therefore, clinicians with expertise in teaching and implementing these important “soft skills” and technical processes may usefully contribute in a mission context. another need in many lmics is to produce well-conducted research in the local context in order 47 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) to improve health interventions, both at a clinical level and at a population level. in lmics, research teams and other research infrastructure, such as ethics review boards, may also need external support.32 this represents another opportunity for christians with appropriate qualifications, and likely affiliated with secular research institutes and universities in hics, to engage in partnerships in lmics to build health research capacity. local partnerships most lmics’ national health systems, driven by international priorities for primary care and universal health coverage, have extended their health services, even to remote areas.33 “unreached areas” necessitating a medical missionary starting a new health service, are few. also, with greater regulations in lmics, opening a new health facility may be difficult for foreigners. therefore, the more sensible model would be to partner with existing local institutions to enhance their quality and capacity. the frontline evangelism role of the missionary doctor may also need re-examining, especially where the local church is establishing its witness. the community’s insiders fluent in language, culture, and relationships are better positioned to evangelize, and less prone to errors of contextualization or reinforcing a neo-colonial mentality. furthermore, theologians with advanced academic qualifications may be better placed to teach and mentor christian leaders, rather than medical missionaries doing it in their spare time with limited theological training. academic, government, secular opportunities some of the least evangelized countries or under-served regions within a country can be hostile to overt christian missions, but remain open to international development assistance or other forms of expatriate expertise, including christian professionals from urban areas going to the remote or other under-served regions of the same country. to enter such countries or regions under the auspices of a mission agency as a missionary may be close to impossible, yet those places may welcome highlyqualified health professionals with open arms. therefore, christian health professionals may be able to serve in those places through government, academic, or other secular institutions, using the wide variety of skills detailed above. the job may come with an income, and perhaps even a high income, but that should not deter a qualified person with a missionary attitude; a paid job may well come with a greater opportunity to influence, and while there may be some restrictions, there should still be ample opportunity to share the gospel creatively. in some places which may not be hostile to christian work, it may still be wise and strategic for christians to work in a secular context. for example, rather than setting up an overtly christian organisation, christians could join or set up a secular organisation that functions on christian principles and with christian leadership. such settings are likely to provide many opportunities to share the gospel message through sustained and close interactions with both colleagues and clients. self-funding, job sharing and fly-in-flyout options the traditional practice of quitting one’s job and being financially supported by other christians to go overseas as a long-term missionary is not the only legitimate mission model. if one has been given the god-given opportunity to have a high earning capacity in one’s home country, then perhaps one should not necessarily give up one’s job and hope that one’s lesser-earning friends will provide the financial support. this may mean working in one’s home country for two to three months a year and earning a high income, which is then used to fund unpaid missionary work for the other nine to ten months of the year. for the two to three months each 48 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) year that one returns to one’s home country, a colleague could pledge to go to the mission field to provide continuity. this may be a more viable model not only for funding purposes, but also for maintaining connections with family and professional development opportunities. other models are also possible, for example, four friends could each pledge to spend three months on the mission field each year. if missionary professionals are involved in teaching or consultancy roles rather than hands-on roles, then perhaps one may make a long-term commitment to go as a teacher or consultant for six weeks each year, for example. that may be sufficient for some settings, or else, a group of colleagues could each pledge to do the same, so that the receiving institution is guaranteed a regular stream of teachers or consultants throughout the year, and continuous presence is not necessarily required. with very convenient international travel, these options are feasible compared to many decades ago before air travel, or even just a decade or two ago, before budget airlines. however, we acknowledge that frequent air travel is not environmentally-friendly, or in christian jargon, caring for god’s creation, and should, therefore, be considered carefully and prayerfully. feminisation of the medical profession female missionaries, especially single women, have always had a prominent role in modern missions, often but certainly not exclusively in nursing. for example, the christian medical colleges of vellore20 and ludhiana21 in india were each founded by a female missionary doctor over a century ago. often, however, the stereotypical medical missionary is still thought of as male with the trailing wife who raises the children and provides endless hospitality and ministers only to the local women while the husband does all the “official” work. this no longer need be the case, though we do not disparage the tremendous importance of the countless women in mission fields who have brought great glory to god by faithfully supporting their husbands, providing hospitality, ministering to women, and educating children, often in places where it is inappropriate for women to be employed outside the home. in an era where over 50% medical students are female in many medical schools around the world and women in professional leadership positions is the norm, in both hics34 and lmics,35 this should also be expected on the mission field. highly-qualified professional women can and are becoming missionaries, so young women considering this calling need to be mentored well and not just assumed to be the traditional missionary wife described above. don’t forget the basics – how to be a missionary when your job title is not missionary while all these models appear radically different from the traditional model of medical missions, some things should not change. even if contemporary missionaries may not live in the host country full time for the long term, may not engage in a great deal of hands-on work, and may not work for a christian organisation, they should still maintain the “traditional” values and practices, with an incarnational approach, including the following: • have a genuine commitment to the people and a strong desire to live out the gospel • learn some of the local language • be immersed in the local culture, for example, in dress • remember the poorest and most marginalised (perhaps this is a significant but hidden temptation when the aim is for high-quality rather than make-do) • acquire and maintain robust theological knowledge, and have a deep and disciplined spiritual practice 49 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) • build up locals to work, lead, and minister • be a learner and listen to the locals who are experts in their system • serve the objectives of the locals and not your own • have strong prayer and practical support from friends and family in the home country (and perhaps also from other countries) short-term medical missions short-term medical missions have become more common due to the ease of international travel. however, undertaking stand-alone, mission trips that have tenuous connections to long term efforts and “voluntourism” which treats volunteering in vulnerable communities in a voyeuristic manner may bring minimal benefit and even harm, to the hosts.36 therefore, any short-term medical mission efforts should fit into the framework above: a high level of professionalism and quality rather than make-do, partnerships with locals rather than substitution or competition, engaging in non-traditional platforms, maintaining “traditional” values, including longterm commitment with a strong foundation of theology and spirituality. stand-alone, short-term medical missions or “voluntourism” have no place on the mission field and may even discourage others from approaching the gospel. conclusion in some settings, the traditional model of medical missions continues to work well, but we need to be aware and acknowledge that their relevance is changing, and that the traditional model may no longer fit many contexts. as the world changes, the opportunities for medical missions are also changing. a certain number of medical missionaries may still be called to work in effective traditional mission settings, but if we insist that is the only way to do “real” medical missions, the effectiveness of missions will decrease, and opportunities will be missed. medical missions must change with the times, but without losing some fundamental values. medical missionaries may look and work quite differently from their predecessors, but their roles as medical missionaries are just as legitimate, and they deserve and require just as much practical and spiritual support as “traditional” medical missionaries. we have met young christian health professionals in the asia-pacific region who are very interested in missions, yet they feel that because of their professional interests, their standard training pathways, or their lack of particular training, they cannot be missionaries. sadly, some resign themselves to a career in the “rat-race” that excludes mission activities; others participate in effective secular global health work without realising this is actually missional and, hence, dichotomise their professional and christian identities; some may even join more traditional-looking mission activities that have questionable effectiveness or relevance. therefore, we sincerely hope that by sharing our observations and experiences, we can expand the perspective of what god is doing in his world, so more christians will be encouraged to use their godgiven gifts to serve god in non-traditional mission settings. we hope that our survey of this topic here will stimulate discussion on non-traditional mission opportunities in the asia-pacific region and beyond. we are keen to read others’ experiences of nontraditional missions globally, as well as any critiques. references 1. johnson tm, bellofatto ga, hickman aw, coon ba, crossing bf, krause m, et al. christianity in its global context, 1970-2020: society, religion and mission [internet]. center for the study of global christianity. 2013 [cited 2021 march 5]. available 50 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) from: https://www.gordonconwell.edu/center-forglobal-christianity/christianity-in-global-context/ 2. tracking universal health coverage: 2017 global monitoring report [internet]. world health organization and the world bank. 2017 [cited 2021 mar 5]. available from: https://www.who.int/healthinfo/universal_health_cov erage/report/2017/en/ 3. tennent c. invitation to world missions: a trinitarian missiology for the twenty-first century. grand rapids: kregel publications; 2010. 4. mettes s. the new faces of medical missions [internet]. christianity today. 2020 jan 6 [cited 2021 mar 5]. available from: https://www.christianitytoday.com/ct/2020/januaryfebruary/medical-missions-africa-paacs.html 5. varghese p, editor. on the wings of dawn: medical mission in india today. chennai: evangelical medical fellowship of india; 2015. 6. o’donnell k, editor. doing member care well: perspectives and practices from around the world. littleton: william carey library; 2013. 7. wood pb. the evolution of church/missions hospitals in africa. evangel missions q. 2011;47(3):336-40. 8. kruk me, gage ad, joseph nt, danaei g, garcíasaisó s, salomon ja. mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. lancet. 2018;392(10160):2203-12. http://doi.org/10.1016/s0140-6736(18)31668-4 9. o’brien bc, forrest k, wijnen-meijer m, cate o tenien bc, editors. a global view of structures and trends in medical education. in: understanding medical education: evidence, theory, and practice, 3rd edition. edinburgh: the association for the study of medical education; 2019. p. 7-22. http://doi.org/10.1002/9781119373780 10. transforming and scaling up health professionals’ education and training [internet]. world health organization; 2013 [cited 2021 mar 5]. available from: https://www.who.int/hrh/resources/transf_scaling_hp et/en/ 11. rigby pg, gururaja rp. world medical schools: the sum also rises. jrsm open. 2017; 8(6):2054270417698631. http://doi.org/10.1177/2054270417698631 12. krztoń-królewiecka a, švab i, oleszczyk m, seifert b, smithson wh, windak a. the development of academic family medicine in central and eastern europe since 1990. bmc fam pract, 2013;14:37. http://doi.org/10.1186/1471-2296-14-37 13. ng cj, teng cl, abdullah a, wong ch, hanafi ns, phoa ssy et al. the status of family medicine training programs in the asia pacific. family med. 2016;48:194-202. 14. flinkenflögel m, essuman a, chege p, ayankogbe o, de maeseneer j. family medicine training in subsaharan africa: south-south cooperation in the primafamed project as strategy for development. fam pract. 2014;31(4): 427-36. http://doi.org/10.1093/fampra/cmu014 15. nambiar b, hargreaves ds, morroni c, heys m, crowe s, pagel c, et al. improving health-care quality in resource-poor settings. bull world health 2017;95:76-8. 16. smits h, supachutikul a, mate ks. hospital accreditation: lessons from lowand middle-income countries. glob health. 2014;10(65). http://doi.org/10.1186/s12992-014-0065-9 17. lankester t, grills n, editors. setting up community health and development programmes in low and middle income countries, 4th edition. oxford: oxford university press; 2019. 18. taylor s. ‘global health’: meaning what? bmj global heal. 2018;3:e000843. http://doi.org/10.1136/bmjgh-2018-000843 19. williams r. canterbury sermon [internet]. 2006 [cited 2021 mar 5]. available from: http://news.bbc.co.uk/2/hi/uk_news/6208653.stm 20. vellore christian medical college foundation, cmc – a historic view [internet]. 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[cited 2021 mar 8]. available from: https://www.cmcludhiana.in/our-story/ 22. ackers hl, ackers-johnson j. ‘first do no harm’: deploying professional volunteers as knowledge intermediaries. in: mobile professional voluntarism and international development. new york: palgrave https://www.gordonconwell.edu/center-for-global-christianity/christianity-in-global-context/ https://www.gordonconwell.edu/center-for-global-christianity/christianity-in-global-context/ https://www.who.int/healthinfo/universal_health_coverage/report/2017/en/ https://www.who.int/healthinfo/universal_health_coverage/report/2017/en/ https://www.christianitytoday.com/ct/2020/january-february/medical-missions-africa-paacs.html https://www.christianitytoday.com/ct/2020/january-february/medical-missions-africa-paacs.html http://doi.org/10.1016/s0140-6736(18)31668-4 http://doi.org/10.1002/9781119373780 https://www.who.int/hrh/resources/transf_scaling_hpet/en/ https://www.who.int/hrh/resources/transf_scaling_hpet/en/ http://doi.org/10.1177/2054270417698631 http://doi.org/10.1186/1471-2296-14-37 http://doi.org/10.1093/fampra/cmu014 http://doi.org/10.1186/s12992-014-0065-9 http://doi.org/10.1136/bmjgh-2018-000843 http://news.bbc.co.uk/2/hi/uk_news/6208653.stm https://www.vellorecmc.org/about/introduction-to-cmc-vellore/history/ https://www.vellorecmc.org/about/introduction-to-cmc-vellore/history/ https://www.cmcludhiana.in/our-story/ 51 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) pivot; 2017. pages 21-50. http://doi.org/10.1057/978-1-137-55833-6 23. dawson aj, nkowane am, whelan a. approaches to improving the contribution of the nursing and midwifery workforce to increasing universal access to primary health care for vulnerable populations: a systematic review. hum resour health. 2015;13(97). 24. rehm j, sheild kd. global burden of disease and the impact of mental and addictive disorders. curr psych rep. 2019;21(2):10. http://doi.org/10.1007/s11920-019-0997-0 25. world report on disability [internet]. world health organization; 2011 [cited 2021 mar 5]. available from: https://www.who.int/disabilities/world_report/2011/r eport/en/ 26. knaul fm, farmer pe, krakauer el, de lima l, bhadelia a, kwete xj, et al. alleviating the access abyss in palliative care and pain relief – an imperative of universal health coverage: the lancet commission report. lancet. 2018;391(10128):1391454. http://doi.org/10.1016/s0140-6736(17)32513-8 27. lescano ag, cohen cr, raj t, rispel l, garcia pj, zunt jr, et al. strengthening mentoring in lowand middle-income countries to advance global health research: an overview. am j trop med hyg. 2019;100(1_suppl): 3-8. http://doi.org/10.4269/ajtmh.18-0556 28. mormina m, pinder, s. a conceptual framework for training of trainers (tot) interventions in global health. glob health. 2018;14(100). http://doi.org/10.1186/s12992-018-0420-3 29. gilson l, agyepong ia. strengthening health system leadership for better governance: what does it take? health policy plann. 2018;33(suppl_2): ii1–ii4. http://doi.org/10.1093/heapol/czy052 30. scott j, morales dr, mcritchie a, riviello r, smink d, yule s. non-technical skills and health care provision in lowand middle-income countries: a systematic review. med educ. 2016;50(4):441-55. http://doi.org/10.1111/medu.12939 31. heiby jr, armbruster d, jacobs ta. better care for every patient, every time: improving quality in lowresource health systems. bjog. 2014;121(suppl. 4):4-7. http://doi.org/10.1111/1471-0528.12903 32. beran d, byass p, gbakima a, kahn k, sankoh o, tollman s, et al. research capacity building – obligations for global health partners. lancet glob health. 2017;5(6):e567-e568. http://doi.org/10.1016/s2214-109x(17)30180-8 33. primary health care on the road to universal health coverage, 2019 global monitoring report [internet]. world health organization, 2019 [cited 2021 mar 5]. available from: https://www.who.int/healthinfo/universal_health_cov erage/report/2019/en/ 34. jefferson l, bloor k, maynard a. women in medicine: historical perspectives and recent trends. brit med bull. 2015;114(1): 5-15. http://doi.org/10.1093/bmb/ldv007 35. russo g, gonçalves l, craveiro i, dussault g. feminization of the medical workforce in lowincome settings; findings from surveys in three african capital cities. hum resour health. 2015;13(64). http://doi.org/10.1186/s12960-0150064-9 36. sykes kj. short-term medical service trips: a systematic review of the evidence. am j public health. 2014;104(7): e38–e48. http://doi.org/10.2105/ajph.2014.301983 peer reviewed: submitted 10 march 2021, accepted 19 may 2021, published 30 july 2021 competing interests: all four authors declare that each of us is actively involved in aspects of nontraditional missions, as described in this paper. note that for reasons of security, pseudonyms were used for the first three authors. comments or inquiries can be sent to the journal editors. cite this article as: nungarai n, paul m, john ng, goh w-l. considering medical missions in all its different forms – a viewpoint from the asia-pacific region. christ j global health. july 2021; 8(1):4252. https://doi.org/10.15566/cjgh.v8i1.523 http://doi.org/10.1057/978-1-137-55833-6 http://doi.org/10.1007/s11920-019-0997-0 https://www.who.int/disabilities/world_report/2011/report/en/ https://www.who.int/disabilities/world_report/2011/report/en/ http://doi.org/10.1016/s0140-6736(17)32513-8 http://doi.org/10.4269/ajtmh.18-0556 http://doi.org/10.1186/s12992-018-0420-3 http://doi.org/10.1093/heapol/czy052 http://doi.org/10.1111/medu.12939 http://doi.org/10.1111/1471-0528.12903 http://doi.org/10.1016/s2214-109x(17)30180-8 https://www.who.int/healthinfo/universal_health_coverage/report/2019/en/ https://www.who.int/healthinfo/universal_health_coverage/report/2019/en/ http://doi.org/10.1093/bmb/ldv007 http://doi.org/10.1186/s12960-015-0064-9 http://doi.org/10.1186/s12960-015-0064-9 http://doi.org/10.2105/ajph.2014.301983 https://doi.org/10.15566/cjgh.v8i1.523 52 nungarai, paul, john & goh july 2021. christian journal for global health 8(1) © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ about:blank commentary nov 2015. christian journal for global health, 2(2):16-19. should christian global health be distinctive? a reflection raymond downing a a senior lecturer, department of family medicine, moi university school of medicine, kenya abstract christian global health is often seen as the overlap of global health activities with christian motivations, sometimes including evangelism. but is there anything distinctive about christian global health? drawing on the insights of jacques ellul, this article proposes how christian global health could be qualitatively different from humanitarian global health. in december 2014, time magazine chose “the ebola fighters” for its person of the year cover story. and while they wisely chose to highlight african as well as western global health workers, most of whom did not get infected by the virus, it was three american medical missionaries who did get infected that made the story so compelling. christian global health workers had suddenly become celebrities. but did they do anything special, anything uniquely christian? many who shared the ebola fighters’ honor were from humanitarian organizations like the red cross and médecins sans frontières (msf), not christian missions. the motivational indistinctness in the ebola fighters’ story is worth pondering and provides a very contemporary example for us to ask: is there a distinctive christian approach to global health, or do we simply draw from the myriad approaches already described, testing each piece for how well it reflects general christian principles? christian ebola fighters had experiences very parallel to humanitarian fighters. is christian global health then simply a matter of finding the overlap of the venn diagrams of global, health, and christian? 1 this seems to have been the approach since christians first became involved in global health over 200 years ago. early medical missionaries, while often passionately evangelistic, built the medical side of their ministry squarely on the emerging secular biomedical paradigm. 2 the same is true today. in the 1970s, primary health care (phc) offered a much needed critique to a purely biomedical model, a critique influenced by the christian medical commission 3 and vigorously adopted by map international. 4 however, a major tenet of this approach, community participation, is not a distinctly christian notion; it draws more from democratic and socialist political notions. current needed modifications to this phc approach, an ecological paradigm 4 and a systems approach 5 , are likewise drawn from the academy, not from christian reflection. then on the opposite side of the “socialist” phc approaches are the individualist 17 downing nov 2015. christian journal for global health, 2(2): 16-19. free-market development notions, not distinctly christian, used especially by indigenous pentecostal churches for social ministries of all kinds, including health care. 6 but are there distinctive christian approaches? at the close of world war ii in france, jacques ellul proposed to address the question, “what part should [the christian] play in the life of the world?” 7 — a haunting question in a country compromised and nearly destroyed by the nazi regime. the question is equally relevant today for christian global health workers. ellul begins his response this way: . . . we need to remember that the christian must not act in exactly the same way as everyone else. he has a part to play in this world which no one else can possibly fulfill. he is not asked to look at the various movements which men have started, choose those which seem ‘good,’ and support them . . . he is charged with a mission of which the natural man can have no idea; yet in reality this mission is decisive for the actions of men. he then presents three specific biblical functions of christian engagement in the world:  to be the salt of the earth: “the fact that christians are, in their lives, the ‘salt of the earth,’ does far more for the preservation of the world than external action.”  to be the light of the world: “the christian . . . reveals to the world the truth about its condition.”  to be sheep in the midst of wolves: “christians must . . . offer the daily sacrifice of their lives, which is united with the sacrifice of jesus christ.” in all of these functions, ellul says, we are to be “signs” of the reality of god’s action in the world. “technical work” needs to be done, he says, “but this work is done by everybody, and it has no meaning unless it is guided, accompanied, and sustained by another work that only the christian can do, and that he often does not do.” the rest of ellul’s book is an exploration of what this involves. ironically — or perhaps understandably — it is a secular study of “humanitarian reason” that most clearly exposes some of what “only the christian can do.” the physician-anthropologist didier fassin, in the conclusion to his example-filled study, considers the foundations of this humanitarianism. 8 for modern western societies, he says, engagement with the world is built around how we deal with suffering: . . . while the spectacle of suffering has disappeared completely from the public places where the physical punishment inflicted on criminals was previously exhibited, the representation of suffering through images and narratives has become increasingly commonplace in the public sphere, not only in the media . . . but also in the political arena, where it furnishes an effective justification for action. think of famine, aids, and ebola. he then probes the origins of this focus on suffering: this fascination with suffering also derives from a christian genealogy . . . [t]he valorization of suffering as the basic human experience is closely linked to the passion of christ redeeming the original sin . . . the singular feature of christianity in this respect is that it turns suffering into redemption. however, modernity marks a turning point in this genealogy of redemptive suffering, both in literature and in politics . . . with the entry of suffering into politics, we might say that salvation emanates not through the passion one endures, but through the compassion one feels. 18 downing nov 2015. christian journal for global health, 2(2): 16-19. humanitarianism has sanitized suffering. this is not the daily sacrifice of our lives, united with the suffering of christ, of which ellul wrote. it is not the role of a sheep, but of one who feels sorry for sheep. “in western societies,” writes fassin, “the paradigm of romantic engagement with the world has thus shifted from the figure of the volunteer risking his or her life alongside liberation movements to the figure of the humanitarian saving lives in spaces set apart from the fighting . . . ,” spaces he describes a bit later as “protected corridors of aid.” or, in a more disturbing example, this scene from the recent movie american sniper: at a dinner table discussion with his children, one of whom will become the sniper, the father explains to them that there are three types of people in the world: sheep, wolves, and sheepdogs. sheep, he says, are people who prefer to believe that evil doesn’t exist in the world, and if evil presented itself on their doorstep, they wouldn’t know how to protect themselves. wolves are predators who prey on the weak. and sheepdogs are rare: they “are blessed with the gift of aggression” and feel an overwhelming need to protect the flock against wolves. the father was clear: “we aren’t raising any sheep in this family . . . we protect our own.” it is the most frightening scene in the movie. there is no longer any conceptual room for, any understanding of, being sent as sheep in the midst of wolves. “yet” (ellul again): the world cannot live without this living witness of sacrifice. that is why it is essential that christians should be very careful not to be ‘wolves’ in the spiritual sense — that is, people who try to dominate others. christians must accept the domination of other people, and offer the daily sacrifice of their lives, which is united with the sacrifice of jesus christ. the world cannot live without this kind of sacrifice, and there is something in our humanitarian western societies that knows this, that remembers this. we knew that mother theresa did nothing to prolong the lives of dying people in calcutta, but we still gave her the nobel peace prize. we knew that three missionaries contracting ebola did nothing to stop the epidemic, but their story still resonates with something dormant in us. though it makes no scientific sense, something deep within us knows that the world cannot live without this kind of sacrifice. but because it makes no scientific sense, we spend our effort promoting sheepdogs and protected corridors of aid — until a missionary gets ebola. our problem as christians is that there can be no algorithm for knowing how and when to be preserving salt, revealing light, and especially sheep in the midst of wolves. ellul admits that we cannot change the world, yet we cannot live with it the way it is. he calls this a “very painful and very uncomfortable situation,” yet “we must accept this tension and live in it.” and, he says later, “see how god’s will of preservation can act in this given situation.” the first sacrifice we must make is letting go of the need to control and the assurance of results and of change. it is god’s will of preservation, not ours. beyond this, there is no formula. for my friend tom little, the sacrifice of his life was literal. a christian optometrist who had worked for over 30 years in afghanistan, i doubt that he saw living in another culture as a sacrifice. the tom i knew in college didn’t share the upwardly mobile dreams of most students, but he did feel passionate about getting health care to those in rural afghanistan — and when he and 9 other global health workers were killed by the taliban on the way back from an eye camp in 2010, they died as sheep in the midst of wolves. for my wife and me, the sacrifice is far more mundane. like tom, we do not find living in africa for nearly 30 years to be a sacrifice. but as we have 19 downing nov 2015. christian journal for global health, 2(2): 16-19. moved from working in mission hospitals under mission agencies to working for a public university in a government hospital, we begin to feel more like sheep among wolves. we feel what other staff, and certainly the patients, must feel: in a place where supplies are inadequate, morale is low, and the corruption of politicians sets the example for institutional leadership, services are woefully inadequate. we miss the relative efficiency of mission hospitals, but they have become places to which many patients can no longer go because they cannot afford them. working for the government is certainly frustrating, but at least we are working with patients who have no other option; at least our view of reality becomes clearer. we must continue the search for “best practices” for christian global health workers. we must continue to name our foundations and debate approaches and gather evidence, for we all need to get up in the morning and do something. being salt, light, and sheep among wolves is not a job description; it is who we are, not what we do. but unless we are being what only christians can be, we will have nothing distinctive to offer global health and will play no role in the enlightenment and preservation of the world. references 1. strand ma, cole ma. framing the role of the faith community in global health. cjgh, 1(2):7-15. http://dx.doi.org/10.15566/cjgh.v1i2.19 2. downing r. the gospel of science. cjgh 2(1):43-8. http://dx.doi.org/10.15566/cjgh.v2i1.25 3. litsios s. the christian medical commission and the development of the world health organization's primary health care approach. am j public health. 2004 nov;94(11):1884-93. http://dx.doi.org/10.2105/ajph.94.11.1884 4. deangulo jm, losada ls. health paradigm shifts in the 20th century. cjgh.2(1):49-58. http://dx.doi.org/10.15566/cjgh.v2i1.37 5. swanson rc, thacker bj. systems thinking in shortterm health missions: a conceptual introduction and consideration of implications for practice. cjgh 2(1):722. http://dx.doi.org/10.15566/cjgh.v2i1.50 6. myers bl. progressive pentecostalism, development, and christian development ngos: a challenge and an opportunity. int bms res.1915 jul;39(3):115-20. 7. ellul j. the presence of the kingdom. 1 st edition. new york: seabury press; 1967. [first edition in french 1948] [all quotes from the first chapter, “the christian in the world.”] 8. fassin d. humanitarian reason: a moral history of the present. berkeley: university of california press; 2012. [all quotes from the conclusion] peer reviewed competing interests: none declared. correspondence: raymond downing, moi university school of medicine, kenya. armdown2001@yahoo.com cite this article as: downing r. should christian global health be distinctive? a reflection. christian journal for global health (nov 2015), 2(2):16-19. © downing r this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.15566/cjgh.v1i2.19 http://dx.doi.org/10.15566/cjgh.v2i1.25 http://dx.doi.org/10.2105/ajph.94.11.1884 http://dx.doi.org/10.15566/cjgh.v2i1.37 http://dx.doi.org/10.15566/cjgh.v2i1.50 mailto:armdown2001@yahoo.com http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ book review nov 2015. christian journal for global health, 2(2): 78-81. health, healing and shalom: frontiers and challenges for christian health missions, by bryant l. myers, erin dufault-hunter, isaac b. voss, eds. wm carey library press. 2015 cynthia b. hale a a md, mph, faap, former medical missionary, united mission to nepal, interserve usa; former associate professor, department of community medicine, tribhuvan university institute of medicine, kathmandu, nepal. technological advances in medical care have led healthcare practitioners in so-called developing countries to copy the biomedical model currently in use in the usa and other western countries. when my husband, dr. thomas hale, jr, and i first went to nepal as medical missionaries, we went thoroughly prepared according to the biomedical model of disease, and we were also prepared to share our faith in christ, disciple believers, and contribute to the growth of the church in nepal. it was in nepal that we learned not to separate our ministry into secular and sacred compartments. we also observed that the strictly biomedical model of medical care was inadequate for helping people who have a much more holistic understanding of health and disease, people who live in traditional societies and societies in transition. we came to realize that a strictly biomedical model for treating the ill does not correlate with biblical concepts of health and healing. health, healing and shalom seeks to redress the compartmentalization and imbalance which plagues many in healthcare missions. contributors to the book are christian healthcare and development practitioners and theologians who share personal lessons and insights gained from years of grassroots-level service in inner cities of the usa and villages and cities around the world. it was their goal to practice according to a definition of health as being a state of complete physical, mental, social, and spiritual well-being, and not merely the absence of disease. each chapter is wellreferenced. contributors’ short bios and an index are included. the introductory section starts with a foreword by peter yorgin, md, in which he writes that this book reflects “best practices,” and the thought and passion from the 2012 west coast healthcare missions and ministry conference. yorgin defines shalom and states that the purpose of this compendium is to provide some answers to questions initially grappled with by daniel e. fountain, md, in a 1968 monograph: 1) what makes christian medical missions “christian”? 2) how do we prepare christian healthcare missionaries so that they embrace a kingdom mindset? 3) what is health really supposed to mean to the church? 4) what should it look like for the church to be fully engaged in ministries of health, healing, and wholeness? (p. xiii-xvi) 79 hale nov 2015. christian journal for global health 2(2): 78-81. in the introduction to the book, bryant l. myers, phd, gives an excellent overview of the contents, making it possible for the reader to prioritize the reading of chapters of special interest. he reviews global health status at the beginning of the 21 st century and reminds readers of historical contributions of christians to healthcare, starting from the early centuries of the christian church and highlighting the more recent role in 1968 of the christian medical commission (cmc) of the world council of churches, which “brought to light new models of communitybased primary health care at a time when the world health organization (who) was searching for alternative concepts for health care.” the “conversation” between the cmc and who led to the alma-ata declaration of 1978 that called for “health for all by the year 2000.” (p. xvii-xxxiii ) the commemorative chapter by dr. fountain is titled, “putting the whole person back together – lessons from africa.” he includes a number of faith-building accounts of the healing of bodily ailments that followed when patients experienced forgiveness for harmful emotions, old hurts, bitterness, rage, resentment, etc. much credit is given by fountain to a zairian nurse counselor who was the “midwife” for many of the spiritual new births. dr. fountain’s approach to whole person health care is fully explained in a training dvd, a team approach to caring for the whole person, which is available from king university (globalhealth@king.edu). myers opens the first main section, “new frontiers in theology and healthcare missions” with two chapters. in the first of these, “theological reflections . . . ,” he delves into the meanings and biblical usages of the greek and hebrew words for salvation and shalom. since humans were created by god as relational beings and consist of mind, body, and soul, it is god’s intention that they experience shalom, in other words, health, wholeness, and flourishing. the chapter develops these concepts with the aid of two diagrams, one showing the impact of sin on health and wholeness, and a second that indicates how the kingdom of god in christ is meant to restore human relationships in all spheres of life. in the second chapter, (chapter 3 in the book), “announcing the whole gospel: health, healing and christian witness,” myers clearly states that “gospel” means “message,” or “good news.” he adds: “messages are not messages unless they are announced.” he urges medical professionals to explain their work as being empowered by god. otherwise, people in “primal cultures” will ascribe healing to the spirits and gods of modern medicine. myers suggests “a different way of thinking about proclamation” by referring to lesslie newbigin, missionary and missiologist, who made a case for evangelism in the early church as being the “second act – not the first.” (p. 41-55) in the third chapter of this first section, “health missions to children in crisis,” david h. scott, phd, delineates a framework for understanding “god’s heart for children,” which consists of seven affirmations from biblical texts and christian doctrines. the longest section of this volume is the middle portion: “new frontiers in healthcare missions practice.” here one can mine the wisdom of experienced christian health and development workers who deal with a wide range of topics. this section contains chapters 5 through 12, summarized below. chapter 5 by myers and arnold gorske, md, proposes that community based health screening and education (cbhse) be used by churches and their congregations to combat prevailing endemic diseases resulting from an unhealthy diet, inadequate exercise, and tobacco use. the teaching and learning style of cbhse is participatory and problemmailto:globalhealth@king.edu 80 hale nov 2015. christian journal for global health 2(2): 78-81. solving. training materials are available for free download from www.hepfdc.info. in chapter 6, drawing from their experience among the urban poor, katy white, md, mph, and kathleen henry, pa-c, define kingdom health care as focused on jesus christ, holistic, and incarnational and focused on those with the least access to healthcare. in order to be effective, it must be rooted in christian community. the authors describe common barriers to providing kingdom healthcare and motivate readers to practice in this way with two excellent examples from inner city christian clinics in chicago and memphis, usa. in this especially well-referenced chapter 7, ana wong-mcdonald, phd, provides credibility for the data she presents about the impact of trauma on individuals and communities, both in the usa and around the world. she shows how restoration of shalom can only take place in community or at least in connection with one caring person. in chapter 8, w. meredith long, phd, and debbie dortzbach, mn, mph, relate the poignant story of mary, an african woman, herself suffering with aids yet caring for her husband, his girlfriend and their child, all sick with aids and lying in one bed. the authors show how jesus’ love alone can heal broken relationships and enable those who “accompany” hiv/aids sufferers. in chapter 9, michael j. soderling, md, estimates that 100,000 health professionals participate yearly in short-term medical missions at great cost of time, talent, and finance. he makes five proposals for changing old paradigms that rely on the dualistic worldview in which health professionals are trained. the most pertinent proposal for short-term missions is avoiding the harm that results from a collision of the holistic worldview of most people in “developing nations” with a secular definition of health and a focus on western solutions for health problems. this chapter is a “must read” for short-term healthcare mission workers and administrators. chapter 10 by rebecca gagne henderson, aprn, achpn, addresses shalom at the end of life by cooperating with “god’s magnificent design” for the end of life. she gives an understandable explanation of the physiology of starvation and dehydration and offers practical ways to care for dying people without resorting to artificial nutrition and hydration, practices which can also have deleterious side effects. erin dufault-hunter, phd, reminds us in chapter 11 that “jesus wept” (john 11:35), so that we too may practice lament with patients who are suffering and in agony, even while we offer the christian hope of god’s ultimate triumph over disease and death. the closing chapter in this section on “new frontiers in healthcare missions practice” is by two psychologists, cynthia eriksson, phd, and ashley wilkins, ma, together with judith m. tiersma watson, phd. these women offer tips to practitioners for maintaining healthy relationships with themselves, with ministry peers and within their organizations, in order to avoid burnout. the third major section, “new approaches in healthcare missions,” begins with chapter 13, “overcoming barriers in the city,” by anntippia short, rn, msn, cne, and isaac b. voss, mph. this chapter explores spiritual practices that can lead to transformed interpersonal relationships of shalom within the context of the city: hospitality, encounter, compassion, christian witness, and justice. the authors define these terms with illustrations from their experience in the inner city of los angeles. this is a particularly helpful chapter for church volunteers as well as full-time practitioners http://www.hepfdc.info/ 81 hale nov 2015. christian journal for global health 2(2): 78-81. and can stand alone as a handout for orientation and training. chapters 14 and 15 are both about empowering lay health workers and local church volunteers to carry out healthcare in their communities. although these models have mostly been used by missionaries in “developing countries” where much of the population does not have access to health care, in chapter 14, grace tazelaar, ms, rn, and carolyn newhof, describe the impressive successes in lowering infant mortality through the work of cary christian center’s home visitors in sharkey county, mississippi. in chapter 15, terry dalrymple, mdiv, and jody collinge, md, describe community health evangelism (che), a tool first developed by stan rowland in uganda, but now used worldwide in varying cultural and religious contexts. the goal of che is the transformation of lives and communities through the power of the gospel by integrating christian discipleship with disease prevention and community-based development. training materials are available through the global che network. 1 the concluding chapter, “looking forward in the healthcare missions movement” is by voss, dufault-hunter, and rick donlon, md. the authors bring together the themes developed throughout the book and conclude that the healthcare missions movement needs to become committed to “kingdom healthcare that is identitytransforming, incarnational, integrative, and innovative.”(265-282) in conclusion, this book is highly recommended for all christian healthcare workers so that they might be better able to treat the whole person in relation to his or her spiritual, mental, social, and physical environment, thus resulting in shalom — physical and spiritual peace and well-being. it must be remembered that to accomplish this worthy goal will require a team approach and reliance on the holy spirit. references 1. global community health evangelism network. 2012a [che lesson plan materials, che training info, and training for trainers]. available at http://www.chenetwork.org/store.php competing interests: none declared. correspondence: cynthia b. hale, cynthiabhale@gmail.com cite this article as: hale, cb. book review: health, healing and shalom. christian journal for global health (may 2015), 2(2): 78-81. © hale, cb. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.chenetwork.org/store.php mailto:cynthiabhale@gmail.com http://creativecommons.org/licenses/by/3.0/ original article may 2023. christian journal for global health 10(1) musculoskeletal discomfort associated with remote work conditions of professors during the covid-19 confinement in colombia margarita portilla diaz a santiago goméz velásquezb clara rocío galvis lópezc and sandra ortegón ávilad a magister en discapacidad e inclusión social, facultad ciencias de la salud, universidad de los llanos, villavicencio, colombia b ingeniero de alimentos, magister en salud pública, doctorando en epidemiologia y bioestadística de la universidad ces. facultad ciencias de la salud. universidad de los llanosvillavicencio, colombia c enfermera, magister en enfermería con énfasis en cuidado crónico. facultad ciencias de la salud. universidad de los llanosvillavicencio, colombia d enfermera, magister en desarrollo educativo y social. facultad ciencias de la salud. universidad de los llanos villavicencio, colombia abstract remote working led to organizational and adaptive processes at workplaces, with ergonomic and psychosocial risk factors being present that could be associated with musculoskeletal symptoms. this study identifies musculoskeletal discomfort developing in this setting among university professors working remotely because of the covid 19 pandemic, evaluates risk levels associated with this workplace, and estimates the need for remedial action. the study had a quantitative, observational, cross-sectional design and used a secondary source of information. statistical analysis used jamovi software. professors reported primarily neck discomfort, followed by discomfort in the dorsal or lumbar region. a statistically significant association was found between the category “requires action” and those who reported dedication to occupational activities more than eight hours per day. work at home conducted by the professors is related to discomfort on the neck and dorsal or lumbar region. risk assessment shows that, under these conditions, the professors required timely action to avoid worsening discomfort, functional limitation, and work absenteeism. el trabajo a distancia generó procesos de organización y adaptación de los lugares de trabajo, con presencia de factores de riesgo ergonómicos y psicosociales que podrían provocar la aparición de síntomas musculoesqueléticos. el estudio identifica molestias musculoesqueléticas, evalúa el nivel de riesgo asociado al ámbito laboral, estima la necesidad de actuación y las asociaciones existentes en los docentes universitarios que realizaron trabajo remoto debido a la pandemia del covid-19. el estudio contó con diseño cuantitativo, observacional, transversal y fuente de información secundaria, con análisis estadístico a través del software jamovi. los profesores reportaron molestias en el cuello, seguido de la región dorsal o lumbar; se encontró asociación estadísticamente significativa entre la categoría “requiere acción” con aquellos que relataron dedicación a actividades ocupacionales > 8 h/día. se concluye que el trabajo en casa realizado por los profesores estuvo relacionado con molestias en el cuello y región dorsal o lumbar; la evaluación de riesgos muestra que en esas condiciones los profesores requerían una actuación oportuna para evitar que se agudizaran las molestias, la limitación funcional y el ausentismo laboral. portilla, velásquez, lópez & ávila 8 may 2023. christian journal for global health 10(1) key words: musculoskeletal pain, ergonomic evaluation, professor, working conditions, pandemic, covid-19 introduction remote work at home was a guideline established by the colombian national government within the framework of the health emergency as a mitigation strategy to counteract the spread of covid19. according to legislation 2121 of 2021, this mode of working indicates that a job can be conducted in any physical space, with the approval of the labor risk administrator (arl, for the term in spanish) as established in a work contract and carried out by using information and communications technology (ict).1 for professors, this strategy, implemented by universidad de los llanos as a safeguard measure, implied transforming the pedagogical dynamics to a model characterized by ict-mediated synchronous remote meetings.2 this work modality was associated with long days in front of the computer, increased study hours and preparation to respond to demands, decreased physical activity, and decreased rest time. these features constitute a psychosocial risk factor, and which – according to molina and valencia3 – lead to feelings of overburdening, exhaustion, and burnout and the appearance or exacerbation of musculoskeletal symptoms. prolonged maintenance of inappropriate sitting postures,4 as reported, cause greater static load on the structures, in the absence of pertinent strategies to decrease risks. garcia salirrosas5 and rosario amézquita6 define musculoskeletal discomfort as a set of disorders of the locomotor system associated with structural and functional conditions of the joints and associated structures, including muscles, fascia, tendons, ligaments, and nerves. the mostfrequent symptom is pain associated with inflammation, loss of muscle strength, and functional limitation. these types of discomfort can affect every individual, at any age, especially actively working people.7 another element that affects the onset of musculoskeletal discomfort is physical inactivity. according to the world health organization (who),8 lack of physical activity and sedentary lifestyle affects the individual’s muscle status, bone health, and functional status. the university professors’ exposure to prolonged static loads and inappropriate postures added to preexisting health problems and constitute risk factors for the onset of musculoskeletal discomfort.9 it is important to note that the ergonomic conditions of the workplace because of the use of the computer, mouse, and work station are factors that affect the onset or worsening of musculoskeletal discomfort.10 such discomfort occurs principally in upper extremities due to repetitive movements and uncomfortable postures in wrists and hands and discomfort in neck and back associated with an incorrect sitting posture or lack of back support.11 the aim of this study was to measure musculoskeletal discomfort, determine the level of risks associated with the workplace, estimate the need for action, and evaluate the possible association between musculoskeletal discomfort and the need for action in university professors who engaged in remote work during the covid– 19 pandemic. methods a quantitative, observational, cross-sectional study was conducted, using a secondary data source. the secondary data stemmed from a study on the characterization of musculoskeletal symptoms and description of risks in the workplace, elaborated by the researchers during the covid-19 pandemic confinement period (2nd semester of 2020). the study was performed with full-time professors at the universidad de los llanos. non-probabilistic convenience sampling was used. google forms were distributed to 170 full-time professors with an invitation to participate in the research in a voluntary but guided manner. the link to the form was shared through the institutional e-mail web server to guarantee exclusive access by the professors; other 9 portilla, velásquez, lópez & ávila may 2023. christian journal for global health 10(1) institutional channels were used (phone call, social media, and e-mail) to notify the professors about the research and encourage their participation. responses were obtained from 61 professors, with 35.8% participation. the form consisted of three parts: the first collected data on variables of interest such as age, sex, relationship time, maximum level of training, hours dedicated to teaching, housework and training studies, dominant laterality, previous disability, and diagnosis of common and occupational disease. the second part was the application of the nordic questionnaire by kuorinca that permitted the study participants to self-report the perception of musculoskeletal symptoms or discomfort by body segments.12 -13 the third part corresponded to the application of the instrument denominated rosa (rapid office strain assessment) method, which through a designed verification list quickly quantifies the potential risks that may be associated with office work.11 to determine the risk level of professors with the rosa method, it was considered that the worker remains in a sitting posture in front of a surface, and manages information equipment with a data visualization screen.14 the evaluation kept in mind the most-common elements in these work stations, chair, work surface, screen, keyboard, mouse, and other peripherals. as a result of its application, an assessment of the risk was measured and an estimate of the need to act to reduce the level of risk was obtained. for the purposes of this article, the results obtained from the risk assessment will be categorized as follows: levels 0 and 1were grouped into the new minimum action category and levels 2, 3, and 4 were grouped into the necessary action category (table 1). table 1. risk and rosa level of action score risk level action modified action 1 inappreciable 0 no action is necessary minimum action minimum action 2 3 4 improvable 1 some elements of the workplace can be improved 5 high 2 action is necessary necessary action necessary action necessary action 6 7 8 very high 3 action is required as soon as possible 9 – 10 extreme 4 action is urgently necessary note. source: prepared by the authors based on the original table of diego-mas, ja. (2019), evaluation of office positions using the rosa method. ergonauts, polytechnic university of valencia, 2019. the database was organized prior to statistical analysis, guaranteeing the completeness of all records. the statistical analysis was performed with the jamovi software, version 2.2.5 solid. for descriptive statistical analysis, the study used absolute and relative frequencies for the qualitative variables. quantitative variables were described according to the type of distribution presented, as per the normality test (shapiro-wilk), determining mean with standard deviation or median with interquartile range. associations between variables of interest were analyzed using chi square tests or fisher's exact test, according to the expected frequencies in the contingency tables. the study was endorsed by external evaluators of the internal call by universidad de los llanos "strengthening research groups" and by the institutional ethics committee; for its part, the database had the informed consent from participating teachers. results characterization of the participants for all the participants, 42.6% were male and 57.4% were female, ranging between 32 and 65 years of age, with a mean age of 49.1 (±8.52) years. the median duration of seniority as professor was 11 years; 23% of the professors were studying in graduate programs (master’s or phd) when they participated in the research. 62.3% of the participants reported spending more than eight hours per day in front of a computer. 14.8% of the professors indicated that in the year prior to the study they had had a medical disability due to a diagnosis of musculoskeletal origin. finally, 21.3% had a pathology related to a musculoskeletal portilla, velásquez, lópez & ávila 10 may 2023. christian journal for global health 10(1) disorder, and 11.5% reported a prior occupational osteo-diagnosis (table 2). table 2. characteristics of the participants age (mean ± sd) 49.1 (8.52) number of years working [median (q3-q1)] 11(16-6) male female maximum formation undergraduate 1 (3.8) 0 specialization 7(26.9) 4(11.4) master’s 15(57.7) 23(65.7) phd 3(11.5) 8(22.9) dominant laterality right handed 26 (100) 34(97.4) left handed 0 1(2.9) previous occupational osteo-diagnosis yes 2(7.7) 5(14.3) no 24(92.3) 30(85.7) musculoskeletal discomfort of all the professors participating, 83.6% reported having had pain in some part of the body. upon assessing the musculoskeletal discomfort reported in table 3, zoned discomfort was observed in neck, shoulders, elbows, wrists, or hands and in the dorsal-lumbar region during the six months prior to the study. of the body regions inquired, neck pain was the most-often reported (67.2%), while dorsal or lumbar pain was second (62.3%), and pain in wrists or hands third (49.2%). according to pain intensity, in the strong and very strong category, the most-affected zone reported by the participants was the dorsal or lumbar region with 34.4%, followed by the neck zone with 27.9%. pain intensity in the wrists or hands was reported between slight and moderate by 36.1%. the time during which professors were prevented from carrying out their work due to the most-often reported musculoskeletal pain was from 1 to 7 days in 33.3% of the professors who reported discomfort in the wrists or hands, in 19.7% of those with pain in the dorsal or lumbar region and in 19.5% of those who reported neck discomfort. of all the participants, 73.8% reported musculoskeletal discomfort on some body segment during the week prior to the study (last seven days). only 9.8% of the professors consulted and received treatment for the discomfort reported. table 3. discomfort self-perceived by professors by body segment neck shoulder elbow or forearm wrists or hands dorsal or lumbar discomfort last six months yes 41 (67.2) 23(37.7) 13(21.3) 30(49.2) 38(62.3) no 20(32.8) 38(62.3) 48(78.7) 31(50.8) 23(37.7) intensity of pain slight 11(18) 7(11.5) 5(8.2) 12(19.7) 8(13.1) moderate 13(21.3) 8(13.1) 4(6.6) 10(16.4) 9(14.8) strong 13(21.3) 6(9.8) 2(3.3) 4(6.6) 10(16.4) very strong 4(6.6) 2(3.3) 2(3.3) 4(6.6) 11(18) time of impediment 1 day 22(53.6) 19(82.6) 9(69.2) 19(63.3) 19(50) 1 to 7 days 8(19.5) 3(13) 2 (15.4) 10(33.3) 12(31.6) 1 to 4 weeks 2(4.9) 1(4.35) 0 0 2(5.3) had no impediment 9(21.9) 0 2(15.4) 1(3.3) 5(13.2) level of risk at the home workplace using the rosa instrument, data shown in table 4, 94.7% of the participants reported pain in the last six months, and 84.2% manifested pain in the last seven days. 76.3% of the professors who reported work duration of more than eight hours daily were classified in the “necessary action” category. 60.9% of professors in the “minimum action” category work more than eight hours daily in a sitting posture in front of a screen; 34.8% and 43.5% do not report pain during the periods inquired. the “requires action” category was 11 portilla, velásquez, lópez & ávila may 2023. christian journal for global health 10(1) statistically significantly associated with the presence of pain in the last seven days, as well as with duration of teaching per day and with change of position. table 4. risk level of professors during remote work at home rosa score minimum action necessary action total p value sex female male 10(43.5) 13(56.5) 25(65.8) 13(34.2) 35(57.4) 26(42.6) 0.088 pain last six months yes no 15(65.2) 8(34.8) 36(94.7) 2(5.3) 51(83.6) 10(16.4) 0.004* pain last seven days yes no 13(56.5) 10(43.5) 32(84.2) 6(15.8) 45(73.8) 16(26.2) 0.033* hours of teaching /day < 8 h > 8 h 14(60.9) 9(39.1) 9(23.7) 29(76.3) 23(37.7) 38(62.3) 0.04 required change of workplace yes no 7(30.4) 16(69.6) 25(67.6) 12(32.4) 32(53.3) 28(46.7) 0.005 note: *the p value obtained corresponds to fisher’s exact test of note, the percentage of women requiring action was 64.8% with respect to 34.2% for men. however, chi square testing did not show these differences to be statistically significant. discussion during the mandatory confinement during the covid-19 pandemic, university professors reported the onset or worsening of musculoskeletal discomfort occasioned by the ergonomic conditions of a home workplace. this agrees with the report by vallejo et al.,4 who found that virtual working is associated with the onset of musculoskeletal symptoms. our study found 83.6% of the participants reporting pain in some body segment associated with sitting postures working at video terminals, a similar result to that reported in the research by garcia salirrosas,5 who, under the same study conditions, found that 100% of the professors participating had musculoskeletal discomfort. the musculoskeletal discomfort associated with work conditions is the result of postural biomechanical alterations characterized by accumulated static muscle tension, especially in the neck and lower back muscles, as well as repetitive movements in wrists and hands, as stated by vernaza-pinzon & sierra torres.14 the areas with the greatest presence of pain reported by the professors participating in the study were the neck (67.2%), the dorsal or lumbar region (62.3%), and wrists or hands (49.2%), similar results to those published by gutierrez & diaz9 who indicated presence of pain in 85.5% of the participants in the following segments: neck (81.9%), dorsal or lumbar (72.3%), and wrists or hands (45.8%). regarding the time dedicated to remote work activities at home, duration more than eight hours was associated with the need to implement action measures. there was also evidence that posture, static load, and repetitive movements were supplement to time in front of the computer in terms of risk. in relation to identifying the level of risk, the study results show that 94.7% of the participants who reported pain were placed in the category of necessary action, an important condition to intervene to avoid the onset of occupational diseases. this finding is higher than that found by vallejo, where 50% of the people placed in the category of necessary or immediate action. these results highlight the importance of studying the management of ergonomic risk by the professors, as well as training the professors on the prevention of occupational risks in work conducted with video terminals, the importance of active breaks to allow rest and comfort for stressed muscles. a low participation by professors is a limitation of the study, which hinders extrapolating the results to the entire population. conclusion the ergonomic conditions of the workplace adopted during work at home by professors during the confinement period are associated with the onset or worsening of musculoskeletal discomfort, especially in the neck, dorsal-lumbar region, and portilla, velásquez, lópez & ávila 12 may 2023. christian journal for global health 10(1) wrist-hand area; the situation was aggravated in professors who reported a work shift lasting more than eight hours and required adaptations to their home workplace. references 1. congress of the republic of colombia. law 2121 of 2021. by means of which the work regime is created and norms are established to promote it, regulate it and other provisions are issued [internet]. 2021. available from: https://www.medigraphic.com/cgibin/new/resumen.cgi 2. vialart vmn. estrategias didácticas para la virtualización del proceso enseñanza aprendizaje en tiempos de covid-19. 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(s.f.). available from: https://www.prevencionintegral.com/canalorp/papers/orp-2014/validacioncuestionarionordico-musculoesqueletico-estandarizado-enpoblacion-espanola 13. instituto de salud pública de chile. jaime ibacache araya. departamento salud ocupacional. cuestionario nórdico estandarizado de percepción de síntomas musculoesqueléticos [internet] [standardized nordic questionnaire for the perception of musculoskeletal symptoms]. available from: https://www.ispch.cl/sites/default/files/ntpercepc ionsintomasme01-3062020a.pdf 14. diego-mas ja. evaluación de puestos de trabajo de oficinas mediante el método rosa. https://www.medigraphic.com/cgi-bin/new/resumen.cgi https://www.medigraphic.com/cgi-bin/new/resumen.cgi https://www.medigraphic.com/cgi-bin/new/resumen.cgi https://www.medigraphic.com/cgi-bin/new/resumen.cgi https://www.academia.edu/43532610/psicolog%c3%ada_en_contextos_de_covid_19_desaf%c3%ados_poscuarentena_en_colombia https://www.academia.edu/43532610/psicolog%c3%ada_en_contextos_de_covid_19_desaf%c3%ados_poscuarentena_en_colombia https://www.academia.edu/43532610/psicolog%c3%ada_en_contextos_de_covid_19_desaf%c3%ados_poscuarentena_en_colombia https://doi.org/10.21897/23460466.2330 https://doi.org/10.15381/anales.v81i3.18841 https://dx.doi.org/10.4321/s0465-546x2014000100004 https://dx.doi.org/10.4321/s0465-546x2014000100004 https://apps.who.int/iris/handle/10665/327897 https://doi.org/10.22267/rus.212303 https://doi.org/10.1186/s12891-021-04652-4 https://doi.org/10.1186/s12891-021-04652-4 https://doi.org/10.1016/j.apergo.2011.03.008 https://www.prevencionintegral.com/canal-orp/papers/orp-2014/validacioncuestionario-nordico-musculoesqueletico-estandarizado-en-poblacion-espanola https://www.prevencionintegral.com/canal-orp/papers/orp-2014/validacioncuestionario-nordico-musculoesqueletico-estandarizado-en-poblacion-espanola https://www.prevencionintegral.com/canal-orp/papers/orp-2014/validacioncuestionario-nordico-musculoesqueletico-estandarizado-en-poblacion-espanola https://www.prevencionintegral.com/canal-orp/papers/orp-2014/validacioncuestionario-nordico-musculoesqueletico-estandarizado-en-poblacion-espanola https://www.ispch.cl/sites/default/files/ntpercepcionsintomasme01-3062020a.pdf https://www.ispch.cl/sites/default/files/ntpercepcionsintomasme01-3062020a.pdf 13 portilla, velásquez, lópez & ávila may 2023. christian journal for global health 10(1) ergonautas, universidad politécnica de valencia [internet]. 2019. [evaluation of office jobs using the rosa method. ergonauts, polytechnic] [consulted 10-03-2022]. available from: http://www.ergonautas.upv.es/metodos/rosa/rosaayuda.php 15. vernaza p, torres c. dolor músculo-esquelético y su asociación con factores de riesgo ergonómicos, en trabajadores administrativos [internet]. [musculoskeletal pain and its association with ergonomic risk factors in administrative workers] revista de salud pública. 2005;77(3):317-26. available from: https://revistas.unal.edu.co/index.php/revsaludpub lica/article/view/96035 peer reviewed: submitted 1 feb 2023, revised & accepted 26 april 2023, published 29 may 2023 competing interests: none declared. acknowledgements: the authors express their gratitude to the professors participating in the study and to universidad de los llanos for funding the project. correspondence: margarita portilla, villavicencio, columbia mportilla@unillanos.edu.co cite this article as: portilla diaz m, goméz velásquez s, galvis lópez cr, ortegón ávila s. musculoskeletal discomfort associated with remote work conditions of professors during the covid-19 confinement. christ j global health. may 2023; 10(1):7-13. https://doi.org/10.15566/cjgh.v10i1.747 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://www.ergonautas.upv.es/metodos/rosa/rosa-ayuda.php http://www.ergonautas.upv.es/metodos/rosa/rosa-ayuda.php https://revistas.unal.edu.co/index.php/revsaludpublica/article/view/96035 https://revistas.unal.edu.co/index.php/revsaludpublica/article/view/96035 mailto:mportilla@unillanos.edu.co https://doi.org/10.15566/cjgh.v10i1.747 http://creativecommons.org/licenses/by/4.0/ abstract key words: musculoskeletal pain, ergonomic evaluation, professor, working conditions, pandemic, covid-19 introduction conclusion original article research as mission: experiences and expectations of mission agency leadership regarding the ministry role of clinical and public health research carlan wendler a, doug lindberg b, greg sund c a md, director of emergency medicine, kibuye hope hospital, kibuye, burundi professor of emergency medicine, hope africa university, bujumbura, burundi adjunct professor of emergency medicine, keck som at usc, los angeles, ca, usa b md, director, center for advancing healthcare missions, christian medical and dental associations, usa. c md, chief anæsthetist, department of anæsthesia, aic kijabe hospital, kenya abstract introduction: research as a focus of healthcare missions is an important component of the evolving role of healthcare missionaries and sending organizations in lmics. there is a lack of data and understanding on what appetite exists to expand and invest in such research initiatives. methods: this study surveyed leaders of north american mission sending agencies engaged in healthcare, seeking to ascertain their current and anticipated future involvement in research, education, and healthcare delivery. results: forty-seven leaders responded (of 211 contacted) to our survey of whom 37 completed all survey questions. eighty-two percent of respondents agreed that they had a responsibility as an organization to study how to improve clinical care and public health. sixty-four percent of respondents anticipated reduced healthcare delivery in the next 10 years. during that same 10-year, time frame, 61% anticipate an increase in health research mentoring, and 79% expect an increased role of student education. however, this emerging shift towards research and education is not yet reflected with a similar degree of perceived enthusiasm among missionaries in doing research or donors in supporting it. discussion: across the spectrum of middleand upper-level leadership in a variety of missions sending organizations, there is recognition of an important and increasing role for healthcare research activities in ministry. about half of the agencies represented in our sample are already involved in research and will need to share best practices with others as healthcare missionaries devote more time and attention to research mentorship. done well, this can provide additional avenues for disciple-making in both home and host cultures as well as improve the care for populations in those remote and rural areas often most served by healthcare missionaries. 69 wendler, lindberg & sund june 2022. christian journal for global health 9(1) conclusion: research as mission has, heretofore, been a neglected methodology, but institutional leaders in healthcare missions anticipate an increasingly important ministry role for it. key words: global health, research, mission, leadership, mentorship introduction from the earliest days of healthcare missions, missionary healthcare providers have been engaged in direct patient care and training national providers. in addition to the countless anecdotes in newsletters and blogs, a series of articles on the impact of faith-based healthcare noted that, “the slowly emerging evidence on faithbased health providers suggests that they are not simply a health systems relic of a bygone missionary era, but still have relevance and a part to play (especially in fragile health systems).”1 that role has and continues to change. the alma ata declaration of 1978 encouraged a move from missionary as clinician to missionary as trainer.2 two generations later, the 2015 lancet commission on global surgery spotlighted the need for safe and affordable surgical and anesthetic care in addition to primary healthcare.3 as the landscape of global health changes, it is imperative that missionary providers re-evaluate the role they play.4 new tools in telecommunications, remote learning, and international scholarship permit a reimagination of what healthcare missions might look like over the next decades. as training opportunities continue to grow in many lowand middle-income countries (lmics), the need for western missionaries to provide direct patient care will inevitably decrease. as the church considers the evolving role of healthcare missionaries in the world, a natural progression might be for the cross-cultural worker to aid in developing and deploying systems that allow homegrown providers to collect and disseminate practice-guiding data. while westerners participate in research in lmics, this is often performed as “helicopter” research, referring to studies performed by westerners dropping into a host country to run studies and then publishing findings with little or no recognition of local staff involved.5 though the challenges to carrying out high-quality data collection and research in low-resource settings are numerous, the christian belief that every person is an imagebearer requires that it be done in a way that honors all.6 missionary healthcare providers are in a privileged position to facilitate ethical research done with excellence. these types of collaborations already exist, as with the pan african academy of christian surgeons (paacs),7 a partnership between loma linda university and a conglomeration of rural christian mission hospitals across africa that has already published numerous academic articles.8-10 to what degree has a trend towards research partnership between missionaries and host communities already begun? how do those in leadership of north american missions anticipate that it will progress? the present study is our attempt to begin to address those questions. materials & methods in march 2021, the study authors emailed 211 members of a healthcare missions leadership mailing list soliciting their participation. most of these individuals are not healthcare workers but are leaders of organizations engaged in healthcare missions. they received an introductory email and a survey link for a 21-item questionnaire administered through the qualtrics platform (see appendix 1 for survey questions). the landing page for the survey included a brief description of the study aims and a consent statement which had to be answered prior to continuing to the actual questionnaire. only wendler, lindberg & sund 70 june 2022. christian journal for global health 9(1) respondents who completed all 21 elements were included in the analysis. for comparisons involving healthcare activity, responses were collated and classified according to a predetermined (5-2-1-0) scoring system according to answers to items 7-9 (see appendix). where appropriate, subgroup comparisons were evaluated for statistical significance by chi-square analysis and student t test. results forty-seven (47) people responded to the survey invitations of which forty-four (44) opted in and thirty-seven (37) provided complete or nearcomplete information and were included in the analysis, giving a response rate of 17.5%. eleven respondents (30%) were female and the majority (51%) were ≥60 years old with four (11%) <40 years old and three (8%) 40-49 years old. ministry experience was likewise split with the majority (51%) reporting ≥15 years of service in missions leadership. nine respondents identified themselves with the highest organizational rank of “president / executive director / ceo or equivalent,” while five self-identified as “vicepresident / director of mission or equivalent.” two respondents chose “medical director/ superintendent or equivalent” and six opted for “other” with descriptions ranging from “board member” to “program director.” the breakdowns of age x gender and rank x age are shown in figures 1 and 2. women were represented in all ranks and in every age range <70 years old. figure 1. age distribution by gender large missions (>250 fielded units) were the most represented group with sixteen (43%) survey respondents though analysis of their answers to other mission-specific questions indicated that no one large mission was responsible for multiple respondents. the weighting of the missions towards healthcare fell into a tripartite division with fourteen (38%) claiming fewer than 15% of their fielded units being healthcare related, eleven (30%) claiming 15-50% of units being healthcare related, and twelve (32%) claiming the majority of their units were healthcare related. figure 2. institutional rank by age 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 <40 40-49 50-59 60-69 ≥70 female male 0 1 2 3 4 5 6 7 8 9 10 11 president vp dept area med dir other <40 40-49 50-59 60-69 ≥70 71 wendler, lindberg & sund june 2022. christian journal for global health 9(1) table 1 summarizes the proportions of large and non-large missions in each healthcare weighting class. table 1. healthcare weighting by mission size large (>250 fielded units) non-large missions minimal (<15%) 5 9 moderate (1550%) 6 5 main (>50% healthcare) 10 2 when asked to rank their mission ’s healthcare activity in three categories, eight (22%) considered healthcare delivery to be their predominant or primary activity, three (8%) considered healthcare education to be so, and none considered healthcare research as such. using a point system (predominant or primary activity-5, major emphasis-2, minor emphasis-1, minimal or not active-0) to grade overall activity in the three domains, healthcare delivery ranked as most active (70 points), healthcare education second (63 points), and healthcare research as least active (17 points). forty-seven percent of respondents reported that someone in their mission had attempted a research project in the prior 24 months while 35% reported that their organization had received some kind of outside assistance for research (including grants, consultation, ethical oversight, etc.) within the same timeframe. if asked by a healthcare missionary for help developing or deploying a research project, 61% of respondents agreed that they could make a contact recommendation immediately, though only 12% agreed that their organizations were ready to pay a consultant to help missionaries conduct research. the median time they thought a healthcare missionary ought to spend on research activities was 8 hours per month (iqr 4,10) though respondents estimated that such only spent a median of 2 hours (iqr 1.25,8) doing so. respondents agreed decisively (82% agreed with 18% unsure) that a christian mission involved in healthcare has a responsibility to study how to improve the clinical care and/or public health of the patients it serves. however, they were less confident (39% agreed with 55% unsure) that the healthcare missionaries in their organizations were eager for more support in doing clinical and public health research with nationals. even greater uncertainty (30% agreed, 61% unsure) marked their assessment of whether donors to their organizations would be eager to support missionary efforts in clinical and public health research with nationals. when asked to make a 10-year prediction about the direction of healthcare missions, 18% of respondents thought that healthcare delivery would increase with 64% anticipating it would decrease. seventy-nine percent of respondents predicted that the role of health student education would increase in the same period, and 61% foresaw a similar increase in the role of health research mentoring. only two respondents (6%) predicted a decrease in health research mentoring, both of whom predicted an overall decrease in health-related activities in missions. figure 3 summarizes these results. figure 3. leaders’ predictions of future direction for healthcare missions (n = 32 responding) wendler, lindberg & sund 72 june 2022. christian journal for global health 9(1) subgroup analyses of responses to the questions about research attempts and experience, research responsibility and enthusiasm, and the future directions of healthcare missions failed to demonstrate any statistically significant differences on the basis of mission size, healthcare weightedness, or healthcare activity focus though there was a trend towards greater missionary eagerness for research support in those missions that were most heavily weighted towards healthcare missionaries (67% vs 32% in less heavily-weighted missions, p ≈ 0.1). discussion demographic comparisons for the makeup of upper and middle leadership in missions organizations are sparse. the email distribution list used for this study was at least 31% female (any indeterminate first names were not counted as female), which tracks with the fraction of female respondents (30%). some recent studies of physician missionaries11,12 have found women to comprise about half to two-thirds of respondents, though it is these authors ’belief that such is unlikely to accurately estimate the current gender distribution among missions leadership. the age distribution skewed older and more experienced than the authors anticipated with slightly more than half of respondents being aged ≥60 years old and having ≥15 years of missions leadership experience. given the distribution of institutional ranks represented, one might have expected a somewhat younger sample. if representative, this finding ought to compel a renewed investment in disciple-making within the home office as the next decade will likely see substantial turnover in healthcare missions leadership. it is no surprise that the largest missions agencies surveyed reported the least focused activity in healthcare. though one respondent claimed that his mission of >250 fielded units was health specific (100% healthcare or allied workers), the authors were unable to independently verify the identity of that organization. likewise, the low estimate of research activity was unsurprising as other methodologies have been ascendant in recent generations. however, the responses regarding missionary time commitments revealed a relatively high priority on research activity. if confirmed, the perceived gap between how much time leaders think healthcare missionaries should spend on research and how much they actually do spend should prompt reflection on what barriers missionaries face in investing in research. an upgrade in missionary and mission research capability is needed, especially when viewed in light of developments in digital communications, data-driven decisionmaking in missions and healthcare, and the successful implementation of well-trained indigenous healthcare providers in cross-cultural ministry. no respondent disagreed that a christian mission involved in healthcare provision has a responsibility to study how to improve the clinical care and/or public health of the patients they serve, and yet, only less than half were aware of any attempts at research from within their missions in the prior two years. if these missions leaders are correct in predicting that healthcare delivery will decrease (64%) and health research mentoring will increase (61%) in the next ten years, then the half of these organizations not doing research will need to pivot towards research mentoring, and the other half will need to share best practices. high-quality data collection and research in lmics (where most healthcare missionaries are working) has been neglected for many years. to offer one example, the african peri-operative research group (aporg), representing over 30 countries and 500 hospitals across the continent, recently drafted their top ten priorities for research in africa, including establishing evidence-based, practice guidelines, establishment of a minimum, dataset, surgical registry, and improved evaluation of perioperative outcomes associated with 73 wendler, lindberg & sund june 2022. christian journal for global health 9(1) emergency surgery.13 all of these priorities present opportunities for collaboration between missionary healthcare providers and their local national partners. rural district hospitals (where missionaries often work) have been particularly neglected from this global conversation about research and quality improvement.14,15 healthcare missionaries are in a particularly advantageous position to strengthen (or initiate) research efforts in these settings. our study had several limitations. though above average for this type of survey, our (completed) response rate was 17.5%. as for any opt-in instrument, there is a risk that our respondents represented the most enthusiastic supporters (or opponents) of research in global healthcare missions, which would bias the results. we did not ask any additional demographic information beyond sex, age bracket, and years of experience in missions leadership, and both the invite and the survey were in english, which could leave our sample skewed towards one ethnolinguistic viewpoint, though follow-up correspondence confirmed that at least some nonwestern perspectives were represented in the sample. further, being christian physicianresearchers interested in the role of research in missions, our own bias in favor of collecting data to guide decisions inevitably colored the wording of survey questions, which may reify our perceptions. conclusion our results suggest that healthcare research is currently neglected amongst healthcare missionaries and their supporting organizations. given the changing landscape in healthcare, in particular in lmics, we believe the time has come for these servants to re-evaluate their strategies and priorities to include healthcarerelated research and research mentoring in the coming years. this will require a shift in the preparation and training of such missionaries and increased collaboration between western-based, academic centers and hospitals found in lowresource settings. this needs to be done circumspectly, as history warns of predatory practices, of local partners used for the purpose of data collection and omitted from presenting or publishing the results. however, if done well, research can honor and empower national partners. the results of such collaborations will be increased capacity to achieve local solutions to local problems and a god-honoring unity between nationals and their mission partners. in addition, these efforts may offer missionaries an opportunity to collaborate with western secular institutions, developing relationships with “unreached” people in the missionaries’ home culture. best practices for such collaborations are already emerging.16-18 the role of the cross-cultural healthcare missionary is changing as a result of god ’s gracious provision for national providers to excel in clinical care and in training their replacements. the waning need in some places for cross-cultural workers to provide direct patient care and technical education opens the possibility for them to devote energy and expertise to research partnerships and mentorships. the disciplemaking potential of such relationships is by no means impoverished compared with other healthcare missionary activities and represents a rich vein for cross-cultural collaboration and reciprocal learning. references 1. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock f, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015 oct 31;386(10005):1765-75. https://doi.org/10.1016/s0140-6736(15)60251-3 2. the world health organization. alma ata declaration. [cited 2022 mar 22]. available from: https://www.who.int/teams/social-determinantsof-health/declaration-of-alma-ata 3. meara jg, leather aj, hagander l, alkire bc, alonso n, ameh ea, et al. global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. lancet. 2015 aug 8;386(9993):569-624. https://doi.org/10.1016/s0140-6736(15)60160-x https://doi.org/10.1016/s0140-6736(15)60251-3 https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata https://doi.org/10.1016/s0140-6736(15)60160-x wendler, lindberg & sund 74 june 2022. christian journal for global health 9(1) 4. wood p. the evolution of church/mission hospitals in africa. evang missions quart online. 2011 july 1; 47(3):336-40. 5. the lancet global health. closing the door on parachutes and parasites. lancet glob health. 2018 jun;6(6):e593. https://doi.org/10.1016/s2214-109x(18)30239-0 6. sund gc. research at the district hospital in lowincome countries. anesth analg. 2020 may;130(5):e156-e157. https://doi.org/10.1213/ane.0000000000004716 7. pan-african academy of christian surgeons. available from: https://paacs.net 8. sund g, huang ah, mascha ej, miburo c, machemedze s, razafimanantsoa m, et al. delays to essential surgery at four faith based hospitals in rural sub-saharan africa. anz j surg. 2022 jan;92(1-2):228-34. https://doi.org/10.1111/ans.17433 9. long c, titus ngwa te, popat ra, lawong ek, brown ja, wren sm. factors associated with delays to surgical presentation in north-west cameroon. surgery. 2015 sep;158(3):756-63. https://doi.org/10.1016/j.surg.2015.04.016 10. van essen c, steffes b, thelander k, akinyi b, li hf, tarpley m. increasing and retaining african surgeons working in rural hospitals: an analysis of paacs surgeons with twenty-year program follow-up. world j surg. 2019:43;75–86. https://doi.org/10.1007/s00268-018-4781-9 11. strand ma, chen a, mellinger j, slusher t, pelletier a. report of the prism survey: patterns and responses in intercultural service in medicine. medical missions survey working group of the continuing medical and dental education commission of the christian medical and dental association. 2011. 8. 12. strand ma, wood a. that healthcare missionaries might flourish: global healthcare workers needs assessment report. medsend. 2015. fargo, nd, usa. 13. biccard bm. african peri-operative research group (aporg) working group. priorities for peri-operative research in africa. anaesthesia. 2020 jan;75(1):e28-e33. https://doi.org/10.1111/anae.14934 14. fort al. the quantitative and qualitative contributions of faith-based organizations to healthcare: the kenya case. christ j global health. 2017 nov;4(3):60-71. https://doi.org/10.15566/cjgh.v4i3.191 15. rajbhandari r, mcmahon de, rhatigan jj, farmer pe. the neglected hospital the district hospital's central role in global health care delivery. n engl j med. 2020 jan 30;382(5):397400. https://doi.org/10.1056/nejmp1911298 16. noor am (2022) country ownership in global health. plos glob public health 2(2): e0000113. https://doi.org/10.1371/journal.pgph.0000113 17. hirner s, saunders c, stassen w. the ethical considerations for emergency care research in lowand middle-income countries: a scoping review of the published literature. af j emerg med. 2022;12(1):71-6. https://doi.org/10.1016/j.afjem.2021.12.001 18. strand m, mellinger j, slusher t, chen a, pelletier a. re-imaging medical missions: results of the prism survey. evang missions q;49(4): 430-9. available from: https://missionexus.org/reimaging-medical-missions-results-of-the-prismsurvey/ peer reviewed: submitted 15 april 2022, accepted 16 may 2022, published 20 june 2022 competing interests: none declared. acknowledgements: this research was supported by a grant from the shen family foundation through the african medical education fund. correspondence: dr. carlan wendler cwendler@serge.org cite this article as: wendler c, lindberg d, sund g. research as mission: experiences and expectations of missions agency leadership regarding the ministry role of clinical and public health research. christ j global health. june 2022; 9(1):68-76. https://doi.org/10.15566/cjgh.v9i1.647 https://doi.org/10.1016/s2214-109x(18)30239-0 https://doi.org/10.1213/ane.0000000000004716 https://paacs.net/ https://doi.org/10.1111/ans.17433 https://doi.org/10.1016/j.surg.2015.04.016 https://doi.org/10.1007/s00268-018-4781-9 https://doi.org/10.1111/anae.14934 https://doi.org/10.15566/cjgh.v4i3.191 https://doi.org/10.1056/nejmp1911298 https://doi.org/10.1371/journal.pgph.0000113 https://doi.org/10.1016/j.afjem.2021.12.001 https://missionexus.org/re-imaging-medical-missions-results-of-the-prism-survey/ https://missionexus.org/re-imaging-medical-missions-results-of-the-prism-survey/ https://missionexus.org/re-imaging-medical-missions-results-of-the-prism-survey/ mailto:cwendler@serge.org https://doi.org/10.15566/cjgh.v9i1.647 75 wendler, lindberg & sund june 2022. christian journal for global health 9(1) © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ appendix: questionnaire (after consent obtained) 1. what is your gender? (male, female) 2. what is your age range? (<40, 40-49, 50-59, 60-69, ≥70) 3. what is your role in your organization? (president / executive director / ceo / equivalent, vicepresident / director of mission / equivalent, department head / assistant director / equivalent, area or regional supervisor / domain-specific leader under department head, other (please describe) 4. how long have you served in missions leadership? (<5 yrs, 5-9 yrs, 10-14 yrs, 15-19 yrs, ≥20 yrs) 5. how many long-term units does your organization currently have on the field? (long-term unit: an individual or family with their own account, designation, or contract with your organization serving for a 2 year term or longer.) (<10, 10-24, 25-49, 50-99, 100-250, >250) 6. approximately what percentage of those long-term units are in healthcare or an allied field? don't worry about exact numbers 7. how active is your organization in healthcare delivery? (wherein the missionary directly diagnoses and treats patients.) (minimal or not active, minor emphasis, major emphasis, predominant or primary activity) 8. how active is your organization in healthcare education? (wherein the missionary trains nationals to care for patients.) (minimal or not active, minor emphasis, major emphasis, predominant or primary activity) 9. how active is your organization in healthcare research? (wherein the missionary & nationals investigate how best to care for patients.) (minimal or not active, minor emphasis, major emphasis, predominant or primary activity) 10. how many hours per month do you believe the average healthcare missionary in your organization should spend on research activities, clinical and/or public health? (includes designing studies submitting ethics approvals, collecting and analyzing data, publishing or presenting results.) ideally (should) (0-20 slider) 11. how many hours per month do you believe the average healthcare missionary in your organization actually spends on research activities, clinical and/or public health? (includes designing studies submitting ethics approvals, collecting and analyzing data, publishing or presenting results.) actually (does) (0-20 slider) 12. has anyone in your organization attempted clinical or public health research in the past 24 months? (even if results were never shared or published) (yes, unsure, no) 13. has anyone in your organization received assistance in clinical or public health research in the past 24 months? (include grants, consultants, ethical oversight) (yes, unsure, no) 14. rate your agreement with this statement: “if a healthcare missionary in my organization asked me today for help developing and deploying a research study, i could recommend someone (or a group to contact) almost immediately.” (agree, neither agree nor disagree, disagree) 15. rate your agreement with this statement: “i believe our organization is ready today to pay someone (either a staff member or contractor) specifically to help healthcare missionaries do research as part of their ministry?” (if your organization already pays such a person, please mark "agree.") (agree, neither agree nor disagree, disagree) http://creativecommons.org/licenses/by/4.0/ wendler, lindberg & sund 76 june 2022. christian journal for global health 9(1) 16. in the next 10 years, i anticipate that the role of healthcare delivery (missionaries caring for patients) in cross-cultural missions will _______ (increase, stay about the same, decrease) 17. in the next 10 years, i anticipate that the role of health student education (missionaries training nationals) in cross-cultural missions will _______ (increase, stay about the same, decrease) 18. in the next 10 years, i anticipate that the role of health research mentoring (missionaries conducting studies with nationals) in cross-cultural missions will _______ (increase, stay about the same, decrease) 19. rate your agreement with the following statement: “a christian mission involved in healthcare has a responsibility to study how to improve the clinical care and/or public health of the patients it serves." (agree, neither agree nor disagree, disagree) 20. rate your agreement with the following statement: “the healthcare missionaries in our organization are eager for more support in doing clinical and public health research with nationals.” (agree, neither agree nor disagree, disagree) 21. rate your agreement with the following statement: “the donors to our organization would be eager to support missionary efforts in clinical and public health research with nationals." (agree, neither agree nor disagree, disagree) (two additional elements pertained to participation in a follow-up interview and processing of a small financial incentive–a donation to the project of the respondent’s choice among 4 pre-selected organizations.) abstract key words: global health, research, mission, leadership, mentorship introduction materials & methods results discussion conclusion references conference report nov 2015. christian journal for global health, 2(2):82-83. global access conference: where disabilities and possibilities meet jonathan chua a a manager, international outreach, joni and friends international disability center february 17-20, 2015: calvary community church westlake village, ca, usa the global access conference was a significant step forward in the mission of joni and friends to communicate the gospel and equip christhonoring churches worldwide to evangelize and disciple people affected by disabilities. over 1000 people from 39 states across the usa and 54 countries around the world heard from more than 100 speakers over 4 days in 10 plenary sessions, 9 panel discussions, and 48 workshops. among the attendees were the representatives of 330 churches, 123 were individuals with disabilities, and 470 were leaders in ministry. the main goals of the conference were to: edify participants with practical knowledge and resources to accelerate their ministry; engage participants in a global network of like-minded people and organizations; and encourage the worldwide mission of the body of christ through people with disabilities. the topics covered at the conference spanned four major categories: leadership development and biblical counseling, ministry in sensitive cultural contexts, mission and disability ministry, and technology and disability. one of the highlights of the conference was a 17 by 6.5 foot mural painted live during the conference by artist hyatt moore. the mural captured an artistic rendition of the banquet described in luke 14 where the poor, the crippled, the blind, and the lame were invited in by the master. this passage is one of the central motivations of joni and friends to do ministry with people affected by disabilities around the world. the mural depicts people of various nationalities in traditional garb—some with disabilities and some typically abled—partaking of a heavenly banquet. association was launched as a continuation of the effort to edify, engage, and encourage those involved in the global disability ministry movement. four hundred fifty participants signed up for the association. speaking about the association, joni eareckson tada said: the world’s 1 billion people with disabilities are desperately crying out for help and hope. this is why the global access association is critically needed. we simply must resource, network with, and help one another reach for christ this global population! participants of the conference also had the opportunity to attend a pre-release screening of “the drop box,” a documentary about pastor lee jong-rak in south korea who cares for unwanted infants—many with disabilities—who are left in a “baby box” that he created. joni and friends also released a short film, “ebenezer,” that celebrates the distribution of the 100,000th wheelchair delivered by the wheels for the world program. the conference was followed up by a lausanne movement consultation called ministry access led by dave duel, the senior associate for disability concerns for lausanne. thirty disability ministry leaders from various countries and organizations gathered on february 21 st to discuss the obstacles that people with disabilities face when it comes to taking on leadership roles in the local church and christian organizations. the participants 83 chua nov 2015. christian journal for global health, 2(2):82-83. included lausanne young leaders, leaders engaged in disability ministry around the world, and leaders from joni and friends, who hosted the event. the passage that set the tone for the discussion was “do not curse the deaf or put a stumbling block in front of the blind, but fear your god. i am the lord” (lev 19:14, niv). ministry access focused on addressing these stumbling blocks so that individuals are enabled to take on leadership roles based on their calling and gifting and not false perceptions of their leadership abilities. competing interests: none declared. correspondence: jonathan chua, joni and friends, united states. jchua@joniandfriends.org cite this article as: chua j. global access conference: where disabilities and possibilities meet. christian journal for global health (nov 2015), 2(2): 82-83. © chua j this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:jchua@joniandfriends.org http://creativecommons.org/licenses/by/3.0/ historical review may 2016. christian journal for global health, 3(1): 11-24. christian milestones in global health: the declarations of tübingen steffen flessa a a phd, professor, department of health care management, university of greifswald, germany abstract the conferences on christian health care which were held in tübingen (germany) in 1964 and 1967 set a foundation for understanding the role of christian health care services in the healing ministry of the church. however, it has to be asked whether the findings of these conferences are still relevant for the 21st century. in this paper we analyze the changes of the global health care provision since the declarations of tübingen. based on this analysis we argue that christian health care services are still called to contribute to the struggle for health and healing worldwide, in particular for the vulnerables. however, this requires a thorough portfolio analysis of our services rendered and a focus on spirituality in particular of the leadership. introduction the healing ministry of the church covers all dimensions of human existence: body, soul, and spirit. thus, christians are called to holistic healthcare as an essential of their faith. 1 consequently, christians have almost always been engaged in healing, caring for the sick, and establishing institutions of charity for the poor and needy. in the late 19 th and early 20 th centuries, church-based hospitals were founded all over the world, frequently growing to major institutions with thousands of co-workers. 2 for many people, christianity and hospitals became almost identical, particularly in the former colonies where mission hospitals frequently constituted the backbone of diaconal work of the new churches. 3 although mission hospitals could never cover the entire population, they were an essential element of the healthcare sector in most regions of the world, particularly in sub-saharan africa and asia. 4 however, the concept of medical-missionbased big hospitals where “white doctors” provided western medicine was challenged. in may 1964, representatives from protestant mission societies gathered in the little town of tübingen, germany, to discuss the “healing ministry in the mission of the church.” 5 the results of “tübingen i” (19 th 24 th of may 1964) and of the subsequent “tübingen ii” (1 st – 8 th of september 1967) conferences had a major impact on the self-perception and the strategies of christian healthwork. 6 although the majority of statements stipulated at these conferences were not completely new, the declarations from tübingen gained an unprecedented momentum and led to the foundation of the christian medical commission (cmc), which had a strong impact on the development of the primary health care paradigm of the world health organization. 7,8 recently, the world health organization (who) titled its world health report as “primary health care — now more than ever.” 9 with this report, who clearly underlined that the principles of primary health care (phc) stipulated in alma ata had become increasingly relevant, even in the 12 flessa may 2016. christian journal for global health, 3(1): 11-24. 21 st century. naturally, some concepts of phc have to be adopted to the “challenges of a changing world.” 9 however, the main paradigms and objectives remain unchanged. this confirmation of phc by the who strongly contradicts the poor perception of the declarations of tübingen by the world-wide churches and the mission societies in the 21 st century where the knowledge of tübingen is almost lost. even the christian medical commission dissolved into the world council of churches, losing almost all relevance for the medical field. consequently, one has to ask whether the declarations of tübingen are merely an historic event without any relevance for the future of christian healthcare services in the 21 st century. under which conditions could we state “50 years of tübingen — now more than ever”? and what must change in christian healthcare and not only in resourcepoor countries so that they can continue fulfilling their call in the future? this paper argues that the core statements of the declarations of tübingen i and ii are not only historical events but of high relevance for the future of christian healthcare services if they are transferred to the 21 st century and adapted to the new conditions. for this purpose, we will present the history of christian health services from an economic perspective. we are aware of the fact that this is only one dimension of christian health services, but one that might be eye-opening for the relevance of the history and the perspectives of the future. consequently, in the next section, we will discuss the basic declarations of tübingen and alma ata. afterwards we will analyze the development of christian health services, focusing on resource-poor countries from early colonial times to the new millennium. the paper then closes with some conclusions. fundamental declarations the declarations of tübingen and alma ata were of high relevance for the development of christian health care in the second half of the 20 th century. in this section, we describe the concepts. the quest for health and healing: tübingen i and ii after world war ii, the traditional approach of providing church-based health services in the colonies or newly independent countries was criticized for its paternalistic approach where western mission societies, missionaries, and (white) doctors knew what their patients needed, as the patients were begging for help. 10-18 at the same time, it became obvious that christian healthcare services were not nearly as successful and sustainable as missionary societies had always believed. as a reply to this critique, directors of major protestant mission societies gathered to analyze and discuss their work in tübingen, germany, from the 19 th to the 24 th of may 1964 (tübingen i). they realized that their services were not reaching the majority of people so their system was very unjust. mcgilvray, the former director of the christian medical commission (cmc), described the situation with these words: “. . . these church-related institutions, together with all the other available facilities of western medicine, were reaching only 20% of the population in these countries and were thus sustaining a grave injustice to the 80% who remained deprived of any services at all.” 19 in addition, they realized that due to technical progress, the costs of medical treatment had increased tremendously in the existing institutions, so that even the little that was being done could not be sustained. 6 table 1 summarizes the most important findings of tübingen i by citing the most relevant headings of the declaration (shortened by the author). 13 flessa may 2016. christian journal for global health, 3(1): 11-24. table 1. most important findings of tübingen i 6 1) the christian concept of the healing ministry a) the christian church has a specific task in the field of healing. b) the specific character of the christian understanding of health and of healing arises from its place in the whole christian belief about god’s plan of salvation for mankind. c) the christian ministry of healing belongs primarily to the congregation as a whole and only in that context to those who are specially trained. d) the christian ministry of healing as exercised by the church is subject to him who is the lord and head of the church and to the continuing guidance of the holy spirit. 2) the role of the congregation in the ministry of healing a) in scripture, both sickness and healing are distinctly corporate experiences. b) all healing is of god. c) within this understanding, it follows that the congregation has a central and responsible role in the healing ministry. d) the congregation has a very special responsibility for those of its members who are engaged in medical institutional work. e) the congregation should encourage its members to enter the healing professions. 3) the healing ministry in theological training a) a christian understanding of healing is already implicit in theology. b) in spite of this, no explicit teaching on the christian understanding of healing is given in most of our theological colleges and seminaries. c) it is imperative that teaching should be given on this subject in all our theological colleges and seminaries. d) the department of theological education in which the practical significance of the ministry of healing can most effectively be made explicit is that of pastoral theology. e) the laity also needs training in the ministry of healing, and this must be kept in mind in theological training. 4) the training of medical and para-medical workers as a task of the church a) continuing efforts to improve the professional quality of medical work and the teaching of co-workers need to be recognized as an integral and essential part of any form of medical evangelistic service. b) the consultation recognizes the churches' responsibility in medical education. c) it is urged that immediate consideration be given to the extension of intern and residency training facilities in existing church-related hospitals. d) the consultation believes that nursing-education should be carried on at every level. e) similar consideration should be given to the training of para-medical workers. f) special attention needs to be given to the selection of the chaplain and specialized training. g) involvement in organized christian medical work must be regarded as a specialty in itself. h) the church should encourage suitably qualified members to accept teaching positions in universities, medical colleges, nurse schools, and similar secular institutions of learning as a special challenge to christian witness in teaching. 5) the institutional forms of a healing ministry a) it will be necessary to study first the role of the medical institution within this context and secondly to see how far other forms of medical service are relevant and necessary. b) we must first confess that the medical institution and the church, on the national and more particularly on the local level, have traveled too often in separate directions. while the hospital or clinic may have substantially aided in the initial creation of a congregation, it has usually failed to commend itself as a continuing expression of that congregation's healing concern. c) the time is long overdue for the complete integration of the hospital and clinic into the life and witness of the church . . . where there appears to be no evidence or potential understanding of this integration of healing function, the continuance of the institution must be seriously questioned. d) the size of a medical institution should never exceed what is necessary for its established purpose or the capacity of the total christian community supporting it and ministering through it. e) we recommend as pilot projects within selected hospitals the initiation of a team concept of therapy, wherein the physician, nurse, psychiatrist, and pastoral counselor should unite to treat the patient in the totality of his sickness. f) other forms of service, through which the church should continue to express its healing ministry, lie in the fields of leprosy, tuberculosis, care of the chronically iii and aged, rehabilitation, psychiatry, and maternal and child health. 14 flessa may 2016. christian journal for global health, 3(1): 11-24. g) the pattern of institutional therapy has too long prevailed in the church to the detriment of the intimate relationship between patient and doctor in the general practice situation. the healing congregation might well involve its doctor members in this new relationship and challenge their response and commitment. h) the church must always recognize that it can never meet all of need and should regard new avenues of service as demonstrations of how need should be met. 6) the relationship of a christian healing ministry to government 7) joint planning and use of resources for the healing ministry a) to an increasing extent, financial resources are being allocated without regard to denominational lines. b) interdenominational and international assignment of medical missionary personnel should be extended. c) churches are not sufficiently aware of the urgent need for joint planning. d) the involvement of the congregation in the ministry of healing demands a reappraisal of existing cooperative structures. 8) a continuing program of study and work a) the first is an effective gathering, analyzing, and making generally available the very large amount of work in survey and study that has been done and is in progress around the world. b) the second is the encouragement of study and survey at local, regional, and international levels. c) the third is the carrying out of pilot and experimental projects in an integrated program of healing. for the topic of this paper, the most important result of this consultation was the insight that mission hospitals practiced a type of medicine that was not in line with the biblical understanding of salvation and healing. instead of placing the healing mission of the church on the shoulders of a few medical experts, the entire church was designated as the “healing body of christ” to fulfill the healing ministry. 20-22 existing hospitals, they concluded, “were, basically, repair facilities which did little if anything to remove the causes of sickness or to promote and maintain health.” it was realized that medical mission must include preventive services and that god is interested in holistic healing, in shalom, including problems of guilt, suffering, and death. 23,24 therefore, the declaration of tübingen i called for the empowerment of the entire church as the healing body of christ. everybody in this church is called to participate in the healing ministry. it was the basic outcome of this consultation that christian healing was only possible in participation with all stakeholders. the declaration of tübingen i was received well in developing countries. several local consultations followed, and in 1967 (tübingen ii, 1.-8. september 1967), a new, community-based approach was declared obligatory for churchrelated healthcare services. 25-27,28 the innovative work was coordinated by the newly founded cmc. from 1973 to the early 1980s, this institution was in close contact with the world health organization, highly influencing the development of the alma ata declaration. 8 health for all by the year 2000: declaration of alma ata some 25 years after its inauguration on april 7, 1948, the world health organization had to recognize that the most important health problems had not declined. on the contrary, financing the existing health services had become more and more difficult as technical progress in medical technology and pharmacology made “health for all” more and more expensive. 29 in a search for new solutions, the director general of the who, halfdan mahler, recognized that the decisions of tübingen were relevant for all health care systems in developing countries, not only for church-related services. the concept of primary health care (phc) that was discussed and approved during the world health assembly in 1978 can be interpreted as a secular advancement of the declarations of tübingen. 30 primary healthcare is based on the traditional concept of hygiene but enriched by a healthpolitical dimension and a strong element of participation. 31-34 primary healthcare is a conception of health policy, i.e., it is not a level of healthcare, but a comprehensive philosophy of 15 flessa may 2016. christian journal for global health, 3(1): 11-24. healthcare underlying all decisions in the health field. it is fundamentally oriented to the needs of the community and intends to include the community in all processes of determining objectives and means of healthcare. the stakeholders of the community are to accept responsibility for their own health, so that institution or program-based healthcare becomes a community based healthcare (cbhc). thus, phc and cbhc introduce the concept of participation as an essential dimension of the health care system. the strong community approach was rejected by many institutions and policy makers. some saw it as expression of a left-wing political movement, as art. iii of the declaration refers to a “new international economic order,” and article x states that high military expenditure is a major reason for poor health. werner & sanders write: “many of the principles of primary health care were garnered from china and from the diverse experiences of small, struggling nongovernmental community-based health programs (cbhp) in the philippines, latin america, and elsewhere. the intimate connection of many of these initiatives to political reform movements explains to some extent why the concepts underlying phc have received both criticism and praise for being revolutionary.” 35 more important was the criticism from health specialists stating that phc was utopian. 1215,36-40 they called for strict priorities, in particular, a concentration on vertical programs to fight childhood diseases. contrary to the original comprehensive primary health care (cphc) concept of the who, the selective primary health care (sphc) and the expanded program on immunization (epi), in particular, could work without strong community participation. 41,42 the failure to implement the comprehensive primary healthcare concept in most developing countries has been frequently discussed and has many reasons. flessa developed an innovative model with several barriers to implementation. 43 firstly, he describes that innovations (such as the revolutionary content of the declarations of tübingen and alma ata) have only a chance to be adopted if the existing system is perceived as unsatisfactory. otherwise, decision-makers will try to improve the existing system instead of accepting the new one. if donors continue supporting the existing curative healthcare system, it is likely that this steady flow of funds stabilizes the old system and blocks the adoption of the new. secondly, the higher the costs of an innovation are, the less likely it will be adopted. the costs of introducing cbhc-systems were frequently underestimated. thirdly, the more decisionmakers seek a quick win, the less likely they will invest healthcare resources in prevention and primary care. some measures of cbhc will only see a return in investment in decades (e.g., vaccinations); whereas, the results of curative care are always visible in the year of investment. this is, fourthly, associated with risk-perception. innovation always involves risk, so that it is generally true that the more risk-averse people are, the less likely they will accept an innovation. finally, leadership style determines the likelihood of adopting primary healthcare innovation. the more freedom superiors grant to their subordinates, the more likely they will experiment, seek for innovations, and find new solutions. however, neither mission societies nor churches in developing countries are well-known for a participatory leadership style that encourages their members to take risks and think beyond existing structures. consequently, flessa concludes that it was very unlikely that the declarations of tübingen and alma ata would be welcome by christian healthcare services and that the original objectives of tübingen and alma ata have — in the years after introducing selective primary healthcare — almost disappeared from the agenda of healthcare policy makers. freedom as the fundamental right to participate in all processes with impact on one’s life was reduced to the freedom to choose between different providers. participation of the local population in setting priorities in healthcare, in designing healthcare services, and in controlling institutions and programs has almost disappeared from the political, as well as from the research, arena. 16 flessa may 2016. christian journal for global health, 3(1): 11-24. however, the declarations of tübingen and alma ata are the two basic foundations of christian health care services. in order to understand their relevance for church-related healthcare, we have to see them in their historic perspective. the next sections will sketch the developments in order to analyse the relevance, in particular, of tübingen i and ii for the future of christian health services. colonial and early post-colonial time the 19 th century saw an increased awareness by christians in europe and northern america for the evangelistic and diaconal call of the church. in many countries, hospitals, homes for the poor, and mission societies were founded and started their charitable work. in particular, mission societies planted health stations and, later, hospitals in the countries of their work. the majority of christian healthcare institutions in these regions were built in rural areas; whereas, colonial powers frequently concentrated on towns of strategic importance. in most rural places, churches had a natural monopoly for “modern” health care. “natural” here means that the next provider was so far away that the catchment population of the healthcare provider had actually no chance to reach the alternative provider. the maximum distance of travel was lower than the distance between the institutions. as a consequence, christian healthcare providers did not have to justify their existence by any other characteristic than by their presence. christian healthcare services in sub-saharan africa and asia were “good” simply because they were there. if they had not existed, nobody else would have been there. in case of a monopoly, the provider did not have to be better than others, and the provider did not have to find reasons why he/she provided services. there was plainly no alternative. the declarations of tübingen came at a time where the contribution of christian healthcare to the health of the population was not challenged. during the conferences, nobody questioned whether there was a need for christian healthcare services in these areas, as they were natural monopolies. the delegates of the conferences were aware of the fact that the newly independent states and their governments would start buildingup a “safety net for the poor,” but at the time of tübingen i and ii, there was hardly any competition in the healthcare field. 44 the economic problems that they saw, such as increasing costs of medical equipment and drugs, were strong forces behind the declarations of tübingen, but they had nothing to do with local competition for patients. late 20th century towards the end of the 20 th century, the situation in almost all parts of the world changed. figure 1 shows the development of public health facilities in kenya between 1959 and 2002. it is obvious that there are some areas where a healthcare facility still has a natural monopoly based on distances. however, these are in sparsely populated regions. the vast majority of kenyans have a choice of provider. christian healthcare providers have lost their monopolies almost everywhere. government facilities cover nearly the entire country, and in many cases, christian and government facilities are within walking distance. 17 flessa may 2016. christian journal for global health, 3(1): 11-24. figure 1. public health facilities in kenya (1959 and 2002). 45 figure 1 does not include private for-profit healthcare providers. the 1990s and the new millennium have also seen a strong rise of these institutions. figure 2 shows that governmental, christian, and private for-profit providers are strongly competing in the thika district, kenya. for a long time a few private providers had offered their services to the rich minorities in major towns. they were no competitors for christian service providers, as they had completely different target groups. however, the situation has changed dramatically. the poor frequently cannot afford christian services anymore and seek help elsewhere. as flessa shows, tanzanian church-based healthcare providers frequently have to charge higher fees than government institutions to recover their costs so that the poorest tend to avoid christian institutions. 43 at the same time, private providers have discovered the poorer strata as their clients, most likely not the poorest of the poor, but, in particular, the “working poor.” that is, many private for-profit healthcare providers have opened their dispensaries, pharmacies, and hospitals, even in rural places, for the non-rich, and they compete directly with christian healthcare services. the time of monopolies for the majority of christian institutions is over, the era of “business of health in africa” has come. 46 18 flessa may 2016. christian journal for global health, 3(1): 11-24. figure 2. hospitals in thika district, kenya (2008). 47 the loss of the monopoly challenges the economic foundation of many christian healthcare providers. in the years after 1990, several of them were poorly utilized as patients moved to the improved governmental providers or to the fast and user-friendly private providers. 48 in many african and asian countries, christian institutions maintained a monopoly of quality for some time as they had access to international drug markets through their international connections. however, through liberalization and economic strengthening in several of these countries, governments and private for-profit providers could offer the same quality of services in the new millennium and, thus, taking the last visible reason of exceptionality of christian healthcare providers. however, the loss of the monopoly position impacted more than the economy. the most crucial impact was that christian healthcare providers had to justify their existence. simple presence does not any longer justify existence as it did decades ago. towards the end of the 20 th century, governments, national and local societies, as well as the international and donor community started asking for good reasons for the existence of these christian institutions. in a market economy, and most countries have moved in that direction even in the healthcare system, any market element must have a comparative advantage to survive. it can be cheaper, have a higher quality, or provide a rare utility component. christian healthcare institutions are no exception; they are asked to justify their existence by lower fees, better quality, or a dimension of services that cannot be offered by other institutions. another important change happened in the international policy arena. the “natural” partner of the christian medical commission (cmc) was the world health organization, both residing in geneva. indeed, cmc gained quite some influence on the who. however, as shown in section 2, a few years after alma ata, unicef adopted the concept of “selective primary healthcare” which degraded the original concept of “comprehensive primary healthcare” to a few target groups and diseases. a few years later, the 19 flessa may 2016. christian journal for global health, 3(1): 11-24. world bank entered the arena as a major player. the 1993 world development report “investing in health” became a milestone in international health policy. 49 this report not only called for more cost-effectiveness in healthcare, but it moved the“philosophical” and value-based discussion in a technical direction with the concept of disability adjusted life year (daly). 50 the daly reduces human health purely to its physical dimension, miles away from the tübingen concept of wholeness. the world bank became the prime mover in global health and not who, where mission societies or christian healthcare services had had a major influence. the who reacted with accusations, but finally accepted and adopted the world bank concepts. although the world health organization came back to the international policy arena in the late 1990s under gro harlem brundland, the christian community has had very little influence in the subsequent developments. neither the “joint commission on macro-economics and health” nor the development of the “millennium development goals” was systematically influenced by the church or church-related institutions. 51 it is a matter of fact that individual christians were in the relevant committees, but they did not bring the value-based discussions of tübingen into these committees. in particular, the mdgs clearly focused on the physical dimension of life without any reference to social or spiritual existence. in the new millennium, we might be closer to “health for all,” but the world bank, unicef, and who concept of “health” is definitely not the concept of tübingen i and ii. universal health coverage and the new millennium this development contributes the concept called “universal health coverage” (uhc). the concept itself is not new, but it gained political relevance in the new millennium. the world health report 2010 was titled “health systems financing: the path to universal coverage.” 52 within the next few years, a number of conferences on uhc were held in mexico city (political declaration on universal health coverage 2012), bangkok (statement on universal health coverage 2012), tunis (declaration on value for money, sustainability and accountability in the health sector 2012), and the unresolution on december 12, 2012, “transition of national health care systems towards universal coverage,” all accepting uhc as a major target of all healthcare systems. who defines uhc as “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.” 53 evans, hsu, & boerma express it in other words: “universal health coverage is the obtainment of good health services de facto without fear of financial hardship.” 54 consequently, uhc is not a revival of “health for all by the year 2000,” but a focus on healthcare provision and social security. figure 3 shows the dimensions of uhc. the concept implies that all members of the society should have a right to receive a comprehensive package of healthcare services at affordable prices. it is generally accepted that uhc will only be achieved by the establishment of some form of social health insurance. local and small-scale initiatives, such as the community based health insurances frequently supported by churches, will not suffice. 20 flessa may 2016. christian journal for global health, 3(1): 11-24. figure 3. universal health care-cube. 52 population: who is covered? services: which services are covered? extend to non-covered reduce cost sharing and fees include other services direct costs: proportion of the costs covered the concept of uhc has been criticized for its strong focus on health financing and technicalfunctional dimensions of health. 55 some critique is inspired by christian theology, e.g., from i. illich. 56 however, this critique has had very little impact on the conceptualization of uhc, and it is about to become, explicitly or implicitly, a backbone of the post-mdg period. we can clearly state that christian healthcare services have had hardly any influence on this development. this is particularly disappointing, as uhc definitely falls short of the holistic concept of health stipulated in tübingen. uhc could require a stronger focus on health instead of healthcare, but christian institutions have lost their influence on healthcare policy-making. in addition, in a number of developing countries, we already see the consequences of social security as an element of uhc. potential patients obtain insurance coverage. they become clients and customers, not just beneficiaries of good christians, and they receive a right to choose between different providers. even the poor, the target group of a number of health insurance projects in developing countries, suddenly have the right to decide where they will go for services. consequently, the future will see in sub-saharan africa and asia a similar situation as exists in europe and northern america already today: christian healthcare services as normal market partners. from a pure economic perspective, they have lost all exceptionality. they compete with other providers: churches, government, and scores of private for-profit enterprises, and some of them will face the same fate as many churchbased healthcare institutions all over the world: after a century of great history, they will go bankrupt and cease to exist. many of the remaining christian healthcare providers cannot be distinguished from their private or governmental competitors. 57 uhc and social protection led to free choice of providers, and it is not yet known whether people will always continue choosing the christian provider. consequently, 50 years after the declaration of tübingen, christian healthcare services are called anew to define their purpose and their distinctiveness. however, today, it is not only a question of defining “a better way to serve the lord,” but it is also a question of life or death. the existence of our institutions must be justified to save their existence. conclusions knowledge of the tübingen declarations among decision-makers of christian healthcare services is declining. it has to be asked whether these declarations are simply historic events or 21 flessa may 2016. christian journal for global health, 3(1): 11-24. whether they still have an important message for christian healthcare services in the new millennium. a first step in the analysis is to compare the situation of the 1960s with today. the economic conditions of christian healthcare services at the time of the declarations of tübingen were quite different from today. church-related healthcare providers were monopolists without competition, providing existential services for their catchment population within rather simple systems. today, the situation is already different for the majority of christian services worldwide. technicalfunctional services for the physical dimension of life are provided by many competent competitors. in many locations, pure presence is not a justification for existence anymore. in sub-saharan africa and asia, there are still christian healthcare providers with limited or no competition. however, this situation is due to change as soon as these countries are successful in their strides towards universal health coverage and the establishment of social security systems. in particular, as the poorest of the poor are covered by subsidized insurance schemes, beneficiaries become customers with rights, with purchasing power, and with choices. all of these expected developments are positive and should be welcomed — but they challenge the selfperception of christian healthcare services. in this situation, the declarations of tübingen i and ii become highly relevant again. thus, in a second step of analysis, we have to ask anew whether we should be distinguishable from all other providers, what criteria could make us special, and how we can find our place in the health care market. the old search for the “proprium” (latin: property, what belongs to someone) or distinctiveness of christian healthcare, as it was stipulated in the declarations of tübingen, is relevant “now more than ever.” if we do not find contemporary answers to the “quest for health and wholeness,” christian healthcare services can neither survive nor fulfill their call for healing and salvation. 6 today, there is a great need for a new vision of distinctiveness and spirituality in christian healthcare services. the findings from 1964 and 1967 can still be guiding principles for the future of christian healthcare services so that we can indeed state “50 years of tübingen — now more than ever!” christians have a unique contribution to give, grounded in the theology of health and healing as well as in the reality of competitive health care markets. but, they have to know their values, their history, and the changes of the demographic, economic, and social environment to make christian healthcare services functional and sustainable. future research is needed on the translation of the principles of the declarations of tübingen for the service portfolio, the leadership, and the spirituality of christian healthcare providers. references 1. evangelische kirche in deutschland. texte zum schwerpunktthema: diakonie, 3. tagung der 9. synode der ekd. munster. 1-6 november 1998. hannover: evangelische kirche in deutschland; 1998. german. 2. 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supported the underlying presentation. correspondence: professor dr. steffen fleßa, universität greifswald, friedrich-loeffler-straße 70 17487 greifswald, deutschland. steffen.flessa@uni-greifswald.de cite this article as: flessa, s. christian milestones in global health: the declarations of tübingen. christian journal for global health (may 2016), 3(1):11-24. ©flessa, s. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:steffen.flessa@uni-greifswald.de http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ book review nov 2015. christian journal for global health, 2(2): 76-77. religion as a social determinant of public health, by ellen idler, ed, oxford university press, 2014 stephen c. ko a a md, ma, mph, mdiv, assistant professor of global health, boston university school of public health, usa. the overall assertion of this unique work lies squarely in its title, religion as a social determinant of public health. as the prevailing research and policy model utilized in public health, the social determinants perspective presupposes that primary determinants of health are not necessarily clinical care and the provision of services, but rather the circumstances and conditions affecting daily living. the authors contend that religion should not only be considered as an independent determinant of health, but also for its various interactions with other influential determinants such as politics and economics. in 2005, emory university began a strategic initiative on religion and human spirit, resulting in the formation of the religion and public health collaborative. the origins of this book stem from this initial collaborative and subsequent interdisciplinary faculty seminar from 2010-2013. during this time, predominantly emory faculty from a diverse set of scientific, scholarly, and professional backgrounds developed the outlines, manuscripts, and eventual chapters of the volume. divided into five parts, the first reports on religious practices within major faith traditions worldwide. categorized by their cycles of repetition, scholars portray time-honored practices contextualized within their religious frames. daily practices of vegetarianism in seventh day adventists and refuge meditation in contemporary buddhism are presented alongside weekly practices celebrating eucharist in roman catholicism. annual religious practices such as fasting in islam are described alongside one-time religious practices of circumcision in judaism and baptism among latin american pentecostals. these depictions provide the groundwork for analysis of associations between religion and public health. the second part traces the impact of religion on public health in the last two centuries, exclusively within the united states and england. major movements are assessed, the first being john wesley’s impact on public health through the methodist church. there, a fundamental burden for the poor led to increased access to healthcare and enhancement of layman medical training through the publication primitive physick. within the united states, the social gospel movement’s positive impact on public health is juxtaposed to the deleterious effects of 19 th century comstock laws on reproductive health. in the third part, authors investigate current research involving religion as a social determinant of individual physical and mental health along a life course perspective. from religious beliefs and their impact on maternal and child health to rituals and the comfort they provide to geriatric patients coping with end of life issues, empiric evidence is deconstructed and examined. meanwhile, the natural intersection between religious practices and mental health is considered, focusing on the impact of ethical values and moral emotions. in the fourth part of the book, the effect of religious institutions on global health is reviewed in the context of low and middle income countries. highlights include a historical narrative of the complex relationship between neighboring world council of churches and world health organization. initial collaborative programs between the two institu77 ko nov 2015. christian journal for global health 2(2): 76-77. tions are uncovered while tracing the evolution of hospital-based tertiary care to an emphasis on primary care reaching individual communities. this christian medical commission focus ultimately led to who’s momentous alma-ata declaration on primary care in 1978. the history of several prominent religious organizations are espoused, including the african religious health assets programme (arhap) with its pioneering focus on identifying and understanding the role of religious assets for health. other highlighted religious institutions include the la leche league, heifer international, shri kshetra dharmasthala rural development program, khaka ahsania mission, and l’arche community. finally, the role of religion and religious institutions is scrutinized during three principal public health challenges in recent history. these include hiv/aids, influenza, and alzheimer’s disease. each is unique in its epidemiology, pathophysiology, morbidity, and mortality. yet, each possesses epidemic potential beyond geopolitical borders. in particular, the complex role of religious institutions within the history of the hiv/aids crisis is conveyed. this includes positive impacts such as the creation of the aids national interfaith network along with more nuanced tensions resulting from religious beliefs that hiv virus is a punishment from god, the consequence of immoral behavior, or the result of karma. the authors have built a compelling argument supporting the addition of religion as a significant determinant of public health. they have done this by investigating the complex effects of religion and religious institutions on public health in various contexts throughout history. the book’s unique interdisciplinary approach yields different perspectives into the complexity of this topic while affirming the need for broader conversation and dialogue. in july 2015, the lancet published a series on “faith-based healthcare” arguing that the extensive experiences, strengths, and capacities of faith-based organizations offer a unique opportunity to improve health outcomes. for christians, the paradigm of holistic ministry encompassing physical and spiritual healing dates back to levitical laws within the pentateuch and the earthly ministry of christ. not surprisingly, christian ideology and christian institutions have had a major impact on public health for some time. however, these roles have largely been overlooked, discounted, and ignored. with burgeoning awareness and momentum, the essays within this book lay the foundation for inclusion of religion, religious beliefs, and religious institutions as social determinants of public health. in doing so, they reinforce the incorporation of christian beliefs, practice, and theology within the framework of public health participation and research. for it is precisely these underlying principles of charity, compassion, and selfsacrificial love that lie at the heart of influential christian engagement. competing interests: none declared. dr. ko is on the editorial board of cjgh correspondence: professor stephen c ko. 801 massachusetts avenue, 3 rd floor, boston, ma 02118. usa. scko@bu.edu cite this article as: ko, s. book review: religion as a social determinant of public health, by ellen ldler, oxford university press, 2014. christian journal for global health (nov 2015), 2(2): 76-77. © ko, s. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:scko@bu.edu http://creativecommons.org/licenses/by/3.0/ original article nov 2015. christian journal for global health, 2(2):39-51. inclusion of physical therapy services on a short term mobile medical mission team to nicaragua: a qualitative description study of team members’ observations and recommendations for improvement douglas steele a and candice beitman b a dhs, dpt, mhs, pa-c, pt, cpt, physican assistant: uf health department of orthopedic surgery and rehabiliation b ot edd, retired associate professor, school of occupational therapy, university of indianapolis abstract context: access to physical therapy (pt) services is sorely limited in many developing countries due to the constraints of poverty and regional insufficiency in the number of pt providers. opportunities exist for physical therapists to participate in short term mobile medical mission (stmmm) efforts to provide pt services in many of those regions. however, there is a relative dearth of research regarding the utility of including pt services in stmmm endeavors. objective: the aim of this study was to ascertain the impressions and recommendations of medical mission team members regarding the inclusion of pt services during a stmmm trip to underserved areas of nicaragua. methods: this was a qualitative description study conducted in 2014. data were derived from interviews with stmmm participants and analyzed using conventional content analysis as described by hsieh and shannon. results: emergent themes included evidence of: (1) patient need for and benefit from pt services; (2) team member need for physical therapy services for trip related disorders; and (3) a high prevalence of patient orthopedic disorders related to strenuous activities of daily living. there were also a number of reported limitations in the delivery of pt services including: (1) language barriers; (2) lack of medical provider familiarity with pt capability; and (3) limited means of providing follow-up care. respondent recommendations included: (1) addition of more translators; (2) inclusion of additional treatment modalities; (3) utilization of nicaraguan therapists or health care workers to facilitate patient follow-up; and (4) the provision of a comprehensive screening program to improve identification of patients in need of pt services. conclusion: this study contributes to the understanding of corollaries associated with the addition of pt services to a stmmm and provides recommendations to improve 40 steele & beitman nov 2015. christian journal for global health, 2(2):39-51. pt services in that context. additional research is needed to evaluate the soundness of participant responses and whether this information is transferable to stmmm efforts in other communities. further research is also needed to establish best pt practices in the stmmm context. introduction the need to improve global health care is agonizingly evident but that mission is fraught with barriers. peters et al. found that people in impoverished countries tend to have less access to health services than those in more prosperous countries and that the poverty-stricken within countries tend to have less access to healthcare as well. 1 access to health care is also negatively affected by a low ratio of healthcare providers to population in many parts of the world. in 2013, the who global health observatory revealed that 83 primarily low income countries located in central africa, southern asia, indonesia, and central america fell below a density threshold of 22.8 skilled health professionals per 10,000 in population. 2 this deleterious synergy of poverty and regional inadequacy of health care providers is a major factor in limiting access to rehabilitation services as well. a 2011world report on disability from the who estimated that nearly one billion people worldwide, mostly in low and middle income countries, experience some form of disability that requires rehabilitation services. 3 unfortunately, these are also the countries with the fewest number of rehabilitation professionals. liao et al. evaluated member countries of the world confederation for physical therapy from europe, oceania, north america, latin america, asia, and africa in the 1990s and found that the median number of physical therapists was 167 per million people. 4 a 2011 study by gupta et al. revealed similar findings of low and middle income countries having the greatest need for rehabilitation services and the least availability of skilled rehabilitation professionals. 5 nicaragua is a superlative example of a low income country in which there is a great need for rehabilitation services and a relative dearth of physical therapists, particularly in rural areas. 6,7 in 2003, cano, coordinator of rehabilitation for the national technological institute in nicaragua, estimated the rate of disability in nicaragua at close to 15% of the population. 8 the number of people with disorders needing physical therapy (pt) intervention in nicaragua coupled with the barriers of poverty and the limited numbers of rehabilitation professionals available to provide care makes expediting the availability and accessibility of pt services a paramount health care issue. there are a number of ministry institutions that include pt in short term mobile medical mission (stmmm) efforts in nicaragua and other countries with limited access to rehabilitation services. 9-13 however, there is a relative dearth of research available regarding the functionality and utility of including pt services in stmmm endeavors. in 2009, bajkiewicz categorized the three main services of a short term medical mission described in the literature as relief care, during which emergency-response services are provided post disaster; surgical-dental teams, which provide surgical and dental procedures in underdeveloped regions, and mobile clinics, during which mobile health clinics are set up in outlying villages where medical care is limited or nonexistent. 14 the mobile clinics bajkiewicz described have the essentially the same structure and purpose as the stmmm referred to in this research. there are a limited number of publications that discuss the role of physical therapists in what bajkiewicz categorized as relief care. 14 ketter 41 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. reported a physical therapist’s account of his role and inter-professional dynamics while assisting a 40-member emergency medical relief team in nicaragua post hurricane mitch in 1998. 15 the physical therapist reported that he was initially assigned to assist in the dental clinic, but when the medical providers learned there was a physical therapist available, they requested consults for patients with orthopedic conditions, open wounds, and mobility limitations. team members also requested treatment by the physical therapist for various musculoskeletal complaints. nixon et al. examined the role of physical therapists in stmmm for disaster relief in haiti after a 7.0 earthquake struck port-au-prince in january of 2010. 16 rehabilitation needs for people with spinal-cord injuries, amputations, head injuries, and other forms of disablement were reported. faanes et al. described the experiences of physical therapists from united states, canada, africa, and the united kingdom who participated in another relief effort after the 2010 earthquake in haiti. 17 common experiential elements reported included: (1) emotional responses of fear, uncertainty, and gratification; (2) challenges of financial strain, language barriers, coping with devastation, and a wider scope of practice; (3) realization that education of patients, patient’s families, and volunteers was critical to success of the relief effort; and (4) a greater sense of responsibility to help people during crisis. participants in the study by faanes and colleagues also described their roles as clinicians, educators, and consultants as adding to the quality of care patients received following the earthquake. 17 currently available literature provides tangential insight at best into the utility of including pt services in non-emergent stmmm. in lieu of the paucity of contextual research, the purpose of this study was to ascertain the impressions and recommendations of medical mission team members regarding the inclusion of pt services during a stmmm trip to areas of nicaragua with limited access to rehabilitation professionals. determining and evaluating the benefits, limitations and recommended improvements for a mobile medical clinic that includes pt services will enable better planning and execution of future clinics that include rehabilitation professionals. they provide foundational insight for additional research to investigate the clinical efficacy of physical therapy services delivered in the stmmm context. methods this study was approved by the university of indianapolis irb on august 8 th , 2013. qualitative description was used to address the research questions, “what are the observations of medical mission team members regarding the inclusion of pt services on a mobile medical mission team to nicaragua, and what are their recommendations for improvement in the delivery of those services?” sandelowski purports that qualitative description is the ideal research method to facilitate a straightforward depiction of phenomena which was the goal of this study. 18 this approach facilitated the procurement of practical information that could improve planning and execution of pt services during future mission trips and enabled the discernment of operational and patient care issues that were in need of further research. the stmmm from which this research originated took place in apanas, yankee, and anita, three rural villages in the department of jinotega, nicaragua in cooperation with mission para cristo. mission para cristo is a christian faith based ministry that works collaboratively with nicaraguan community and church leaders to provide spiritual, medical, educational, and sustenance resources to impoverished communities within nicaragua. nicaraguans living in rural settings have access to limited healthcare from the minsa health department outposts. 19 however, there are no minsa outposts near the villages of apanas, yankee, and anita. people living in those communities have difficulty accessing health services, especially more specialized services such 42 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. as pt due to the scarcity of providers in the region, difficultly traveling to these sites, and inability to pay for private sector health services. the inclusion criterion was mobile medical mission team members with us stateside phone service. the exclusion criterion was mobile medical mission team members with very limited or no interaction with the delivery of pt services during the mission trip as determined by question one of the post clinic interview. all individuals meeting the inclusion criterion and agreeing to participate in the study reviewed and signed an informed consent document. each of the individuals who agreed to participate in this research was given a copy of the study interview questions during the informed consent process. (appendix a) research participants included: (1) three physical therapists with aggregate expertise in orthopedics, neurology, gerontology, and pediatrics; (2) a broad range of medical professionals including a physician specializing in internal medicine, a nurse practitioner/dietician, a physician assistant /physical therapist, a pharmacist, and triage nurse; and (3) eleven nursing students that included both entry level and rn to bsn transition students. each clinic day, patients were triaged by a nurse with the assistance of nursing students and referred to medical providers first but on occasion directly to pt based on patient complaints. all patients receiving pt for whom synergistic medication was indicated were assessed by medical providers and screened for drug allergies, contraindications, and comorbidities prior to prescribing those medications. this interactive format facilitated consultations between the pt and other professionals on a regular basis. a semi-structured phone interview was performed and digitally recorded within 14 days of the last clinic by the primary researcher to enhance dependability (the degree to which data and its analysis remain stable over time). 20 seventeen of the 19 individuals who agreed to participate were ultimately included in the study. one individual could not be reached by phone and one individual indicated she did not have the opportunity to observe or participate in pt in any significant way and was therefore excluded from the study. the digital recordings were then transcribed verbatim by the primary researcher. intermittent rechecks of the accuracy of transcription was performed periodically during the process. the data was de-identified to ensure confidentiality with methods recommended by mclellan et al. 21 upon completion of the de-identification process, data analysis of the transcripts was performed using qualitative content analysis. according to hsieh-fang and shannon, conventional content analysis is a good option when: (1) the study aim is description of a phenomenon; (2) there is limited research on the topic; (3) open ended inquiry is used to acquire data; (4) and when direct information from participants that has not been influenced by preconceived categorization or theory is desired. 22 these were all features of our research project; therefore, conventional content analysis was selected as the method of data analysis. data analysis was initiated by the primary researcher based on repeated readings of the text and preliminary labels were given to themes that reflected key thoughts and concepts to form the bases for an initial coding scheme. a panel was formed of three individuals: (1) a pt phd with expertise in health care administration, ethics, and physical therapy clinical science; (2) an ot edd with expertise in geriatric wellness and rehabilitation, qualitative research, and ot/pt medical missions in belize central america; and (3) a pt scd with expertise in clinical orthopedics, pt medical missions in rural africa. each panel member performed an analysis of the data individually, utilizing the de-identified transcripts based on written instructions that duplicated the analysis format used by the primary researcher. each of the panel member’s individual coding schemes was reconciled with the initial coding scheme by that panel member and the primary 43 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. researcher. this process of panel member and primary researcher review was then continued aggregately until there was agreement on coding scheme that was acceptable to the primary researcher and all panel members for generation of study results. there is general agreement among qualitative researchers that concepts of credibility, transferability, dependability, confirmability, and authenticity can be used to assess the trustworthiness of qualitative research. 20,23-27 definitions of trustworthiness assessment concepts and their sources and application of these concepts in this research study are presented in table 1. table 1. tools utilized to assess research rigor definitions of assessment tools application methods of assessment tools used in this study credibilitya reliable interpretation of the data drawn from participants 28 peer examinationcoding scheme was developed by collaborative data analysis of the primary researcher and expert panel members environmental triangulationthe experiences of participants with pt care included three different communities thereby avoiding isolated phenomena prolonged engagementresearcher and participants had adequate time and context exposure to: (1) understand the research context; (2) facilitate research participant frankness; and (3) recognize and avoid personal preconceptions regarding pt services in stmmm transferabilitydegree to which findings apply beyond the project 20 detailed description of the research context was provided to enable research consumers to determine the applicability to other contexts of inquiry dependabilitydegree to which data and its analysis remain stable 20 digital recording and verbatim transcription of the data from interviews dense description of the research process to facilitate peer review of data during collaborative production of coding scheme confirmabilitydegree to which results can be verified by others 29 reconciliation of the primary researcher’s coding scheme with the independent coding schemes of expert panel members authenticitydemonstration of true reporting of participant ideas 20 prolific use of supporting text for data generated themes results a summary of observation themes and selected supporting text is presented in table 2. table 2. summary of research participant observations and textual support 1) need for and benefits of pt services for patients  patients willingness to travel and wait in long lines for pt demonstrated the need for pt services (respondent 001) “they come and they walk to get to this clinic; some parents walk up to an hour to get to the clinic. they stand in long lines to get services for their child.”  activities of daily living (adl) demands associated with life in rural nicaragua created need for pt (respondent 001) “including the pt into this particular mobile medical mission trip had tremendous benefits for people…. lot of orthopedic issues…related to the life style and their working conditions.”  patient disorders required the expertise of physical therapists for thorough diagnosis and treatment (respondent 008) “the most challenging were pediatric patients. in particular i remember one who was a failure to develop normally who i referred to the pediatric physical therapist, a neuromuscular specialist, got some good insight back on that patient.”  demand for pt services increased as patients attending the mobile clinic learned it was available (respondent 005) “….a lot of people came with a cough and a cold but when they found out pt was there they were like, “oh i have this problem.” 44 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. 2) types of diagnosis and conditions seen in pt  the largest category of conditions reported for children and adults were orthopedic related (respondent 003) “we saw people with neck problems, back problems, hip problems, leg problems, knee problems, ankle problems.”  additional conditions included: 1) pediatric developmental delays; 2) polio; 3) and open wounds (multiple respondents) 3) benefits of pt services for mission team members  having physical therapists enabled collaboration with and education of team members regarding the nature of pt diagnosis and the scope of feasible treatments within a mobile medical mission setting (respondent 002) “i thought it was a very, very beneficial collaboration between the members on the team and pt.  having pt intervention for the team members themselves was beneficial (respondent 004) “a number of people had musculoskeletal complaints that appeared to bother them when they were working in the stressful conditions that mobile medical missions often present with…. there was a definite need for pt intervention for the team members themselves”  physical therapists were able to expand their skill sets contextual to provision of pt services within the constraints of practice in these rural, limited resource environments. (respondent 008) “i think the people benefited and i think the physical therapists benefited from seeing how they could provide care in that kind of setting.” 4) limitations of pt services in the mobile medical mission setting.  language barriers in the context of an inadequate number of translators hindered the delivery of pt (respondent 004) “normally…. there have been more than enough translators, but there were a number of personal emergencies that reduced our number of translators and slowed the process”  limited follow-up for assessment of efficacy of pt and for further intervention if necessary (respondent 003) “part of the issue for me would be wondering about long term follow-up. as we know from the states, we give people exercise programs, they might do it for a short period of time, then they stop, so i would assume that would be the case with people in nicaragua”  limited availability of durable medical rehabilitation and pt treatment equipment (respondent 004) “you simply cannot carry all the equipment that you would like to carry with you”  lack of medical provider awareness of the capability of participating physical (respondent 002) “i think a lot of times some providers are not um, are not knowledgeable on what physical therapy and what things they can possibly do.” a summary of recommendation themes and selected supporting text is presented in table 3. table 3. summary of recommendation themes and textual support 1) recommendations to improve efficiency of delivery of pt during stmmm  increase the number of translators (respondent 004) “…. to ensure that there are an adequate number of qualified translators….is critical in these type of settings.”  devises a more efficient means of provision of durable medical equipment for patients (respondent 012) “obviously you can’t bring a hundred of each….so a little more, more structural supports…..other than that it’s hard to say that there was any better way to of planned….” 45 steele, beitman nov 2015. christian journal for global health, 2(2):39-51.  ensure that medical providers referring to pt are familiar with services the therapists can provide (respondent 002) “possibly, before the, the trip starts is to have a list of things they (physical therapists) would be able to do”  use portable computer and printing technology to provide home exercise programs more efficiently (respondent 004) “i would look at trying to get a battery powered printer that i could hook into a laptop with that exercise program so i could tailor it to each person specifically”  conduct a stmmm that offers only pt services (respondent 017) “….maybe physical therapy were to be a complete clinic of their own” 2) recommendations for additional pt treatment interventions available during stmmm  bring portable physical therapy modality devices such as ultrasound (respondent 002) ”… it might have been beneficial…. to have some type of ultrasound”  include physical therapy providers with women’s health expertise (respondent 002) “…. since this particular uh, mobile medical mission had some women’s health providers on it, a women’s health physical therapist may have been a very, beneficial” 3) recommendations to facilitate sustainability of pt care post stmmm  include nicaraguan physical therapists in the stmmm to facilitate follow-up pt care (respondent 008) “….involve local physical therapy providers…. allow some referrals, some follow-up, some long term care”  train healthcare workers in basic pt interventions that could in turn be taught to the community (respondent 017) “i know on the medical side we would teach the health care providers that serve the community the things that we were doing….then that way they can educate their patient base. i think maybe pt could have benefited from that”  establish a permanent pt clinic that could provide follow-up for communities served by stmmm (respondent 004) “our plans for a new fulltime physical therapy clinic in the pantasma area of nicaragua would be a real benefit for follow-up” 4) recommendations for more comprehensive screening for patients in need of pt services  utilize local missionaries to pre-screen communities for pt related problems prior to the stmmm (respondent 007) “missionaries that were in the field could….have patients that they knew could benefit from physical therapy, have those particular people come to the clinic with a doctor’s order saying this is a physical therapy patient””  screen all patients seen during the stmmm trip for pt related problems (respondent 018) “i would say, maybe ask the patients, after they had stated all their complaints that they wished to bring up, do you have any type of physical needs.”  including an onsite school screening for children in need of pt services (respondent 013) “i think it would be good if they would be able to go when the kids were in school” 46 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. discussion a substantial need for health and rehabilitation services in rural nicaragua has been described in the literature. 7,8 the present study provided evidence consistent with those findings based on respondent observations of a high prevalence of adl related etiologies of musculoskeletal disorders and the tenacity of nicaraguans seeking pt intervention for themselves and their children. respondents also noted the benefits of having the skill sets of physical therapists as diagnosticians and interventionists. respondents also reported that having a pt service on a stmmm was beneficial to the team members for both professional collaboration and for personal treatment of various orthopedic problems that arose during the trip. similar benefits were reported by ketter in a 1999 pt bulletin interview of a physical therapist who had been involved in a stmmm hurricane mitch relief effort. 15 that therapist reported that there were repeated requests for pt consults for both patients and team members. respondents in our study also noted that physical therapist involvement in the stmmm clinic enabled the therapists to expand their skill sets contextual to provision of pt services within the constraints of practice in these rural environments with limited resources. similar adaptability of pt intervention and improvement of skill sets was reported in the ketter interview. 15 another potentially useful theme that emerged from our investigation was regarding the types of diagnoses and conditions treated in the pt service. dupre and colleagues observed that knowing the contextual health care needs of the community you’re attempting to serve with medical mission outreach is of paramount importance. 7 they reported that 95% of the patients their pt team encountered in rural nicaragua presented with a chief complaint of pain and that there were limited complaints of a decline in function. our study similarly found a high prevalence of pain related to orthopedic disorders and limited reports of dysfunction. the respondents in our study also reported other disorders including pediatric developmental delay, open wounds, posture abnormalities, and residual limitations from rare diseases such as polio. both dupre’s and our study indicate that practitioners working in stmmm in similar environments may see a wide variety of disorders but should expect to encounter a large number of musculoskeletal disorders related to the demands of rural living in impoverished conditions. respondents noted a number of limitations of pt practice during this stmmm. having only a limited number of translators was reported to slow the delivery of pt care and may have affected its quality at times. flores assessed the impact of having a medical interpreter service for patients with low english proficiency (lep) on the quality of health care in the us and found that multiple studies documented that quality of care is compromised when lep patients do not get interpreters. 30 in the current study, patients typically had no english speaking skills, magnifying the need for a sufficient number of professional translators which was recommended by numerous respondents. limited means for follow-up and sustainability of pt care was also reported as a limitation of pt services during this stmmm. jack et al. found that in stateside outpatient pt settings where follow-up is readily available, depression, poor social support, and increased pain levels during exercise were all barriers to treatment adherence. 31 sluijs et al. found that forgetfulness to do exercises, lack of positive feedback, and lack of confidence to perform the exercise correctly were all factors in patient non-adherence to pt. 32 the overall degree of compliance with prescribed exercise and pt programs as reported in the literature is between one-third and twothirds of participants . 31-38 based on these research findings, in stateside settings, it seems reasonable that the rates of compliance with pt prescription would be even less in the stmmm setting where no follow-up is available. 47 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. respondents recommended a number of means to address the problems of limited follow-up and sustainability. one was to involve local pt providers in the stmmm and patient follow-up at local facilities. this would be feasible if mission para cristo is able to establish a pt clinic in the region. it was also recommended that physical therapists on the stmmm team teach local health providers how to instruct patients in pt related group classes. in 2014, mission para cristo included simple pt interventions in the continuing education for its community health educators. this allowed the community health educators to provide basic pt services for their patients during community health encounters. limitations in the amount of durable medical and treatment equipment that can be taken on a stmmm trip was a topic of respondent discussion. information regarding the types of diagnoses encountered in a particular setting, as gathered in this study, or in the needs assessment study by dupree, could be helpful in determining the type of physical therapy and durable medical equipment to pack. 7 however, as one respondent in this study noted, the need is ultimately determined by which patients happen to come to that particular stmmm clinic. another noteworthy limitation to the delivery of pt during this stmmm was the lack of medical provider awareness of physical therapists’ scope of practice. this could be a significant problem when using a medical referral model as it constrains referrals to the referring medical provider’s familiarity of pt practice. stanton et al. found a deficit in resident physicians' knowledge of pt. 39 uili et al. found that physician knowledge of pt procedures was dependent on medical specialty and duration of practice. 40 harrison and kisicki assessed the knowledge of arizona-based physician assistants (pas) and nurse practitioners (nps) regarding technical and professional skill sets of physical therapists. 41 while the knowledge level of pas was greater than nps, both demonstrated notable limitations in the understanding of basic modalities and professional interventions. one respondent offered a simple solution to the problem of limited knowledge of pt by medical providers, which was to familiarize them with the expertise and skill sets of the physical therapists participating in the stmmm prior to starting clinic. an additional option would be to use a direct access model with the inclusion of a physical therapist in the triage process and, thereby, ensure that all patients with pt related diagnosis are seen by a pt at some point in their clinic encounter. respondent recommendations to increase community exposure to pt within the stmmm model had strengths and weaknesses. one recommendation was to conduct a clinic that exclusively provided pt services. while a dedicated pt clinic would likely increase community access to pt, it would not provide a venue for treatment of those patients found to have a medical problem. another recommendation was to carry out a community screening program for problems contextual to pt prior to the stmmm using resident missionaries. a better option for this type of screening program would be to utilize government recognized health educators employed by mission para cristo, who already have a basic knowledge of general health issues and practices. another respondent recommendation was to screen all patients seen during the stmmm clinic for pt related issues. as previously noted, this could be facilitated by having a physical therapist work with the triage team. a respondent also recommended that the stmmm be used to facilitate onsite pt screening and treatment of children while at school. while this is likely feasible and worthwhile, it would not facilitate developmental screening beginning at age nine months as recommended by the american academy of pediatrics (aap). 42 there were a number of constraints in this study. phone interview was the most feasible means of ensuring timely respondent contact due to medical professional and nursing student travel schedules and obligations. phone interviews limit 48 steele, beitman nov 2015. christian journal for global health, 2(2):39-51. respondents’ time to think about their answers to the interview questions. this limitation was hopefully negated by providing participants with a copy of the interview questions at the time of informed consent. the use of a phone interview also has the potential to introduce researcher interpretation bias unless exacting measures are taken to ensure data dependability. steps taken to ensure data and analysis dependability included: (1) verbatim transcription of the digitally recorded text to avoid inadvertent interpolation of content; (2) close adherence to the text during production of the primary researcher’s initial coding scheme; (3) scrutiny of the primary researcher’s initial coding scheme by subjecting it to reconciliation with the coding drafts of a three member panel from diverse professional backgrounds; (4) support of analysis themes with multiple textual excerpts. another limitation of this study was the exclusion of stmmm participants that did not have u.s. based phone service. this eliminated nicaraguan translators and transporters participation in the study, both of whom could have provided a unique prospective regarding the inclusion of pt services in the stmmm trip. since the completion of this research, a no cost phone service to the us has been installed at mission para cristo. this could facilitate the inclusion of the nicaraguan members of stmmm in the future or another means of more inclusive data collection could be prearranged in harmony with the stmmm planning. not having the input of local health care providers, particularly physical therapists, in the study was an intrinsic limitation. the lack of physical therapists and other community based health care providers in the areas served by these efforts is of course part of the rationale for conducting stmmm in the region. there are future plans to add a fulltime nicaraguan physical therapist to the staff of mission para cristo. that individual’s participation could facilitate follow-up pt care, provide local provider insight into future qualitative research, and provide a means to collect post stmmm outcomes data to facilitate quantitative inquires. conclusion this study examined the acumens of medical mission participants regarding the inclusion of physical therapists in a stmmm team working in rural nicaragua. four major themes emerged contextual to the research question, “what are the observations of medical mission team members regarding the inclusion of pt services on a mobile medical mission team to underserved areas of nicaragua?” these included need for and benefits of pt for patients, identification of types of diagnosis and conditions seen in pt, benefits of pt services for mission team members, and limitations of pt services in the mobile medical mission setting. there were also four major themes that emerged contextual to the research question, “what are the recommendations of team members for improvement in the delivery of pt services during a mobile medical mission to underserved areas of nicaragua?” these included recommendations to improve efficiency of delivery of pt, recommendations to make additional pt treatment interventions available, recommendations to facilitate follow-up assessment, and sustainability of pt care and recommendations for more comprehensive screening for patients in need of pt intervention. the results were consistent with the objective of the study, which was to add to the understanding of corollaries associated with the addition of pt services to a stmmm and to discern measures that could improve the delivery of pt services in that context. additional 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[epub 2014 may 15]. appendix: a (interview questions) 1) did you have any significant interaction with physical therapy services during the mobile medical mission trip? for instance, did you work directly with the physical therapy service, refer patients to the physical therapy service or assist in the coordination of the service in some way?(if the answer is no, the participant will be thanked for their participation and informed that this is the conclusion of their interview). 2) tell us about your experiences with physical therapy service during this mission trip? 3) what were the most common medical diagnoses of the patients you referred to physical therapy? what were the most interesting or challenging diagnoses of patients you referred to physical therapy? (medical providers) 4) what were the most common physical therapy diagnoses of patients you treated in physical therapy? what were the most interesting or challenging diagnoses of patients you treated in therapy? (physical therapy providers) 5) what were the benefits and limitations associated with including physical therapy services in the mobile medical mission context? 6) what changes could be made to improve the delivery of physical therapy care in the mobile medical mission context? peer reviewed competing interests: none declared. correspondence: douglas steele, harding university, united states. dasteele@harding.edu ; candice beitman, university of indianapolis, united states. cbeitman@uindy.edu cite this article as: steele d, beitman c. inclusion of physical therapy services on a short term mobile medical mission team to nicaragua: a qualitative description study of team members’ observations and recommendations for improvement. christian journal for global health (nov 2015), 2(2): 39-51. © steele d, beitman c this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://dx.doi.org/10.1177/009182969302100305 http://dx.doi.org/10.2105/ajph.2014.301983 mailto:dasteele@harding.edu mailto:cbeitman@uindy.edu http://creativecommons.org/licenses/by/3.0/ review article december 2021. christian journal for global health 8(2) effects of local faith-actor engagement in the uptake and coverage of immunization in lowand middle-income countries: a literature review sara melillo a, rebecca strachan b, carolyn j o'brienc, chizoba wonodid, mona bormete, doug fountain f a mph, usaid’s momentum country and global leadership b msc, usaid’s momentum country and global leadership c msph, usaid’s momentum country and global leadership, christian connections for international health d md, mph, drph, usaid’s momentum country and global leadership, johns hopkins bloomberg school of public health, international vaccine access center e mph, ches, usaid’s momentum country and global leadership, christian connections for international health f mpa, usaid’s momentum country and global leadership, christian connections for international health abstract introduction: religious leaders are universally recognized as having an influence on immunization uptake and coverage in lowand middle-income countries (lmics). despite this, there is limited understanding of three questions: 1) how do religious leaders impact the uptake and coverage of immunization in lmics? 2) what successful strategies exist for working with local faith actors to improve immunization acceptance? and 3) what evidence gaps exist in relation to faith engagement and immunization? methods: in january 2021, we searched pubmed and google scholar databases covering the period from january 1, 2011 to january 15, 2021 with key search terms related to faith engagement and immunization in peer-reviewed literature and conducted a gray literature review to answer these three questions. we excluded articles covering faith engagement and immunization in high-income countries, news articles, online blogs, social media postings, and articles in languages outside of english. data were coded to guide thematic analysis. results: we found extensive evidence supporting the value of religious engagement for immunization promotion and acceptance in lmics across faiths. however, there was limited rigorous evidence and examples of specific approaches for engaging local faith actors to strengthen immunization uptake in lmics. as a result, there is a lack of widely shared knowledge of what works (or doesn’t) and successful models for engaging local faith actors. additional current evidence gaps include: few rigorous study designs; a lack of vaccine hesitancy studies outside of nigeria and pakistan; and limited exploration of faith engagement and immunization in religions other than islam and christianity. melillo, strachan, o’brien, wonodi, bormet & fountain 3 may 2022. christian journal for global health 9(1) conclusions: our review findings reinforce the powerful role local faith actors play in diverse communities within lmics in both promoting and inhibiting immunization uptake. the literature review comes at a critical time, given the urgent need to expand access to covid-19 vaccination in lmics. findings from this review will advance understanding on how to more effectively engage local faith actors in promoting immunization campaigns and addressing vaccine hesitancy, which is more complex than expected. further study is needed to understand how to most effectively counter vaccine hesitancy in different geographic, linguistic, and socio-cultural context. key words: vaccine hesitancy, systematic review, immunization, lowand middleincome countries, faith-based organizations, religious leaders, local faith actors introduction religious leaders and local faith actors are universally recognized as having an influence on immunization uptake and coverage in lowand middle-income countries (lmics).1,2 this association between religion and vaccination dates back to as early as 1,000 ad, when a buddhist nun was described as grinding scabs from a smallpoxinfected person into a powder, blowing it into a nonimmune person’s nostrils to induce immunity.3-5 today, many major religions commonly believe that vaccination—the act of administering a substance that stimulates the body’s immune response against diseases—supports their shared objectives of preserving and protecting life, health, well-being, equity, and prevention of suffering, especially among children and other innocents.5 some religions even call for vaccination as a moral imperative to preserve the lives of children or within a community.3,6 yet, despite the powerful positive potential to reduce and eliminate diseases such as smallpox and polio, religious factors remain the third most frequently cited reason for vaccine hesitancy in global surveys.7-13 vaccine hesitancy in this case is defined as delay in acceptance or refusal of vaccines despite the availability of vaccination services. religiously-linked, vaccine hesitancy concerns are especially pronounced and rising in lmics, though often these concerns are inter-mixed with others related to political, economic, or social issues.13-15 prominent media coverage and academic study of widespread polio vaccine hesitancy among muslim communities in northern nigeria and pakistan in the 2000s and 2010s has further heightened awareness and interest in vaccine hesitancy and faith communities. specific aims of the literature review there is still limited information on and understanding of how faith actors impact the uptake and coverage of immunizations in lmics, as well as what interventions work to counter vaccine hesitancy among local faith actors. to date, the bulk of research on vaccine hesitancy and faith communities has been conducted in high-income countries. we are unaware of efforts to validate vaccine hesitancy measurement tools in sub-saharan africa.16 this is a critical evidence gap, as vaccine hesitancy among faith communities has been demonstrated to negatively impact immunization coverage in certain lmics.17 the rollout of covid19 vaccinations in lmics also represents an acute challenge and opportunity to engage faith leaders in what will be the largest public health vaccination campaign in the past 100 years. the faith engagement team of the us agency for international development’s (usaid’s) momentum country and global leadership program undertook a study of the role of faith communities in vaccine hesitancy. in january 2021, 4 melillo, strachan, o’brien, wonodi, bormet & fountain may 2022. christian journal for global health 9(1) we conducted a literature review to answer three key questions: 1) how do religious leaders and faithbased organizations impact the uptake and coverage of immunization in lmics? 2) what successful strategies exist for working with local faith actors and communities to improve immunization acceptance and reduce vaccine hesitancy? and 3) what evidence gaps exist in relation to faith engagement and immunization? findings will advance understanding on how to more effectively engage local faith actors in promoting routine and supplementary immunization campaigns and reducing vaccine hesitancy. methods search strategy the research team searched pubmed and google scholar databases for peer-reviewed literature for the period from january 1, 2011 to january 15, 2021 with key search terms related to faith engagement and immunization (figure 1). figure 1. literature review search terms we combined the following terms: vaccin*, immuniz*, immunis*, vaccine hesitancy and faith, faith-based, faith actors, relig*, church, mosque, temple, christian, muslim, islam, hindu, buddhis* and lowand middle-income countries, lmics, africa, asia, latin america. note. the asterisk* indicates a wildcard symbol enabling a broader search by finding words that start with the same letters/word stems. we supplemented the peer-reviewed database searches with a gray literature search, recognizing that many interventions related to religious leaders are not published in peer-reviewed journals. the review included a keyword search across several online databases and organizational websites for the same period: google, the vaccine confidence project literature archive, and usaid’s maternal and child survival program website. references in papers meeting inclusion criteria were searched for further relevant studies for potential review. the authors also solicited submissions from a cohort of key informants who included experts from the usaid momentum country and global leadership program and from a cohort of 18 global faith engagement and immunization experts drawn from christian connections for international health’s (ccih) networks. inclusion/exclusion criteria we included peer-reviewed studies and gray resources meeting the following criteria: 1) the study context was an lmic; 2) it included any of the search keywords in the title or abstract; 3) the main focus of the study or resource was related to faithactor engagement and immunization and/or vaccine hesitancy; 4) it was published between january 1, 2011 and january 15, 2021; and 5) it was published in english. resources were excluded if they were about faith engagement and immunization in highincome countries, news articles, online blogs, or references to social media postings. as depicted in figure 2, the literature review found an initial 434 articles through initial search terms and an assessment of relevance using the preidentified inclusion criteria. all articles that met the inclusion criteria (137) were included for quality assessment and data extraction. of these, 27 duplicate references were manually removed, leaving 110 resources. these are presented in appendix 1. figure 2. literature review search strategy melillo, strachan, o’brien, wonodi, bormet & fountain 5 may 2022. christian journal for global health 9(1) note. *using literature review search terms in figure 1 data extraction and analysis we reviewed the 110 relevant papers and entered qualitative and quantitative descriptive information into an excel data extraction matrix template that included the following categories: author, year, publication; country(ies), and/or region covered; type of study/article/resource; focal religion(s); and topical area of focus (including vaccine hesitancy, specific types of vaccine). the matrix also captured key observations and findings, vaccine hesitancy findings, evidence-based interventions related to engaging local faith actors and immunization, promising practices for faith engagement and immunization, and reported evidence gaps. data were coded using a predefined set of themes and sub-themes from the matrix categories to answer the three literature review questions. results description of the resources reviewed despite results, there is still scant published evidence of the role of religion and local faith actors on immunization.1 most studies treat religion as a confounding variable without a detailed examination of the nuanced impact or inter-related factors (social/political/economic) that impact immunization uptake.1,2 the review did find a number of key thematic foci, as depicted in table 1. table 1. key themes found in literature review (see appendix 1 for full listing of resources) 6 melillo, strachan, o’brien, wonodi, bormet & fountain may 2022. christian journal for global health 9(1) theme relevant materials main topical focus of article religion/local faith actors and immunization akseer, n (2018); alemu m (2016); ames h (2017); asress a and bezabih l (2018); bangura jb (2020); berkley center (2020); berkley center (2012); boulton ml and wagner al (2021); catholic relief services (2019); christian connections for international health (2017); costa jc (2020); gavi (2015); glatmanfreedman a and nichols k (2012); grabenstein jd (2013); international interfaith peace corps (2016); jalloh mf (2020); makoka m (2020); malande oo (2019); marshall k (2013); morry c (2019); mukungwa t (2015); mupere e (2020); nnadi c (2017); olivier, j (2016); oyo-ita a (2020); soura a (2013); unicef (2012); unicef (2015); vatican commission for covid-19 (2021); vermandere h (2016); wesevich a (2016); wilkinson o and marshall k (2021); wonodi cb (2012); woo, yl (2012); world council of churches and world jewish congress (2020); world faiths development dialogue (2012); world health organization (who) (2017); (who) (2018); who/sage working group on vaccine hesitancy, systematic review (2014); world vision, barrier analysis (2021) religion/local faith actors and vaccine hesitancy abakar mf (2018); abubakar a (2019); agrawal a (2020); ahmed a (2018); ahmed s (2014); ansari, mt (2020); anyene, b (2014); balbir singh hk (2019); barmania s and reiss mj (2020); berkley center (2021); cobos muñoz d (2015); cooper s (2018); de figueiredo a (2020); dubé e (2014); ebrahim, af (2013); evans d (2019); falade ba (2014); gallup and wellcome global monitor (2018); gerede r (2017); ghinai i (2013); grandahl m (2018); greenberger c (2017); guzman-holst a (2020); ha w (2014); habib ma, community engagement (2017); habib ma, knowledge and perceptions (2017); hamdi s. (2018); harapan h (2021); hussain sf (2016); international vaccine access center (2020); jalloh mf (2019); jamal d (2020); jarrett c (2015); kalok a (2020); khan mu, muslim scholars’ knowledge (2017); khan mu, knowledge, attitudes (2017); khowaja ar (2012); kriss jl (2016); kucheba f (2021); lane s (2018); larson, hj (2016); machekanyanga z (2017); marti m (2017); mcarthur-lloyd a (2016); muslim religious scholars (2014)l nasir ja (2017); nasir sg (2014); ndiaye k (2013); njeru i (2016); olivier j. (2014); olorunsaiye cz (2017); olufowote jo (2016); owoaje e (2020); padela ai (2014); padmawati rs (2019); peckham r (2018); pelčić g (2016); pugliese-garcia m (2018); remes p (2012); renne e (2010); sabahelzain mm (2019); syiroj atr (2019); taylor s (2017); tefera ya (2018); turiho ak (2017); wagner al (2019); wong lp and wong pf (2020); wong lp (2020); who/sage working group on vaccine hesitancy, systematic review (2014); who/sage working group on vaccine hesitancy, report (2014) new vaccine acceptance padmawati rs (2019); wonodi cb (2012) faith-based concerns or interest with specific vaccines polio agrawal a (2020); ahmed s (2014); falade ba (2014); ghinai i (2013); habib ma, community engagement (2017); habib ma, knowledge and perceptions (2017); hussain sf (2016); khan mu, muslim scholars’ knowledge (2017); khan mu, knowledge, attitudes (2017); khowaja ar (2012); mcarthur-lloyd a (2016); nasir ja (2017); nasir sg (2014); ndiaye k (2013); njeru i (2016); olufowote jo (2016); owoaje e (2020); peckham r (2018); renne e (2010); taylor s (2017) covid-19 barmania s and reiss mj (2020); berkley center (2021); berkley center (2020); vatican commission (2021); wilkinson o and marshall k (2021); world council of churches and world jewish congress (2020); world vision, powerpoint (2021); world vision, website (2021) rotavirus padmawati rs (2019); wesevich a (2016) table 1. key themes found in literature review [continued] melillo, strachan, o’brien, wonodi, bormet & fountain 7 may 2022. christian journal for global health 9(1) religion of focus in relation to immunization exploration multiple religions or no specific religion akseer, n (2018); bangura jb (2020); barmania s and reiss mj (2020); berkley center (2021); berkley center (2020); berkley center (2012); boulton ml and wagner al (2021); catholic relief services (2019); christian connections for international health (2017); cobos muñoz d (2015); cooper s (2018); costa jc (2020); dubé e (2014); gavi (2015); glatman-freedman a and nichols k (2012); grabenstein jd (2013); guzman-holst a (2020); international interfaith peace corps (2016); jalloh mf (2020); jarrett c (2015); lane s (2018); larson, hj (2016); marshall k (2013); marti m (2017); morry c (2019); mupere e (2020); nnadi c (2017); olivier j (2014); olivier j (2016); olorunsaiye cz (2017); remes p (2012); soura a (2013); tefera ya (2018); turiho ak (2017); unicef (2012); unicef (2015); wagner al (2019); wilkinson o and marshall k (2021); wonodi cb (2012); wong lp (2020); world council of churches and world jewish congress (2020); world faiths development dialogue (2012); who (2018); who (2017); who/sage working group on vaccine hesitancy, systematic review (2014); world vision, barrier analysis (2021) muslim abakar mf (2018); abubakar a (2019); agrawal a (2020); ahmed a (2018); ahmed s (2014); ansari, mt (2020); anyene, b (2014); balbir singh hk (2019); de figueiredo a (2020); ebrahim af (2013); falade ba (2014); ghinai i (2013); habib ma, community engagement (2017); habib ma, knowledge and perceptions (2017); hamdi s (2018); harapan h (2021); hussain sf (2016); jalloh mf (2019); jamal d (2020); kalok a (2020); khan mu, muslim scholars’ knowledge (2017); khan mu, knowledge, attitudes (2017); khowaja ar (2012); mcarthur-lloyd a (2016); muslim religious scholars (2014); nasir ja (2017); nasir sg (2014); ndiaye k (2013); olufowote jo (2016); owoaje e (2020); oyo-ita a (2020); padela ai (2014); padmawati rs (2019); peckham r (2018); remes p (2012); renne e (2010); sabahelzain mm (2019); syiroj atr (2019); taylor s (2017); vermandere h (2016); wong lp and wong pf (2020); woo, yl (2012) christian alemu m (2016); ames h (2017); asress a and bezabih l (2018); evans d (2019); gerede r (2017); ha, w (2014); kriss jl (2016); kucheba f (2021); machekanyanga z (2017); makoka, m (2020); malande oo (2019); mukungwa t (2015); njeru i (2016); pugliese-garcia m (2018); remes p (2012); vatican commission for covid-19 (2021); wesevich a (2016) non-muslim or non-christian grandahl m (2018); greenberger c (2017); malande oo (2019) study/resource type and quality the review found a total of 110 relevant articles, 69% of which were peer reviewed, and the other 31% were from gray literature. while the literature review did not explicitly assess and score study quality, the quality of literature reviewed appears mixed based upon the study designs found. most peer-reviewed literature cited was observational in nature; gray literature or discussion papers represented 44.5% of resources reviewed. the review found only three intervention studies (2.7%) examining approaches for engaging faith leaders. as the dominant resource type, the descriptive literature consisted of cross-sectional studies, qualitative studies, mixed methods, and data analysis. additionally, there were several commentaries and discussion papers along with both literature and systematic reviews. the gray literature consisted of tools, guidelines, various resources, and reports. there were a variety of additional gray resources found including books, evaluations, poster/oral presentations, and unpublished theses. topical focus the relevant literature was predominantly focused on vaccine hesitancy (60%) among different faith groups, versus a general exploration of religious engagement and vaccines (36%). the remaining 4% of resources focused on new vaccine acceptance among local faith actors and vaccines delivered by local faith actors in humanitarian environments. of the articles that examined a 8 melillo, strachan, o’brien, wonodi, bormet & fountain may 2022. christian journal for global health 9(1) specific vaccine type, there was a focus on campaign-based vaccinations and so-called “controversial” vaccines (those causing hesitancy), rather than routine immunizations. the resource breakdown included: • polio (20) • human papillomavirus (hpv) (9) • covid-19 vaccination (8) • childhood immunization generally (5) • rotavirus (2) time period at least five articles have been published every year since 2012 on the topic of local faith actors and immunization in lmics. interest in the topic appear to be rising as 70% of the resources identified were published within the last five years of the review (2016–2020). last year (2020) was the peak, with 20 articles published. religions of focus just under half the resources found (42%) focused on multiple religions or general local faithactor engagement and immunization rather than specific religions. the majority of studies with an explicit religious focus examined large-scale organized, monotheistic faiths (islam, christianity), and mainline religions—those linked to established denominations in the global north. only eight studies explored immunization and faith engagement in traditional, folk, or growing non-networked religions such as pentecostal or charismatic denominations (12.5%), a growing proportion of religions in lmics. we found few studies exploring immunization in the context of buddhist or hindu faiths in asia. the literature also reflects a heavy focus on polio vaccine hesitancy among muslim populations, with 19% of all resources focused on that topic. the hesitancy literature in general focuses primarily on countries with large or predominantly muslim populations, with the exception of apostolic christian denominations within zimbabwe. geographic focus nearly half of the studies that met the inclusion criteria (44%) offered a global or multi-country focus in lmics, rather than zeroing in on a specific geographic area. the other resources were localized to specific regions, predominantly sub-saharan africa (34%), followed by southeast and south asia (19%). within sub-saharan africa, the majority of resources focused on nigeria (16 articles), with fewer resources from ethiopia, kenya, uganda, tanzania, zambia, and zimbabwe (figure 3). figure 3. literature review findings: top focal countries (as of january 15, 2021) melillo, strachan, o’brien, wonodi, bormet & fountain 9 may 2022. christian journal for global health 9(1) within the southeast and south asian region, the majority of resources were specific to pakistan (12 articles), while afghanistan, bangladesh, india, indonesia, and malaysia had fewer published research resources. the literature review uncovered major research gaps for the latin american and caribbean region, and only three resources were found for the middle east and north africa. there were no articles published for eastern europe nor the asia pacific region. discussion question 1: how do religious leaders and faith-based organizations impact the uptake and coverage of immunization in lmics? measuring the precise impact and causality of local faith actors on immunization rates is challenging. most studies generally treat religion as a confounding variable without a detailed examination of the nuanced impact or inter-related factors (social/political/economic) that effect immunization uptake.1,2 this remains an important area for future research and exploration. the reviewed literature did demonstrate four main mechanisms through which religious leaders and faith actors impact immunization uptake in lmics: 1) influencing caretaker beliefs and values,1,2,17,18 2) impacting access to resources that facilitate immunization uptake,1 3) communicating immunization messages and conducting mobilization,2 and 4) providing routine immunizations in hard-to-reach areas or humanitarian settings. these findings suggest that continued investment in and engagement with faith leaders can be a valuable strategy for immunization programming.2,19 at the same time, the review did not find detailed explorations and analysis of the dynamics and mechanisms of how faith actors specifically influenced immunization uptake and coverage within local communities. this may warrant additional research in this area to unpack the influence and interplay of local faith actors within communities to better understand these mechanisms and design evidence-based interventions. religiously-linked vaccine hesitancy vaccine hesitancy is a complex phenomenon. few religious groups or their sacred texts explicitly reject immunization (figure 4).3,5,11,12,20,21 figure 4. what major religions say about vaccines 10 melillo, strachan, o’brien, wonodi, bormet & fountain may 2022. christian journal for global health 9(1) multiple resources reviewed suggested that vaccination hesitancy is often cloaked under the guise of “religion,” without a theologicallygrounded objection.3,12 instead, religious objections to vaccination serve as a cover or proxy for concerns about safety, social norms, socio-cultural issues, political, and economic factors.2,3,5,26,27 common faith-linked vaccine hesitancy views across religions included the belief(s) that: • humans should not attempt to override god’s will with man-made solutions.3,4,28 • god created a perfect world, including a perfect immune system: humanity should not attempt to improve on it.4 • the human body is a temple of god— immunizations introduce potentially harmful viruses, bacteria, and/or derivatives of forbidden substances.4 • violations against taking life, including the use of fetal tissue from abortions, which are used in the development of cell lines used to make certain vaccines.4,21 • violation of dietary laws (such as using vaccine development materials with porcine or bovine origins).3 the review found additional vaccine hesitancy themes, including: promotion of faith healers and/or the power of prayer over the use of vaccines or medicine,11,29,30 distrust of western medicine/fear that vaccines are being tested on their community,29,30 worry that vaccines will sterilize recipients/impact fertility, and the promotion of traditional remedies rather than biomedical solutions.8,30,31 while these vaccine hesitancy themes were explored in numerous resources in the review, we did not find systematic analysis or study of the specific actions that local faith actors took to translate these beliefs into action and influence social norms, outside of specific references to case studies of vaccine hesitancy in certain countries among local faith actors. in these specific country examples, actions taken by local faith actors included sharing anti-vaccine messaging within houses of worship; disseminating anti-vaccination messaging informally within the community outside religious structures; broadcasting anti-vaccine messaging on mass media channels; and establishing formal or informal boycotts and encouraging adherents to avoid immunizing their children. heavy emphasis on islam and vaccine hesitancy the literature review found extensive documentation and exploration of islam and vaccine hesitancy in lmics, amounting to 69% of all studies with a specific single religion focus. this is likely due, in part, to very visible cases of vaccine hesitancy and boycotts in the early 2000s in northern nigeria, pakistan, and afghanistan as well as the finding that muslim religious leaders are especially influential in impacting vaccine uptake and hesitancy.32,33 several references underscore the principle that islamic theology generally supports immunization,14,22,23 and there are predominantly muslim countries with low rates of reported vaccine hesitancy, including bangladesh, malaysia, niger, and saudi arabia. the review did find multiple studies that suggested lower coverage of immunizations among muslim populations in lmics (across countries and within countries of heterogenous religions).1,14-16,34 major drivers of vaccine hesitancy among muslim faith communities identified in the studies included concerns that vaccines may contain haram materials (those prohibited under islamic law) ,14,33,35 fears that immunization would impact the fertility of recipients,32,36 and beliefs that vaccinations were part of a western conspiracy to harm their population.29,30 other religions of interest christian denominations accounted for 23% of all resources with a single religious focus in the literature review, with a strong focus on apostolic melillo, strachan, o’brien, wonodi, bormet & fountain 11 may 2022. christian journal for global health 9(1) denominations in zimbabwe and southern africa. originating from the protestant pentecostal church, apostolic churches reflect a desire to emulate firstcentury christianity in its faith, practices, and government and have historically objected to most medical interventions in lieu of prayer for healing.9,11 multiple studies showed lower basic immunization uptake and completion in zimbabwe among apostolic communities, with varying attitudes and degrees of refusal toward immunization among subsects, indicating a need for further study and interventions to address this growing population in southern africa. 8,9,11,20,37 despite much coverage in news media and popular culture focused on the use of cells from aborted fetuses to develop vaccines, the review only found two resources meeting inclusion criteria focused on vaccine hesitancy among catholic populations where catholic bishops in kenya led a call for the boycott of the maternal tetanus toxoid (fertility concerns) and childhood polio vaccines (safety concerns).29,38 vaccines of concern to faith actors religiously-linked polio vaccine hesitancy featured most prominently within the literature (representing 20 articles/41.7% of all articles with a specific vaccine focus), with examples from pakistan,32,35,39,40 nigeria,41–43 and kenya.38 this hesitancy contributed to increased reported caretaker vaccine refusal in kenya due to safety concerns.38 polio vaccine rejection by religious and community leaders was linked with overall reduced polio vaccine coverage in nigeria.41,43 in pakistan, multiple barriers were found, including concerns that vaccines include non-halal ingredients35 and fears of a western plot to sterilize muslims or reduce the muslim population.32,39 hpv immunization was found to be the second most frequently cited vaccine with religious objections. the hpv vaccine creates faith-linked challenges in both higherand lower-income countries due to its perceived links to sexual activity. the review found broader religious objections to hpv vaccination among catholic7 and muslim44 communities globally and specific concerns in brazil,8,45 indonesia,8,45 kenya,46 malaysia,47 tanzania,8,45 and zambia.28 the literature review also found instances of religiously-linked vaccine hesitancy among the following specific immunizations (as opposed to general immunization hesitancy): measles, mumps, and rubella (indonesia18,34, sudan 48); rotavirus (indonesia33, zambia49); cholera (zambia30); and pertussis (nigeria14,36). question 2. what successful strategies exist for working with local faith actors and communities to improve immunization acceptance and reduce vaccine hesitancy? the literature review found limited highquality evidence and examples of specific approaches for engaging local faith actors to strengthen routine immunization and campaignbased immunization uptake. most interventions involved engaging religious leaders and the local community in dialogue-based interventions50 and engaging religious leaders and church structures in social mobilization and advocacy.1,2,44,49,51–53 improving immunization uptake and coverage one study found that working with religious leaders on a multi-pronged immunization promotion and delivery strategy, including targeting priority populations and increasing service delivery availability, was more effective for increasing vaccine uptake than messaging with religious leaders alone.50 using church infrastructure, faith-based health facilities, and religious rituals as vaccination messaging or delivery points, including in humanitarian settings, was also found to be effective for increasing vaccine coverage.19,28,54 reducing religiously-linked vaccine hesitancy the review found limited examples of evidence-based approaches for tackling faith-linked 12 melillo, strachan, o’brien, wonodi, bormet & fountain may 2022. christian journal for global health 9(1) vaccine hesitancy. engaging faith-based organizations and faith leaders in the rollout of new vaccines was found in multiple studies to be important for increasing community acceptability and uptake and preventing potential vaccine hesitancy.55–57 several studies found that religious concerns focused on the bioethics of vaccine production may be effectively addressed through theological analyses of sacred text and dialogue with faith leaders, including understanding the alternatives among available vaccines.25,55,58 in muslim countries, where there is concern that vaccines were manufactured with haram (forbidden) materials, acknowledging these concerns and communicating effectively about them with muslim faith leaders and structures is critical.14,59 question 3. what evidence gaps exist in relation to faith engagement and immunization? the literature review found promising evidence of the value of religious engagement for immunization promotion and acceptance in lmics across faiths. in particular, we found multiple articles demonstrating the value of religious engagement for immunization promotion and acceptance,2,16, 60 studies of vaccine hesitancy among muslim leaders,32,33,35,36,40,41 comparisons of immunization among different faiths within the same countries,14,15,34 and reviews and discussion papers on the correlation between faith engagement and vaccine acceptance.1,2,17,18 despite these findings, this literature review found significant evidence gaps—described below—that limit the generalizability of some findings, such as: • a dearth of peer-reviewed research and gray literature on the influence of local faith actors on vaccine hesitancy in lmics as compared to high-income countries.16 • low-quality evidence of impact of religious leaders’ engagement on uptake of vaccines and the relative contribution of faith actors in vaccine uptake.2,16, 60 the review found few rigorous study designs. most literature found was observational in nature and gray literature or discussion papers represented 44.5% of resources reviewed; the review found only three intervention studies (2.7%) examining approaches for engaging faith leaders. • nearly 25% of all 110 reviewed resources focused on nigeria (16 total resources) and pakistan (12 total resources%), raising questions if such findings are applicable to other countries or regions. • similarly, the majority of studies with an explicit religious focus examined large-scale organized, monotheistic faiths (islam, christianity), limiting their potential applicability to differently organized religions. • few studies or resources examined or evaluated the effectiveness of specific interventions with local faith actors and immunization and/or vaccine hesitancy. as a result, there is a lack of widely shared knowledge of what works (or doesn’t) and successful models for engaging local faith actors. we found few published articles or gray literature that included the voices of local faith actors as primary authors or significant contributors discussing their role within immunization programs, indicating a need for further dialogue and research in this area. limitations it is well-known that many local faith-based organizations and actors maintain practice-based knowledge and are less likely to publish their findings in journals. this literature review and its conclusions may therefore be subject to publication bias, in that unsuccessful interventions may be less likely to be documented in either the peer-reviewed or gray literature. in addition, the review excluded non-english language resources, potentially missing observations and promising practices. several other factors also warrant caution on extrapolating findings more broadly. while the literature did not explicitly assess and score study melillo, strachan, o’brien, wonodi, bormet & fountain 13 may 2022. christian journal for global health 9(1) quality, the quality of literature remains mixed, based upon review of study/resource type, limiting generalizability and rigor of conclusions. as noted above, the review found evidence gaps among certain geographies, religion types, and different vaccines. finally, this literature was conducted amid the early launch and rollout of covid-19 vaccination (january 2021). as such, the review found very limited and explicit gray or peer-reviewed literature on the topic of faith engagement and covid-19 immunization. while many of the findings and interventions may be applicable and effective if applied to covid-19 immunizations, further study and investigation is warranted for this urgent public health crisis. conclusions our literature review findings suggest that continued investment in and engagement with local faith actors can be a valuable strategy for immunization programming in lmics. the review found that engaged religious leaders have long contributed to achieving full immunization coverage within their communities and today offer the potential to help counter growing vaccine hesitancy in some lmics. at the same time, the review found numerous troubling examples of religiously-linked vaccine hesitancy, some well-known, such as indonesia, nigeria, and pakistan, and some lesserknown examples in burkina faso, chad, and sudan. more investigations and evidence are needed regarding what interventions that involve local faith actors are most effective, and in which contexts, in promoting vaccine uptake. vaccine hesitancy is a highly complex phenomenon. the current peerreviewed and gray literature does not provide an adaptable, concise roadmap for tackling these issues in different geographic, cultural, linguistic, and other contexts. in particular, further study is needed on the role of faith leaders in the promotion of routine immunization (rather than campaign-based immunization), the impact of local faith actors on vaccine uptake among growing pentecostal, charismatic, and so-called “un-networked” faiths, and vaccine hesitancy among buddhist and hindu faiths in asia. multiple studies and resources within the review did identify the importance of listening, understanding, and diagnosing some of the complex and inter-related socio-cultural factors that contribute to religiously-linked vaccine hesitancy. these review findings should reinforce an important caution for public health planners, policymakers, and implementers to avoid the temptation to oversimplify or blame faith actors for vaccine hesitancy. evidence repeatedly demonstrates that apparent faith-based objections are sometimes a convenient proxy for more complex, inter-related socio-cultural, and political issues related to immunization. in cases where vaccine hesitancy is identified among local faith actors, the review suggests that listening and dialoguing with faith leaders is critical to finding theologically-acceptable solutions to vaccine hesitancy. in addition, this review suggests that more work is needed to foster global and national-level discussions to engage faith leaders in vaccine hesitancy reduction efforts. country-level strategies to stimulate research and dialogue with religious structures, interfaith networks, and theological institutions may help identify some of these underlying socio-cultural and political issues. to increase understanding and scale-up of successful strategies, we also encourage local faith actors and implementers to more widely share their experiences engaging religious leaders in immunization programs, which are largely absent from peerreviewed and gray literature. this review comes at a critical time, given the rollout of covid-19 vaccination in lmics. at the time of the literature review, most covid-19 vaccine hesitancy research in lmics was just getting underway. however, emerging research in six countries shows that 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project (grant/award number: cooperative agreement #7200aa20ca00002), led by jhpiego and partners correspondence: carolyn j. o’brien, ccih, virginia, usa. carolyn.obrien@ccih.org cite this article as: melillo s, strachan r, o’brien cj, wonodi c, bormet m & fountain d. effects of local faith-actor engagement in the uptake and coverage of immunization in lowand middleincome countries: a literature review. christ j global health. may 2022;9(1):2-32. https://doi.org/10.15566/cjgh.v9i1.587 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ mailto:carolyn.obrien@ccih.org https://doi.org/10.15566/cjgh.v9i1.587 http://creativecommons.org/licenses/by/4.0/ melillo, strachan, o’brien, wonodi, bormet & fountain 19 may 2022. christian journal for global health 9(1) appendix 1. articles reviewed reference and year country(s) and/ or region religions resource type/ study type areas of focus/ key themes link to reference 2010 renne, e. islam and immunization in northern nigeria. nigeria islam draft book chapter vaccine hesitancy; polio https://www.ascleiden.nl/pdf/paperrenn e.pdf 2012 berkeley center for religion, peace & world affairs/world faiths development dialogue. faith and immunizations meeting report. global multiple meeting report religion & immunization https://berkleycenter.georgetown.edu/n ews/new-meeting-report-faith-andimmunizations. glatman-freedman a, nichols k. the effect of social determinants on immunization programs. global low income countries multiple review religion & immunization hum vaccin immunother. 8;3:293-301. https://doi.org/10.4161/hv.19003 khowaja ar, khan sa, nizam n, omer sb, zaidi a. parental perceptions surrounding polio and self-reported nonparticipation in polio supplementary immunization activities in karachi, pakistan: a mixed methods study. pakistan islam mixed methods study vaccine hesitancy; polio bull world health organ. 90(11):822-30. https://doi.org/10.2471/blt.12.106260 remes p, et al. a qualitative study of hpv vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest tanzania. tanzania christian; islam qualitative semi-structured interviews vaccine hesitancy; hpv vaccine. 30(36):5363-7. https://doi.org/10.1016/j.vaccine.2012.0 6.025 unicef. partnering with religious communities for children. global multiple report religion & immunization https://sites.unicef.org/about/partnershi ps/files/partnering_with_religious_com munities_for_children_(unicef).pdf wonodi cb, et al. using social network analysis to examine the decision-making process on new vaccine introduction in nigeria. nigeria none mixed methods study using qualitative [key informant interviews (kiis)] and quantitative (survey) data collection methods religion & immunization health policy plan. 27(suppl 2): ii27–ii38. https://doi.org/10.1093/heapol/czs037 https://www.ascleiden.nl/pdf/paperrenne.pdf https://www.ascleiden.nl/pdf/paperrenne.pdf https://berkleycenter.georgetown.edu/news/new-meeting-report-faith-and-immunizations https://berkleycenter.georgetown.edu/news/new-meeting-report-faith-and-immunizations https://berkleycenter.georgetown.edu/news/new-meeting-report-faith-and-immunizations https://doi.org/10.4161/hv.19003 https://doi.org/10.2471/blt.12.106260 https://doi.org/10.1016/j.vaccine.2012.06.025 https://doi.org/10.1016/j.vaccine.2012.06.025 https://sites.unicef.org/about/partnerships/files/partnering_with_religious_communities_for_children_(unicef).pdf https://sites.unicef.org/about/partnerships/files/partnering_with_religious_communities_for_children_(unicef).pdf https://sites.unicef.org/about/partnerships/files/partnering_with_religious_communities_for_children_(unicef).pdf 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(2021). covid-19 vaccines: resources for church leaders. global catholic guidance/tool covid-19 https://www.humandevelopment.va/con tent/dam/sviluppoumano/vaticancovid19response/reports/resource%20kit%20%20march%202.pdf. wilkinson o, marshall k. a quick analysis guide, part i: for health and development actors: engaging faith actors in covid-19 vaccine rollout. multiple countries multiple guide/tool covid-19 world faiths development dialogue and the berkley center for religion, peace and world affairs. georgetown university. https://jliflc.com/wpcontent/uploads/2021/02/final_faithand-covid-vaccines-analysis-matrix1.pdf. world vision. barrier analysis studies on covid-19 vaccines. bangladesh, mynamar, india, tanzania, kenya multiple barrier analysis/formative research/survey covid-19 powerpoint presentation. world vision. faith leaders must play key role in covid-19 vaccine roll-out. bangladesh, mynamar, india, kenya, tanzania islam, christian web article religion and immunization; covid-19 https://www.worldvision.org/aboutus/media-center/faith-leaders-must-playkey-role-in-covid-19-vaccine-roll-out. https://www.humandevelopment.va/content/dam/sviluppoumano/vatican-covid19-response/reports/resource%20kit%20-%20march%202.pdf https://www.humandevelopment.va/content/dam/sviluppoumano/vatican-covid19-response/reports/resource%20kit%20-%20march%202.pdf https://www.humandevelopment.va/content/dam/sviluppoumano/vatican-covid19-response/reports/resource%20kit%20-%20march%202.pdf https://www.humandevelopment.va/content/dam/sviluppoumano/vatican-covid19-response/reports/resource%20kit%20-%20march%202.pdf https://www.humandevelopment.va/content/dam/sviluppoumano/vatican-covid19-response/reports/resource%20kit%20-%20march%202.pdf https://jliflc.com/wp-content/uploads/2021/02/final_faith-and-covid-vaccines-analysis-matrix-1.pdf https://jliflc.com/wp-content/uploads/2021/02/final_faith-and-covid-vaccines-analysis-matrix-1.pdf https://jliflc.com/wp-content/uploads/2021/02/final_faith-and-covid-vaccines-analysis-matrix-1.pdf https://jliflc.com/wp-content/uploads/2021/02/final_faith-and-covid-vaccines-analysis-matrix-1.pdf https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out. https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out. https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out. https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out. https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out. abstract introduction methods results description of the resources reviewed despite results, there is still scant published evidence of the role of religion and local faith actors on immunization.1 most studies treat religion as a confounding variable without a detailed examination of the nuanced impact or inter-related fact... figure 3. literature review findings: top focal countries (as of january 15, 2021) references © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited... commentaries may 2023. christian journal for global health 10(1) on missional medicine: institution building, fragile places, and sheep among wolves c. phifer nicholson, jr. a bruce dahlmanb and martha c. carloughc a md(c), mts, duke university school of medicine, usa b md, mshpe, faafp, christian academy of african physicians, founding head, department of family medicine and community care, school of medicine and health sciences, kabarak university, kenya c md, mph, professor, unc-chapel hill and theology, medicine and culture initiative of duke divinity school, usa abstract from the healing narratives of jesus in the gospels to the genesis of the first hospital to the practice of modern medicine, questions surrounding health and care for those who are sick and dying run through the heart of the christian story. one way that individuals and communities have sought to live into their faith has been through missional medicine, that is, seeking to intentionally use the tools of medicine in step with and to bear witness to the life of christ, particularly in crosscultural and global contexts. in this commentary, we take up the incisive question of the late missionary physician raymond downing, “is there a distinctive christian approach to global health?” or, what sets (and should set) christian approaches to global health apart from other interventions? here, we argue that there are at least three distinctive christian contributions to global health. first, missional medicine movements have been committed to the building of long-standing hospitals and academic medical institutions that have left indelible marks on long-term health outcomes for people and communities. second, practitioners motivated by christian convictions disproportionately serve and remain long-term in marginalized, rural, and underserved areas; many of which are connected to fragile or under-developed health systems. thirdly, christian medical missionaries and global health workers ought to be, in the words of jacques ellul: preserving salt, revealing light, and “sheep in the midst of wolves.” this is a theologically framed vocation that accepts suffering and sacrifice, embracing solidarity through accompaniment. this paper is not meant to be a comprehensive history of missional medicine nor a defence of its problematic manifestations over the centuries. rather, we candidly explore examples of the distinctive contributions that have been made, and we hope will continue to be made, by medical missionaries and global health workers who are motivated by their faith. key words: missional medicine, mission hospitals, accompaniment, theology 25 nicholson, dahlman & carlough may 2023. christian journal for global health 10(1) the church has been doing medical missionary work for 2000 years. these days it seems that people…don't realize the role that christian mission doctors and hospitals play in most of the developing world. anyway, selfpromotion is a bit counter to the gospel so perhaps not a bad thing.1 introduction: is there a distinctive christian contribution to global health and healing? from the healing narratives of jesus in the gospels to the genesis of the first hospital,2,3 to the practice of modern medicine, questions of health and care for those who are sick and dying run through the heart of the christian story.4 christianity itself has been described as a religion for the sick.5 in many ways, the above quote from medical missionary, tom catena, rings true — the church has been doing the work of healing since the earliest days of the faith. yet, the “medical missionary” as a concept and medical missions as a whole largely developed in the 19th and 20th centuries in the wake of the expansion of european colonialism, significant developments in the fields of medicine, surgery, and pharmacology,6,7 as well as the significant growth of the modern missionary movement in the western church.8 the work of medical missionaries and missions come under criticism as they are often linked with colonialism and western hegemony.9 more recently, the enormous growth of short-term medical mission trips have only deepened this criticism. these generally one to two week-long endeavors, however well intended, often fail to account for cultural differences, the needs of the community, structural drivers of global health disparities, and the local health care infrastructure. they may cause more harm than good in the name of “serving the needy.”10 many also are concerned that medical missions are often tied to proselytization. is offering medical care simply a means for conversion or is the work of healing in of itself “good news?” or, is it some mix of the two? these serious concerns (among others) invite deep interrogation of all cross-cultural medical work, religiously-motivated or otherwise. this leads to a provocative question asked by late missionary doctor raymond downing, “is there a distinctive christian approach to global health?”11 bound up in this question are the various critiques of medical missions and the modern global health movement which has been named by paul farmer and others as a form of neoliberalism and western imperialism.12–14 this question is both a practical and theological one, challenging christian practitioners who engage in global health work to contend with the implications of the gospel. what difference do the life and teachings of jesus make in broken and needy individuals now and not just towards eternity or salvation? is there any place for missional health care, including direct medical and surgical services, as well as community health and development work, that can be supported and embraced in view of the good news of christ? in this essay, we take up this question, arguing that there are at least three distinctive christian contributions to global health. first, missional medicine movements have, over and above other global health interventions, been committed to the building of long-standing hospitals and academic medical institutions that have left indelible marks on long-term health outcomes for people and communities. second, practitioners motivated by christian convictions disproportionately serve and remain in marginalized, rural, and underserved areas; many of which are connected to “fragile health systems.”15 thirdly, christian medical missionaries and global health workers ought to be, in the words of jacques ellul, “preserving salt, revealing light, and…sheep in the midst of wolves…offer[ing] the daily sacrifice of their lives, which is united to the sacrifice of jesus christ.”16 this is a theologically framed vocation that accepts suffering and sacrifice and embraces solidarity, through accompaniment, or the intentional practices of being present and deepening relationships to do the work of the gospel in the model of christ.17–19 nicholson, dahlman & carlough 26 may 2023. christian journal for global health 10(1) this paper is not meant to be a comprehensive history of missional medicine nor a defense of its problematic manifestations over the centuries. rather, we intend to candidly explore examples of the distinctive contributions that have been made, and we hope will continue to be made, by medical missionaries and global health workers motivated by their faith. to accomplish this, we will first briefly trace the parallel development of colonial medicine and missionary medicine. then, we explore the institutional emphasis and impact of missional medicine movements with a focus on the lasting impact of mission hospitals in india and sub-saharan africa. finally, we explore christian engagement in remote, unstable, and otherwise challenging contexts, concluding with a brief theological reflection on the work and writing of raymond downing and jacques ellul and the importance of accompaniment. in parallel: colonial medicine and medical missions to global health, a brief history westernized biomedicine arose around the same time european colonialism was at its height in the 18th and 19th centuries. as evidence of its ties to extraction, racism, enslavement, and expansion of imperial power, medical care from the health care practitioners among the colonizers was only sparingly offered to locals. when the services of modern medicine were extended to indigenous communities, it was largely in the interest of the empire and to protect those serving in colonial outposts from tropical diseases and other maladies. biomedicine was “often cited as one of the virtues of the imperial enterprise, even long after other defenses of colonialism had been discarded.”7 colonial leader hubert lyautey said that “the only excuse for colonization is medicine,” for to him the “action of the doctor” both “ennobles” and “justifies” the brutality of colonialism.7 he and others viewed colonial medicine as the “most effective of our agents of penetration and pacification,”7 weaponizing biomedicine as a tool for domination. cross-national and cross-cultural christian missions span back to the earliest iterations of the global church. although there are significant examples of medical missionaries venturing into far-off lands before colonialist enterprises — including famously, dr. peter parker (china) in the 1830s and dr. david livingstone (congo and zimbabwe) in the mid-1850s — european colonialism opened new opportunities for missionary activity. the adoption of modern medicine as a form of missionary activity is a complex story. the desire to share the goods afforded by modern medical, surgical, and public health interventions was a motivator for many at the time. still others learned that scientific medicine could be a means for entry to difficult and distant locales, a “door opener” for proselytization.6 some early missionary doctors viewed their work as part of “civilizing the savage,” a means for furthering western domination not unlike the explicit aims of colonization, while others like albert schweitzer7 and daniel mcgowan20 viewed medicine as a form of “atonement” for the atrocities of the colonial period. it is important to note that although some aspects of the medical missionary movement were made possible by colonialism and have been deeply colonial in nature, most of the overarching aim was different than that of colonial medicine. colonial medicine generally focused on the prevention and treatment of disease in the colonists and placed a greater emphasis on population-level interventions. conversely, medical missionaries cared primarily for the indigenous population and invested in the health and clinical care of individuals, often outside the centers of colonial power.7 in short, although missionary medicine and colonial medicine broadly developed in the same era, they did so with largely different aims and outcomes, as well as the commitment and involvement of different groups of people. from the end of the colonial period to the rise of “tropical” and “international” medicine to the current global health enterprise, there has been limited collaboration between “faith-based organizations” (fbos) and “secular” health 27 nicholson, dahlman & carlough may 2023. christian journal for global health 10(1) initiatives. this persists despite the significant impact of fbos on healthcare in resource-limited settings,15 as well as global health’s shared focus on engagement with local populations. built to last: the role of missions and institution building jon fielder is a longtime missionary physician and chief executive of african mission healthcare.21 he cites the gap between grantdependent large ngo global health initiatives and medical mission institutions (personal interview, october 2022). fielder speaks of the reality of funding within large ngo global health programs, citing that most of the major funding goes towards discrete projects focused on water, sanitation, and hygiene, and generally neglect institution building and clinical care. the projects, though well intended, are often designed via top-down mechanisms funded by external private foundations and government agencies, resulting in unpredictable cycles of funding and recurrent personnel turnover in country. this work often feels distant from the stated and tangible needs of the local population. in addition, extractive research without local, tangible benefits as well as economic exploitation tied to large scale global health projects seems to be the latest iteration of colonial influence — now, steeped in neoliberalism.12–14 fielder also explains a phenomenon he has noticed in his context in kenya. if health care workers from the hospital he has been involved with for years interact with locals, even far from the hospital, people immediately recognize and trust them. this is attributed to the longstanding presence of this institution in the region, for this mission hospital has been there for over 100 years. for example, locals can recall the time their mother was treated for ovarian cancer or uncle was cared for after an accident. this institutional presence shifts the entire area’s health care seeking behaviors and fosters trust and solidarity between the hospital and community. it has a lasting and significant impact on the health care outcomes of the community. this long-term investment, and the resultant outcomes, is also demonstrated in the indian context in a recent paper from the field of developmental economics. in this study, the authors constructed: a novel, fully geocoded dataset that combines contemporary individual-level data with historical information on protestant missions in colonial india and their activities…to study the link between individuals’ proximity to a protestant medical mission (i.e., a mission equipped with a hospital or a dispensary) and their health outcomes today…[focusing] primarily on anthropometric indicators to measure health and use geocoding tools to compute the distance between the current location of individuals and the location of protestant health facilities operating in early twentieth century india. indeed, we find that proximity to a protestant medical mission is positively associated with current individuals’ health outcomes.22 the authors controlled for many variables, including religious conversion, the location’s relative prosperity/natural resources, missions without medical care or hospitals, level of urbanization, and presence of educational facilities. all demonstrated the most important factor for long-term impact on health was proximity to a medical mission/mission hospital. this effect was more significant in socially disadvantaged groups, namely women, the poor, and less educated individuals.22 the positive impact was more pronounced if the hospital offered surgical care.22 these improved outcomes persisted whether the hospital was still operational or not. the authors attribute this longstanding impact to 1) changes in health habits and practices, as well as health seeking behaviors and hygiene, and 2) a significant improvement in maternal and child health outcomes (likely tied to surgical obstetric care and other advanced maternal health care) that were the result of local medical mission impact. further, this long-term effect is primarily nicholson, dahlman & carlough 28 may 2023. christian journal for global health 10(1) attributed to the generational memory of poor women and uneducated individuals. the “least of these” became a positive driver of the community’s health for generations, and hard-won trust left a lasting mark. this study supports fielder’s intuition. there is a tangible, long-lasting, durable impact on health outcomes associated with mission health care institution-building, particularly among the poor and marginalized in the surrounding communities. building and maintaining institutions focused on delivering clinical care has been a distinctive contribution of christian medical missions, ranging from larger teaching and referral hospitals like aic kijabe and tenwek (kenya), kilimanjaro christian medical centre (tanzania), and vellore (india), to district level hospitals such as hope kibuye (burundi), malamulo adventist (malawi), and selian lutheran (tanzania), to smaller but geographically essential facilities such as mother of mercy-gidel hospital (sudan) and the twenty eha hospitals sprinkled throughout india — to name a few examples. at its best, this institution-building also includes the training of local nationals to build up clinical capacity and enable sustainability, a practice that traces back at least to the founding of the che jung wan medical school in seoul, korea in 1886. starting with the training of nurses almost immediately after initiating any health program in a remote area, mission institutions continue to expand the breadth of their educational efforts to include physicians, surgeons, clinical officers, and other essential clinical staff. a paradigmatic example is the christian medical college (cmc) vellore in india.23 founded by dr. ida scudder in the early 20th century as a response to the dire need of indian women dying in childbirth, cmc-vellore still stands as a world-class training and research institute that offers advanced surgical care and community health interventions for the entire region. today, it is known as one of the best medical schools and hospitals in all of india. the pan-african academy of christian surgeons and the similar christian academy of african physicians for primary care are examples of local and international partnerships designed to share knowledge and build local capacity for postgraduate, apprenticeship-focused training toward building local clinicians who practice excellent, holistic care.24,25 long-term investment in institutions and training local health care workers to high standards remains a distinguishing characteristic of a christian approach to global health. this is not just good for short-term health outcomes of the patients they serve, but also seeks to empower individuals and invest in local capacity building. for this investment to remain appropriate, these health care workers would do well to understand theologies of health and suffering, the rich history of christian involvement in healthcare delivery, and the important cross-cultural implications of engagement now being provided in a seminar course, christian global health in perspective.26 sheep among wolves: suffering, accompaniment, and solidarity there have been persistent gaps in understanding and collaboration between government, non-governmental organizations (ngos), the more recently burgeoning academic global health world, and missional medicine. it is a much less common practice for missionary physicians to publish and publicize their work in academic journals or for mission hospitals to be integrated into or “counted” by governmental health systems. this makes the impact of medical missions difficult to quantify. one of the most notable academic engagements with faith-based commitments in health care was the lancet series on faith-based health care from 2015. one article from the series explores the impact of fbos in africa.15 in this piece, the authors acknowledge that faith-based institutions and communities provide a significant percentage of health care across africa. some estimate anywhere from 30%-70% of health care is provided by fbos.15 regardless of the overall magnitude of care covered by mission hospitals and other faith-based medical work, including large scale community health and development programs, the authors noted two key contributions that set them apart 29 nicholson, dahlman & carlough may 2023. christian journal for global health 10(1) from the public sector. first, available studies show that the “quality of the services provided is perceived as high because of a particular attention paid to the dignity of patients, sometimes articulated as more compassionate care than received elsewhere.”15 this is supported in a gates-funded study of religious health care in subsaharan africa that found that many people preferred to go to faith-based institutions over government hospitals.27 further, in several studies, mission hospitals were found to be preferred over other health care institutions.28,29 second, there is an emphasis on giving care to poor and vulnerable populations, which today has resulted in a disproportionate number of faithbased health care institutions in rural, remote, and hard-to-reach areas.15 this commitment can be difficult to sustain and often requires creative adaptations to survive in changing economic and social conditions, as well as sometimes necessitates continued external support from communities and churches to be sustainable.30 yet, it marks a particular contribution of medical missions to the landscape of health care globally. olivier and colleagues conclude, “the slowly emerging evidence on faith-based health-care providers suggests that they are not simply a health systems relic of a bygone missionary era, but still have relevance and a part to play (especially in fragile health systems).”15 the reality that missional medicine has a distinctive role in rural, remote, unstable, or resource-limited health systems is almost a normative, distinctive marker of christian contributions to global health, but is often underrecognized, even from within mission organizations who pride themselves on quiet consistent service and humility. commitment to offering care in solidarity with those at the margins goes to the very roots of the historical missional medicine movement and is powerfully articulated theologically with the language of liberation theology and accompaniment.31,32 this theological imagination, stemming from mid-20th century grassroots movements in catholicism in latin america, is grounded in scripture, including the exodus narrative (exodus 1-18), the book of job, and the life and work of jesus as demonstrated in the gospel of luke: the spirit of the lord is upon me, because he has anointed me to bring good news to the poor. he has sent me to proclaim release to the captives and recovery of sight to the blind, to let the oppressed go free (4:18, nrsv). at its roots, liberation theology asks the question, “how does the life, death, and resurrection of christ matter here and now, and not just for eternity?” theologies of liberation, particularly as articulated in the latin american experience, but also in africa and parts of asia, have put forward “accompaniment” as a theologically-based framework for ethical action.33 accompaniment, with its emphasis on listening, solidarity, and physical proximity to the poor, has been demonstrated to improve health outcomes not just for individuals, but communities. this stands in contrast to some global health programs that are directed from afar with limited relational commitments and long-term presence.18,19,33,34 although many practitioners of missional medicine predate these theological frameworks, we believe that the values put forward in accompaniment articulate the commitments to proximity and solidarity prevalent in faithmotivated health care at the margins. in one of his final books, global health means listening, raymond downing reflects on the concept of accompaniment and nearly 30 years of experience as a medical missionary in east africa. in a chapter titled, “is suffering necessary?” he asks, “is there a distinctive christian approach to global health, or do we simply draw from the myriad approaches already described, testing each piece for how well it reflects general christian principles?”11 drawing from french philosopher and theologian jacques ellul, downing contends that the three distinctive christian contributions are to “be preserving salt, revealing light, and…sheep in the midst of wolves.” regarding this “vocation,” downing again quotes ellul, nicholson, dahlman & carlough 30 may 2023. christian journal for global health 10(1) it is essential that christians should be very careful not to be ‘wolves’ in the spiritual sense -that is, people who try to dominate others. christians must…offer the daily sacrifice of their lives, which is united with the sacrifice of jesus christ.16 christians must be open to suffering as they draw near to those on the margins. there is no formula for this contribution or assurance of what the outcomes might be, but it entails a surrendering of our “need for control and the assurance of results and of change,” and a willingness to throw in our lot, as it were, with the weak and discarded of this world – to serve, teach, and befriend.11 taking up our distinctive vocation as sheep among wolves may not be a “winning” strategy as it is most typically construed. but, christians follow a god in christ who, “chose what is weak in the world to shame the strong” (1 corinthians 1:27, nrsv). perhaps such an approach is fitting. conclusion we have proposed that there are at least three distinctive christian contributions to global health. first, missional medicine movements historically focused on building health care institutions, a practice that has left deep and lasting improvements in health outcomes of proximate communities. second, christians serving in missional medicine are more likely to have a particular and lasting commitment to working in challenging situations, including underserved and impoverished areas and to being particularly committed to work with those who are poor and marginalized in society. thirdly, those pursuing the fullness of a christian approach to global health are to draw close in accompaniment and relationship. they are to offer their time and talents as “sheep among wolves,” refusing to dominate and willing to sacrifice and suffer alongside the communities they are accompanying. for those seeking to bring their christian commitments to bear in global health, considering these distinguishing qualities might help motivate, sustain, and frame faithful engagement. references 1. thomas (tom) catena, medical director of the catholic mother of mercy-gidel hospital, sudan (personal communication, september 2015). for more information on dr. catena's work and the story of the mother of mercy-gidel hospital, see verini j. the doctor. the atavist magazine. 2015. available from: https://magazine.atavist.com/the-doctor/ 2. crislip at. from monastery to hospital: christian monasticism and the transformation of health care in late antiquity. ann arbor: university of michigan press; 2005. 3. heyne t. reconstructing the world’s first hospital: the basilead. hektoen int j. [published online spring 2015]. available from: https://hekint.org/2017/02/24/reconstructing-theworlds-first-hospital-the-basiliad/ 4. for a rich exploration of the history of health care as it relates to the early church, see ferngren g. medicine and health care in early christianity. baltimore: johns hopkins university press; 2016. 5. larchet jc. the theology of illness. yonkers: st. vladimir’s press; 2002. 6. grundmann ch. sent to heal! emergence and development of medical missions. lanham: university press of america; 2005. [introduction] 7. greene j, basilico mt, kim h, farmer p. reimagining global health: an introduction. 1st ed. los angeles: university of california press; 2013. [all citations from ch. 3, "colonial medicine and its legacies" and ch. 9, "values and global health."] 8. the development of the modern missionary movement is complex, for more context see anderson gh, coote rt, horner na, phillips jm, eds. mission legacies: biographical studies of leaders of the modern missionary movement. maryknoll: orbis books; 1994. 9. wall bm. medical missions in context. in: into africa: a transnational history of catholic medical missions and social change. new brunswick: rutgers university press; 2015:1-31. 10. roberts m. duffle bag medicine. jama. 2006;295(13):1491-2. http://doi.org/10.1001/jama.295.13.1491 11. downing r. global health means listening. nairobi: manqua books; 2018. [all citations from the final chapter, "is suffering necessary"] 12. farmer p. fevers, feuds, and diamonds: ebola and the ravages of history. new york: farrar, straus and giroux; 2020. [of note, physiciananthropologist paul farmer, although not a https://magazine.atavist.com/the-doctor/ https://hekint.org/2017/02/24/reconstructing-the-worlds-first-hospital-the-basiliad/ https://hekint.org/2017/02/24/reconstructing-the-worlds-first-hospital-the-basiliad/ http://doi.org/10.1001/jama.295.13.1491 31 nicholson, dahlman & carlough may 2023. christian journal for global health 10(1) medical missionary, was a practicing catholic deeply influenced by core principles of liberation theology, including the preferential option for the poor and accompaniment. this framework motivated and sustained medical work in solidarity and advocacy alongside the poor in haiti and all over the world. in a sojourners piece titled “sacred medicine: how liberation theology can inform public health,” farmer writes: over the course of my 20s, the slender, frayed thread of my own faith, which i had believed cut, slowly came back into view. there was a filament a bit stronger than imagined, made visible in part by my haitian hosts and patients and friends, and in part by catholic social activists working against poverty in settings as different as tough neighborhoods in boston, the farms of north carolina, and the slums of lima. some were nuns or priests, some were engaged laity, from many professions. most were people living in and struggling against their own and others’ poverty. their activism taught me a lot about a space in the catholic church i’d not seen clearly before, and about the promise of long-term engagement in the monumental struggle against poverty and discrimination in all its forms. to read more, see https://sojo.net/magazine/january-2014/sacredmedicine. a new book on paul farmer’s religious influences and thought is a valuable resource: block jw, lysaught mt and martins aa, eds. a prophet to the peoples: paul farmer’s witness and theological ethics. pickwick press; 2023.] 13. richardson e. epidemic illusions: on the coloniality of global public health. 1st ed. boston: the mit press; 2020. 14. lincoln m. global health is dead; long live global health! critiques of the field and its future. bmj global health. 2021;6(7). https://doi.org/10.1136/bmjgh-2021-006648 15. olivier j, tsimpo c, gemignani r, shojo m, coulombe h, dimmock f, et al. understanding the roles of faith-based health-care providers in africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. lancet. 2015;386(10005):1765-75. https://doi.org/10.1016/s0140-6736(15)60251-3 16. ellul j. the presence of the kingdom. 2nd ed. colorado springs: helmers & howard; 1989. [all quotes from pp 4-5] 17. block jw, griffin m. introduction. in: in the company of the poor: conversations with dr. paul farmer and fr. gustavo gutièrrez. maryknoll: orbis books; 2013. 18. nicholson jr cp. made known in the breaking of the bread: accompaniment and the practice of medicine. linacre q. 2021;88(3):281-90. https://doi.org/10.1177/00243639211026495 19. farmer p. to repair the world: paul farmer speaks to the next generation. weigel j, ed. los angeles: university of california press; 2013. 20. see this essay for an engagement with the motivations of macgowan and other early medical missionaries, as well as a critique of “development” as a goal of the church/medical missions: downing r. the annunciation of the gospel. christ j global health. 2018;5(1):16-20. https://doi.org/10.15566/cjgh.v5i1.202 21. african mission healthcare [internet]. “about.” [cited 2022 dec 30]. available from: https://africanmissionhealthcare.org/about-amh/ 22. calvi r, mantovanelli fg. long-term effects of access to health care: medical missions in colonial india. j develop econ. 2018;135:285-303. https://doi.org/10.1016/j.jdeveco.2018.07.009 [of note, the authors focused on protestant medical missions because there was not a strong catholic mission presence in india in the early 20th century] 23. wilson dc. ida b. scudder: life and health for women in india. in: anderson gh, coote rt, horner na, phillips jm, eds. mission legacies: biographical studies of the leaders of the modern missionary movement. maryknoll: orbis books; 1994:307-15. see also https://www.cmchvellore.edu/content.aspx?pid=p171127016[other examples similar to cmc vellore include the peking union medical college in china (http://medicine.yonsei/ac.kr/en/) , mengo medical school in uganda (https://mengohospital.org/ucu-medical-school/), and the north indian school of medicine for christian medicine (http://www.cmcludhiana.in/), all of which persist today under different names and/or leadership but often remain among the top training institutions in their respective countries.] 24. till b. god’s surgeons in africa. atlantic. 28 dec 2012. available from: https://www.theatlantic.com/health/archive/2012/1 2/gods-surgeons-in-africa/266635/ 25. van essen c, steffes bc, thelander k, akinyi b, li hf, tarpley mj. increasing and retaining african surgeons working in rural hospitals: an analysis of paacs surgeons with twenty-year program follow-up. world j surg. 2019;43(1):75https://sojo.net/magazine/january-2014/sacred-medicine https://sojo.net/magazine/january-2014/sacred-medicine https://doi.org/10.1136/bmjgh-2021-006648 https://doi.org/10.1016/s0140-6736(15)60251-3 https://doi.org/10.1177/00243639211026495 https://doi.org/10.15566/cjgh.v5i1.202 https://africanmissionhealthcare.org/about-amh/ https://doi.org/10.1016/j.jdeveco.2018.07.009 http://medicine.yonsei/ac.kr/en/ https://mengohospital.org/ucu-medical-school/ http://www.cmcludhiana.in/ https://www.theatlantic.com/health/archive/2012/12/gods-surgeons-in-africa/266635/ https://www.theatlantic.com/health/archive/2012/12/gods-surgeons-in-africa/266635/ nicholson, dahlman & carlough 32 may 2023. christian journal for global health 10(1) 86. http://doi.org/10.1007/s00268-018-4781-9 [paacs is just one example of a reinvigorated approach to the training of local clinicians for work in sustaining and expanding health care all over the world (see paacs.net). see also caap (caaphome.org); ihii (https://inhisimage.org/international/); and prime (https://www.prime-international.org/home.htm).] 26. christian global healthcare in perspective [internet]. health for all nations [cited 25 feb 2023]. available from: https://www.cghiperspective.com/ 27. schmid b, thomas e, olivier j. the contribution of religious entities to health in sub-saharan africa. african religious health assets programme; 2008. [p 115]. 28. 2013 kenya household health expenditure and utilisation survey. kenya ministry of health; dec 2014. available from: https://www.healthpolicyproject.com/pubs/745_k hhuesreportjanuary.pdf 29. fort a.. the quantitative and qualitative contributions of faith based organizations to healthcare: the kenya case. christ j global health 2017;4(3): 60-71. https://doi.org/10.15566/cjgh.v4i3.19 30. lindtjorn b. the role of a mission organization in building a sustainable government hospital in southern ethiopia. christ j global health. 2020;7(2):133-46. https://doi.org/10.15566/cjgh.v7i2.351 31. farmer p. health, healing, and social justice. in: pathologies of power. los angeles: university of california press; 2003:139-59. 32. farmer p, gutierrez g. in the company of the poor: conversations between dr. paul farmer and fr. gustavo gutierrez. griffin m, block jw, eds. maryknoll: orbis books; 2013. 33. goizueta r. caminemos con jesus: toward a hispanic/latino theology of accompaniment. maryknoll: orbis books; 1995. 34. block jw. paul farmer: servant to the poor. collegeville: liturgical press; 2018 peer reviewed: submitted 6 feb 2023, accepted 2 march 2023, published 29 may 2023 competing interests: none declared. acknowledgements: this paper's earliest draft was the product of a directed study that pn and mc participated in at duke divinity school. we want to thank abigail knoble, who served as a conversation partner during the directed study and embodies the qualities and commitments described in this commentary. we also want to thank dr. thomas "tom" catena, whose missional life and work served as the catalyst for pn to pursue a vocation in medicine. correspondence: c. phifer nicholson, jr, durham, nc, usa phifer.nicholson@duke.edu cite this article as: nicholson cp jr, dahlman b, carlough mc. on missional medicine: institution building, fragile places, and sheep among wolves. christ j global health. may 2023; 10(1):24-32. https://doi.org/10.15566/cjgh.v10i1.751 © authors. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ http://doi.org/10.1007/s00268-018-4781-9 https://inhisimage.org/international/ https://www.prime-international.org/home.htm https://www.cghiperspective.com/ https://www.healthpolicyproject.com/pubs/745_khhuesreportjanuary.pdf https://www.healthpolicyproject.com/pubs/745_khhuesreportjanuary.pdf https://doi.org/10.15566/cjgh.v4i3.19 https://doi.org/10.15566/cjgh.v7i2.351 mailto:phifer.nicholson@duke.edu https://doi.org/10.15566/cjgh.v10i1.751 http://creativecommons.org/licenses/by/4.0/ abstract key words: missional medicine, mission hospitals, accompaniment, theology the church has been doing medical missionary work for 2000 years. these days it seems that people…don't realize the role that christian mission doctors and hospitals play in most of the developing world. anyway, self-promotion is a bit counter to the ... introduction: is there a distinctive christian contribution to global health and healing? conclusion short communications nov 2015. christian journal for global health, 2(2):64-68. music in the mountains: creating sustainable therapy programs from short-term missions rachel foxell a a rmt, mmusth, bmus, gdtl, music therapist teacher, glenroy specialist school, australia. abstract this field report describes the experiences of a registered music therapist (rmt) living, working, and musicking 1 during a short-term health mission to northern india. using a sustainability approach, collaboration with several local and global health organisations resulted in the development of a therapeutic music program for children with disabilities. disability is a complex phenomenon, and in rural areas of india, disability is viewed as a foundation for shame and exclusion. the community-based project, samvedna, oversees the therapy, healthcare, and education of over 100 children with a disability in remote villages and is heavily involved in disability advocacy in the area. sustainable programs are more effective for individuals and communities in both the short and long term. rmts and other health professionals can be instrumental in setting up sustainable programs, such as teaching specific skills and knowledge to local teams, provided there is thorough preparation and ongoing collaboration to determine the priorities and expectations of the program. in a remote village not accessible by road, a little girl with an intellectual disability lives with her grandmother. they have come with their neighbours to their village leader’s house to see doctor nathan and his visiting friends. sakshi is non-verbal and appears to have little understanding or interest in the conversation around her. her parents do not want her. our translator relays her grandmother’s words: they have said, in her hearing, that it would be better if she were dead. how can i respond? it is my third day in india. 65 foxell nov 2015. christian journal for global health, 2(2):64-68. disability is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. disability is not just a health problem or a social problem, but describes the way a person’s physical impairment relates to their society, environment, and the political landscape. 2 overcoming the difficulties faced by people with disabilities may involve medical interventions to correct or reduce impairment, but should equally require interventions to remove environmental and societal barriers. 2-4 in india, particularly in rural and remote regions, people with a disability can be considered worthless individuals and may be abandoned by their families or treated as a lesser part of the family unit. traditional hindu culture places great shame on people who have a disability, whether through accident, illness, or a disability from birth. people with a disability struggle to be accepted into their communities, make marriages, and participate in daily village life. when a child is born with a disability, both mother and child are blamed, with the implication that the disability has been caused by a sin committed in a past life. in 2014, my husband and i volunteered for two months for the emmanuel hospital association (eha) india, a network of 20 hospitals in central and northern india. eha hospitals also support a number of communitybased rehabilitation (cbr) projects such as disability support and advocacy, mental health, and work in slums and low-caste rural villages. samvedna, which means “empathy,” is a cbr project working to establish attitudes of inclusiveness in families and village communities through spreading the message that jesus loves every person regardless of their abilities, using both words and actions. samvedna, established four years ago, oversees the education, healthcare, and ongoing therapy of over a hundred children with disabilities across dozens of remote mountain villages in the foothills of the himalayas, about 350km north of new delhi. as an australian registered music therapist (rmt), and special education teacher, my goal was to create a sustainable music therapy program for the samvedna project. 5 however, good crosscultural aid or development work does not simply implant one way of working straight into another culture. 6 in addition to an awareness of specific communication and cultural differences between the foreigner and the local community, there are always complex layers of power dynamics at play in any cross-cultural interaction. 7-9 significant preparation is necessary for any cross-cultural work to be effective in both the shortand longterm. 10-11 one of the critiques of short-term health missions (sthms) is that they do not adequately meet the needs of a community or address complex health problems of the local area. sthm workers often do not fully consider the impact of their initial presence and inevitable absence on the continuing lives of those they have come to “help.” serious implications may arise, resulting in continued unequal partnerships between hosts and visiting professionals and also negative consequences for patients and communities. 10 conversely, programs that work in collaboration with local stakeholders through fostering equal partnerships of learning and knowledge sharing and actively following up through training and resource provision have been able to generate sustainable, positive results for locals. 10-11 in this way, sustainability and collaboration are intertwined, the success of one being dependent on the other. rmts and other health professionals working cross-culturally are well equipped to create sustainable music therapy programs provided there is:  ongoing collaboration with the community regarding the aims and purpose of the project.  adequate time for development.  realistic expectations regarding the outcomes of the project. 11 knowing my time on the ground was limited, it was important to develop good relationships with the stakeholders, both individuals and 66 foxell nov 2015. christian journal for global health, 2(2):64-68. organisations, in the months before my arrival. rather than set my own priorities for the mission, i wanted these to evolve naturally from collaborative discussions with the samvedna staff team. over time, it became clear that one of my main aims during the four-week placement would be a plan for training volunteers and staff in therapeutic music skills. however, as the samvedna volunteers and families would be the ones actually participating, their buy-in was crucial to the success of a sustainable program. the buy-in process formed three stages over five weeks (the first two overlapping by a week or more): 1. listening to the community’s needs 2. demonstrating and teaching skills 3. facilitating local ownership of the program listening the staff, volunteers, and families at samvedna have had regular contact with foreign visitors. when my husband and i arrived in the village of dhana, a group of about 50 people gathered in the centre to welcome us and tell their stories. this pattern continued throughout the week as we travelled to different villages in the region, visiting families and listening. being a woman also opened unexpected doors for me. three women, mothers of children with a disability, had refused to speak during a mixed meeting, despite urging from the samvedna co-ordinator. during a chai-break outside, they immediately beckoned me over. in three-way translation (garwhali-hindi-english and back), the women shared with me their isolation and the hard, constant work of 24-hour care with no help from neighbours or family. why did they choose to hold back in the group? it is normal for women to remain silent in mixed meetings, perhaps due to the gender inequality prevalent in rural areas; but, i think it is possible that they wanted to hold power over their stories until they felt they could trust me with them. demonstrating and teaching skills whenever i met with families or visited learning centres, i made a point of sitting with the children and doing simple, child-led vocal or percussive dialogue. when possible, i demonstrated and explained how i worked with rhythm and songs in australia. this ground work, coupled with my willingness to listen and learn, helped the volunteers to buy-in to the concept of music therapy and show interest in learning the skills i offered. the resulting three-day workshop co-facilitated with colleagues from the music therapy trust (tmtt) in delhi was a hands-on approach to learning therapeutic music skills. 12 by the end of the workshop, the volunteer team had come up with nine principles for therapeutic music-making that they could apply straight away to their own practice, such as: letting the child lead the interaction; engaging on the child’s level; using the child’s name as a rhythm or melody as the basis for interaction. local ownership of the project after the final session of the workshop, three volunteers were appointed music ambassadors, representatives who felt confident enough in their new skills to help others problem-solve any issues and contact tmtt with any issues. in the week following the workshop, volunteers who had returned to their village centres to practise their new skills, enthusiastically reported the children’s increased engagement through music. at this stage, the volunteers felt real ownership of their new skills and knowledge, which spoke volumes to me about the potential of this program to continue long after i left india. when i last heard from the samvedna co-ordinator, he told me the volunteers are still using music weekly in their learning centres. when considering cross-cultural interventions in music therapy, or any health profession, it is vital to consider and plan for a sustainable outcome in collaboration with local stakeholders. sustainable programs are more effective for individuals and communities in both 67 foxell nov 2015. christian journal for global health, 2(2):64-68. the shortand long-term. rmts and other health professionals can be instrumental in setting up sustainable programs, such as teaching specific skills and knowledge to local teams, provided there is thorough preparation and ongoing collaboration to determine the priorities and expectations of the program. as i sat there next to sakshi, i realised something: although we had certainly spent time talking about her, not one person had spoken to her that whole afternoon. so i began to gently seek eye contact and invite her into a wordless vocal dialogue. it took just a few minutes for her to completely transform. in her village, she had been known as alternately withdrawn and aggressive. but in reality, she was eager to connect with those around her and had never before had an opportunity. witnessed by her neighbours, her vocal sounds during our dialogue were loud, insistent, and full of joy. this interaction has changed her life, forever. references 1. small, c. musicking: the meanings of performing and listening. middletown, ct: wesleyan university press; 1998. 2. who: health topics: disability [internet]. geneva: world health organization; c2015 [cited 2015 august 29] available from: http://www.who.int/topics/disabilities/en/. 3. anastasiou d, kauffman j. disability as cultural difference: implications for special education. remedial and special education. 2012;33(3): 139– 149. http://dx.doi.org/10.1177/0741932510383163. 4. rickson d. the relevance of disability perspectives in music therapy practice with children and young people who have intellectual disability. voices: a world forum for music therapy. 2014;14(3). http://dx.doi.org/10.15845/voices.v14i3.784 5. australian music therapy association. what is music therapy? [internet]. melbourne, australia; c2012 [cited 2015 september 20]. available from: http://www.austmta.org.au/content/what-music-therapy 6. elmer d. cross-cultural servanthood: serving the world with christ-like humility. madison, wi: intervarsity press; 2006. 7. bolger l. music therapy and international development in action and reflection: a case study of a women’s music group in rural bangladesh. australian journal of music therapy. 2012;23: 22-39. 8. mahoney e. multicultural music therapy: an exploration. voices: a world forum for music therapy. 2015;15(2). http://dx.doi.org/10.15845/voices.v15i2.844 9. brown j. towards a culturally centred music therapy practice. voices: a world forum for music therapy. 2002;2(1). http://dx.doi.org/10.15845/voices.v2i1.72 10. swanson r, thacker b. systems thinking in shortterm health missions: a conceptual introduction and consideration of implications for practice. christian journal for global health. 2015;2(1): 7-22. http://dx.doi.org/10.15566/cjgh.v2i1.50 11. bolger l, skewes mcferran k. demonstrating sustainability in the practices of music therapists: reflections from bangladesh. voices: a world forum for music therapy. 2013;13(2). http://dx.doi.org/10.15845/voices.v13i2.715 12. the music therapy trust. new delhi, india; c2013 [cited 2015 september 18]. available from: http://www.themusictherapytrust.com/index.htm competing interests: none declared. acknowledgments: with thanks to eha india; the samvedna staff, families and volunteers, and the music therapy trust, new delhi. correspondence: rachel foxell rachel.foxell@live.com cite this article as: foxell r. music in the mountains: creating sustainable therapy programs from short-term missions. christian journal for global health (nov 2015), 2(2): 64-68. http://www.who.int/topics/disabilities/en/ http://dx.doi.org/10.1177/0741932510383163 http://dx.doi.org/10.15845/voices.v14i3.784 http://www.austmta.org.au/content/what-music-therapy http://dx.doi.org/10.15845/voices.v15i2.844 http://dx.doi.org/10.15845/voices.v2i1.72 http://dx.doi.org/10.15566/cjgh.v2i1.50 http://dx.doi.org/10.15845/voices.v13i2.715 http://www.themusictherapytrust.com/index.htm mailto:rachel.foxell@live.com 68 foxell nov 2015. christian journal for global health, 2(2):64-68. © foxell r this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://creativecommons.org/licenses/by/3.0/ original article nov 2015. christian journal for global health 2(2): 23-38. characterizing the global context for cross-cultural healthcare work by regions of the world mark strand a , eckert paulson b and timothy myrick c a phd, professor, school of pharmacy and department of public health, north dakota state university, fargo, nd b country director for ngo in central asia c md, assistant professor, university of missouri at kansas city family medicine, kansas city, mo abstract healthcare missionaries (n=393) from 18 english-speaking countries, serving in 67 countries, were surveyed. with an average of 11 years of field experience and working primarily in the local language, participants in this study were able to report on healthcare situations and experience for expatriate healthcare missionaries in their countries of service. the healthcare institutions in most countries of the world were reported to be improving. most countries were reported hospitable to the presence of expatriate missionaries, but there also existed some resistance to expression of christian faith in the workplace. as mission organizations consider where to place healthcare professionals for medical service, consideration should be given to the trends and opportunities present in different regions of the world, so as to achieve the greatest outcomes and to provide the best match between the missionary and the context in which they work. introduction there are an estimated 400,000 christian missionaries working cross-culturally around the world. 127,000 of them are from the united states. 1 42,000 north american missionaries are serving in assignments of four or more years. 2 healthcare professionals make up a significant portion of the missionary workforce, and among some organizations, it is growing. 3,4 at the cmda medical missions summit in atlanta in 2012, it was determined that 6.4% of the missionaries in the eight organizations attending were involved in healthcare. 5 of the 66 evangelical missions organizations studied in the global healthcare workers needs assessment, 24% of new missionary candidates in 2013 were healthcare workers. 6 in this paper, healthcare missionaries are considered those whose service in the healthcare field is done directly or indirectly in support of the spiritual purposes of their sending organization. the purpose of this paper is to describe the geographic context in which these missionaries serve, the unique characteristics of each region of the world, and how these characteristics impact the work of these missionaries. since the 1960s, different regions and countries of the world have adopted different stances to healthcare mission work. after independence, some african nations called for a moratorium on christian missions work in general. yet most african nations have maintained an open door policy toward christian missionaries, except for the muslim nations in north africa. most asian nations have adopted a position of national sovereignty such that religious worker visas have not been particularly welcomed. most 24 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. south american countries have a roman catholic history and, thus, have remained open to christian missionaries. in recent decades, many countries around the world have developed their economy and their own national healthcare systems, becoming less dependent on christian health ministries. healthcare missionaries are particularly vulnerable to mental health challenges given the nature of their work. 7,8 unlike physicians in private practice or government service, missionary doctors are the “poorest and most isolated of [their] profession.” 9 traumatic experiences such as natural disasters, warfare, terrorism, and epidemics are experienced frequently by healthcare missionaries, not to mention the added anxiety of feeling responsible for spouses and children likewise subjected to the same risks. there are many areas in the world where security issues are a daily concern and real dangers are a daily part of healthcare professionals’ lives. healthcare missionaries also experience significant levels of anxiety associated with occupational issues, acculturation, and physical illness. 10,11 added administrative and leadership responsibilities are also contributing factors. in recent years, however, many authors have pointed to a need for increased research in the field to better support healthcare mission-aries. 12 the present study set out to determine the distribution of surveyed medical missionaries by region of the world and the characteristics of those regions. experiences of medical missionaries in those regions differ in various ways. an important factor is the attitude of their host government toward their presence in the country. finally, trends in healthcare in the major regions of the world are explored. materials and methods instrument the patterns and responses in intercultural service in medicine (prism) survey was designed and administered by an expert team of researchers associated with the christian medical and dental association (cmda) in 2010-2011. the purpose of the cross-sectional survey was to determine the current challenges and opportunities in medical missions from the perspective of english-speaking medical missionaries from western countries. the prism survey contained 34 items, as described below. statements were measured using likert scales, while questions gathered data in the form of categorical and continuous variables. among the variables assessed were depression and anxiety. depression and anxiety scores were derived from two separate questions as follows: on a scale of 0 to 5 (0 = none to 5 = significant), how serious a period of [anxiety, depression] have you ever experienced? the diagnostic and statistical manual of mental disorders (dsm) iv diagnostic criteria and the patient health questionnaire (phq-9) for depression and anxiety were not used because the length and nature of the survey did not allow for inclusion of the number of questions needed to make a diagnosis. 13,14 role satisfaction was measured using three items: (1) with regard to your current role as a cross-cultural medical worker, are you: (1 = extremely satisfied to 5 = not satisfied); (2) i am satisfied with the balance of medical and nonmedical aspects of my work: (1 = strongly agree to 5 = strongly disagree); and (3) the role i currently fill is consistent with what i envisioned before coming to the field: (1 = strongly agree to 5 = strongly disagree). respondents were asked about the attitude of the local health bureau toward their presence as a foreigner (1 = unfavorable to 5 = highly favorable) and the relative ease of obtaining permission to initiate effective longterm medical work for expatriate medical workers in that country (1 = getting harder, 2 = about the same, 3 = easier, 4 = don’t know). additional variables included gender, age, professional discipline, current country of service, language used at work, years of service in cross-cultural medical work, and years of intended service. respondents were asked to report their region of service from the following options: south america (bolivia, chile, dominican re25 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. public, ecuador, guatemala, haiti, honduras, paraguay, and peru), africa (angola, benin, cameroon, central african republic, chad, democratic republic of congo, ethiopia, gabon, ghana, ivory coast, kenya, lesotho, liberia, madagascar, malawi, mauritania, mozambique, namibia, niger, nigeria, rwanda, senegal, south africa, sudan, tanzania, uganda, zambia, and zimbabwe), middle east (afghanistan, albania, bahrain, bangladesh, jordan, kazakhstan, pakistan, united arab emirates, ukraine, and yemen), asia (china, macau, mongolia, russia, singapore, south korea, and taiwan), and south and southeast asia and pacific (cambodia, guam, india, indonesia, nepal, papua new guinea, the philippines, and thailand). the variable “positive external environment” was a continuous variable with a score from 3-13 ranging from the most negative to the most positive external environment. this variable was created by merging the responses to three items: the attitude of the local health office toward one’s presence as a foreigner in the country, changes in ease of getting permission to initiate effective long-term medical work for expatriate medical workers, and degree of improvement in the quality of the local healthcare system compared to 5 or more years previously. the variable “changing medical need” was a continuous variable with a score from 2-10 ranging from the lowest to highest need for external medical assistance. this variable was created by merging the responses to two items: perception of need in the country for cross-cultural medical workers in their traditional roles and degree of improvement in the quality of the local healthcare system compared to 5 or more years previously. operationalization of the variables was carried out through an iterative process. a table was created containing each construct of interest, with each construct being assigned to one of the five expert panel members. the expert created 3-5 survey questions that could provide essential information regarding that construct. to select the survey questions that would best provide what was needed for that construct, the group discussed all constructs. this group discussion went through five cycles of discussion and modification in order to ensure the validity of the questions and to eliminate nonessential or redundant questions. content validity was established by a delphi process among the members of the research team. neither a content validity ratio nor a construct validity score was computed. face validity was established by pilottesting the survey in paper form on 10 people who met the inclusion criteria. the validity of the one-question screen for depression and anxiety was established as described above. internal consistency of the instrument items was measured using the chronbach’s alpha and the guttman split-half tests. the chronbach’s alpha test for anxiety and depression items was 0.597. this level was considered acceptable for a selfadministered survey of this nature. a guttman split-half coefficient of 0.639 was determined for the role satisfaction items. the survey was made available in on-line and paper format. the online version was made available through survey monkey. for security, an ssl survey link was used to encrypt response content in the event case responses were intercepted in transmission. sample the population of interest in this study was english-speaking career missionaries working in healthcare. inclusion criteria included: being an expatriate cross-cultural healthcare worker with qualifications in their home country, having served more than two years in their host country, officially associated with a christian sending organization, and able to read and understand english well. the survey was open for 13 months, from february 2010 to february 2011. the paper version was distributed to attendees of the 2010 continuing medical and dental education conference of the christian medical and dental association held in limuru, kenya and the 2011 conference held in chiang mai, thailand, with 263 responses for a response rate of 54%. online versions of the survey were sent out to healthcare missionaries by a designated person from each of eight different mission organiza26 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. tions willing to participate (crosslink global, project medsend, christian medical and dental association, christian connections in international health, hcjb, the international mission board, reachglobal, and sim), with 130 responses. it was not possible to calculate response rate for the on-line version because it was unknown how many individuals received the invitation to respond. a total of 419 surveys were completed. twenty-six surveys were discarded because respondents did not complete the mandatory 60% of the questions or did not meet inclusion criteria, resulting in 393 valid responses. the protocol was approved by the institutional review board of the center for the advancement of healthcare education and delivery (cahead), colorado springs, co on november 24, 2009. c-ahead (www.c-ahead.org) is registered with the department of health and human services. analyses statistical tests all used significance level of .05. anova and chi-square tests were performed on continuous variables to detect difference of means. ibm spss version 19 was used in data analysis. the prism survey data base is available from the authors to others who might be interested in exploring other research questions. results demographics survey respondents came from 18 different english-speaking countries, with 76.5% from the united states. mean age of respondents was 48 years (range: 24-85 years), with 49.9 and 50.1% of respondents reporting to be male and female, respectively. respondents reported an average of 11 years of field experience, with 41.2% reporting that they intended to serve in cross-cultural healthcare missions until retirement. of those who responded, 67.7% were physicians, 17% were nurses, and 15.3% served in other healthrelated areas (table 1). work situation by region of the world nurses made up 34.2% of the respondents from south america. a majority of the people from asia and the pacific were in family medicine. africa and the middle east had a greater proportion of surgeons than other regions (table 1). the 67 countries of service were relatively evenly dispersed across the six main regions of the world (fig 1), except that 38.9% of respondents were working in africa, which reflects the approximate proportion of christian healthcare workers who work in africa. table 1. healthcare missionaries primary area of training area of training region of service total south america africa middle east asia south and se asia and pacific family/general medicine 23.7% 30.1% 41.9% 44.4% 52.2% 37.9% nursing 34.2% 20.9% 7.0% 8.6% 14.9% 17.0% surgery or surgical sub-specialties 2.6% 20.9% 18.6% 2.5% 3.0% 11.7% pediatrics 10.5% 7.2% 9.3% 4.9% 17.9% 9.4% internal medicine or other medical sub-specialties 5.3% 6.5% 4.7% 8.6% 1.5% 5.6% public health 2.6% 1.3% 4.7% 4.9% 6.0% 3.3% dentistry 5.3% .7% 7.4% 1.5% 2.5% therapy, rehab 2.6% 1.3% 4.7% 3.7% 1.5% 2.3% ob, gyn, midwifery 3.3% 4.7% 1.2% 2.0% infectious diseases 2.6% .7% 4.7% 1.2% 1.5% psych, soc, counseling 2.0% 2.5% 1.3% optometry, opthalm 2.6% .7% .5% pharmacy 1.5% .3% other: 7.9% 4.6% 9.9% 4.6% n 38 153 43 81 67 393 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note. chi-square=120.48, p<0.000 http://www.c-ahead.org/ 27 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. 77.5% of the medical missionaries were working in a clinical setting (table 2). healthcare missionaries in south america, africa, and the middle east primarily worked in a private hospital or clinic, including mission hospitals. missionaries in asia worked in a government clinic or out of their home or in an office space more than in other regions of the world. figure 1: distribution of respondents by region of the world table 2. primary work setting work setting region of service total south america africa middle east asia south and se asia and pacific private hospital/clinic, including mission hospitals 63.2% 60.1% 60.4% 32.1% 45.5% 65.0% government hospital/clinic 5.3% 10.5% 9.3% 24.7% 6.1% 12.5% office of one’s own organization or community partner 10.5% 15.1% 4.6% 17.3% 24.3% 15.3% at home 2.6% 4.6% 4.7% 14.8% 7.6% 6.9% in the community 18.4% 3.9% 9.3% 4.9% 3.0% 6.1% medical university 5.2% 7.0% 4.9% 10.6% 5.9% other: .7% 4.7% 1.2% 3.0% 1.8% total (n) 38 153 43 81 66 392 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note: chi-square=94.67, p<0.000 table 3. language used at work language region of service total south america africa middle east asia south and se asia and pacific a local language other than english (national language, trade language) 78.9% 32.9% 51.2% 46.9% 34.3% 41.8% english 7.9% 31.6% 14.0% 8.6% 22.4% 21.4% a mix of english and local language 13.2% 35.5% 34.9% 44.4% 43.3% 36.8% total n 38 152 43 81 67 392 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note: chi-square=60.95, p<0.000 missionaries that worked in south america reported using the local language the most in their work (table 3). the workers with the lowest rate of using a local language were found in africa. they relied on english or a mix of english and a local language more than other regions. the middle east and asian regions required good facility in the local language as it is required for most of the work. 0 50 100 150 200 south america africa middle east asia south and se asia and pacific 28 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. table 4: main purpose of primary work setting main purpose of work setting region of service total south america africa middle east asia south and se asia and pacific purpose is like-minded to my christian faith 94.6% 80.3% 65.1% 45.7% 70.1% 71.1% secular but tolerant of expressions of my faith in the workplace 5.4% 16.4% 16.3% 28.4% 17.9% 18.2% secular and not supportive of expressions of my faith in the workplace 3.3% 18.6% 25.9% 11.9% 10.7% total 37 152 43 81 67 391 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note: chi-square= 53.71, p<0.000 most respondents reported working in explicitly christian settings, the exception being asia, where the proportion was only 45.7% (table 4). south america and africa were both primarily christian healthcare work, with some secular work settings. the middle east and asia had christian healthcare work, but also some secular work settings, many which are not supportive of the christian faith, particularly in asia. table 5. quality of local health care system compared to five or more years previously quality of health care delivery by the local healthcare system region of service total south america africa middle east asia south and se asia and pacific greatly improved 12.1% 4.3% 14.1% 11.5% 7.8% somewhat better 39.4% 46.4% 47.5% 69.2% 47.5% 51.1% about the same 33.3% 31.2% 37.5% 14.1% 26.2% 27.7% somewhat worse 9.1% 13.0% 12.5% 1.3% 6.6% 8.9% greatly deteriorated 6.1% 5.1% 2.5% 1.3% 8.2% 4.5% total 33 138 40 78 61 358 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note: chi-square= 39.76, p=0.005 most regions of the world reported the local healthcare system significantly improved in the last five years, especially in asia and south and se asia and pacific and much less so in the middle east (table 5). 64.8% of respondents reported the local government to be very favorable or favorable to their presence there (table 6) and only 1.3% considered the local government to be unfavorable. african workers report their local health office to be favorable toward them at a higher rate than in other regions. this favorable working relationship is extremely important to the ability of healthcare missionaries to have a positive impact and requires constant attention from leaders in medical missions. table 6. attitude of local health officials toward your presence there region of service total attitude of your local health officials toward your presence as a foreigner south america africa middle east asia south and se asia and pacific highly favorable 13.2% 23.5% 19.0% 11.1% 19.4% 18.9% favorable 34.2% 55.0% 31.0% 46.9% 41.8% 45.9% somewhat favorable 34.2% 13.4% 33.3% 23.5% 19.4% 20.5% unfavorable .7% 2.5% 1.5% 1.3% not aware of your work 18.4% 7.4% 16.7% 16.0% 17.9% 13.5% total 38 149 42 81 67 386 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note: chi-square= 41.19, p=0.004 29 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. the middle east and south america had the largest portion of local health officials who were not highly favorable to their presence there. south america, asia, south and se asia, and the pacific reported the highest rate of their local government not being aware enough of their work to have an opinion that they would express (16-18.4%). they were working out of public view more than others. table 7. difficulty for expatriate healthcare workers to obtain permission to initiate long-term medical work region of service total difficulty to obtain permission south america africa middle east asia south and se asia and pacific getting harder 13.2% 22.4% 51.2% 46.9% 35.8% 32.3% about the same 55.3% 58.6% 34.9% 29.6% 47.8% 47.2% easier 7.9% 5.9% 16.0% 3.0% 7.2% i do not know 23.7% 13.2% 14.0% 7.4% 13.4% 13.3% total 38 152 43 81 67 390 % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% note: chi-square=50.92, p<0.000 getting permission to initiate effective long-term medical work for expatriate medical workers is getting more difficult (table 7). as is shown below, health care delivery by the local system is improving in most regions of the world. also, poor cooperation with the local system is considered to be the biggest external challenge workers face in their medical work in asia and a significant challenge in other regions of the world. it isn’t clear if this challenge to cooperation is due to reluctance on the part of locals or expatriate workers. but it could threaten the sustainability of medical missions in those contexts. figure 2: changing need for external medical support note: higher values represent less need 30 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. figure 3: positive environment for the work of cross-cultural healthcare workers note: higher values represent more positive environment the middle east and african regions have the greatest need of external medical support, as defined by a worsening medical system and an ongoing perceived need of cross-cultural medical workers (figure 2) (anova f=10.97, p<.000). on the other hand, asia has the least medical need as defined by an improving medical system and a decreasing perceived need of cross-cultural medial workers. a less positive working environment was indicated by an unfavorable attitude of local officials toward one’s presence in their country, increasing difficulty in getting permission to work there long-term, and a worsening local healthcare system. the middle east had the least positive working environment (fig 3), but this difference was not statistically significant (anova f=2.35, p<.056). a less positive working environment was found associated with lower role satisfaction (f=2.81, p=.026) and lower satisfaction with the balance of medical and non-medical aspects of their work (f=2.44, p=.048). table 8. attitude of your local health office and work satisfaction attitude of local health officials toward your presence there. “i am satisfied with the balance of medical and non-medical aspects of my work.” “i am satisfied with my current role as a crosscultural medical worker.” highly favorable mean ± sd 2.11 ± 1.205 1.93 ± 1.079 n 72 72 favorable mean ± sd 2.29 ± 0.929 2.31 ± 0.981 n 172 170 somewhat favorable mean ± sd 2.35 ± 1.057 2.34 ± 1.021 n 80 77 unfavorable mean ± sd 3.00 ± 1.000 1.80 ± 0.837 n 5 5 anova f-value (p) 1.59 (0.190) 3.07 (0.028) note: the values are read in reverse so a higher score reflects less satisfaction. the more favorable the attitude of the local government toward their work, the more satisfied surveyed medical missionaries were with the balance of medical and non-medical aspects of their work (f=1.59, p=0.190) and their role as a crosscultural medical worker (f=3.07, p=0.028) (table 8). 31 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. table 9. mean anxiety and depression scores (0-5) and between group difference of means. region of service anxiety depression south america 3.69 2.78 africa 3.08 2.47 middle east 3.17 2.52 asia 2.92 2.44 south, se asia and pacific 2.72 2.37 total 3.05 2.48 anova (p-value) 2.539 (.040) .405 (.805) workers in south america and the middle east reported the highest levels of anxiety, and the differences between regions were statistically significant (table 9). in total, more than half of all respondents reported having experienced a bout of anxiety of level 4 or 5. the prevalence of anxiety was higher than depression in all regions, with 30% of all respondents reporting having experienced a bout of depression of level 4 or 5, with a mean score of 2.48 out of 5 (table 9). this cohort of respondents had been in missions an average of 10.8 years. it is frequently the case that those with organic depression, less influenced by situation, will have left the field by this time, as is supported by the small but significant negative correlation between depression score and years of service (r=-0.13, p=0.015). there was a trend toward individuals residing in countries with lower perceived need of medical missionaries and a less positive work environment, having higher rates of depression and anxiety, but this difference was not statistically significant. table 10. summary of characteristics of the healthcare mission situation in each major region of the world. region characteristics of the political and healthcare system characteristics of healthcare missionaries working there south america · improving healthcare system · local health officials favorable, but significant lack of support also · no change in difficulty of obtaining permission to work there · nursing and family medicine. · working in private hospital/clinic (including mission hospital) · almost exclusively christian healthcare work · use the local language · highest level of anxiety experienced africa · improving healthcare system · local health officials most favorable toward expatriate workers · no change in difficulty of obtaining permission to work there · need of expatriate workers remains · the most positive working environment · family medicine, surgery and nursing · working in private hospital/clinic (including mission hospital) · primarily christian healthcare work, but also some secular work settings · use mainly english more than other regions, but also use a mix of english and local language · significant level of anxiety experienced middle east · the least improved healthcare system · local health officials favorable, but significant lack of support also · getting harder to obtain permission to work there · need of expatriate workers greater than other regions · the least positive working environment · family medicine and surgery · working primarily in private hospital/clinic and mission hospital) · much christian healthcare work, but also some secular work settings, many which are not supportive of the christian faith · use the local language or a mix of english and the local language · high level of anxiety, and highest level of depression, experienced · the most improved healthcare system · family medicine 32 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. asia · local health officials favorable, but significant lack of support also · some reports of getting harder to obtain permission to work there, but the highest portion reporting to be getting easier · need of expatriate workers less than other regions · working in government hospital/clinic, or at home more than other regions · least amount of christian healthcare work, with many secular work settings, and many that are not supportive of the christian faith · use the local language or a mix of english and the local language · moderate level of anxiety and depression experienced south and se asia and pacific · improving healthcare system · local health officials favorable, but significant lack of support also · some reports of getting harder to obtain permission to work there, but mostly no change · family medicine and pediatrics · working in private hospital/clinic, or own office or office of a community partner · much christian healthcare work, with many secular work settings, some not supportive of the christian faith · use a mix of english and the local language · lowest level of anxiety and depression experienced table 10 summarizes the findings of this study for each region of the world. it is meant as a guide to organizations and individuals to assist in choosing a location for healthcare missions and knowing how to best support healthcare workers in those regions. there are differences in the range of improvement within countries from the same region, for example, gaza to the united arab emirates or afghanistan to thailand, but the summary in this table serves as a starting point for evaluating the characteristics of the political and healthcare institutions in the region. discussion work situation by region of the world south america based on this research, missionaries in south america work almost exclusively in the local language and in christian ministries. nearly a fifth of them characterize their workplace as in the community. the level of engagement with the local healthcare system is relatively low compared to other regions studied. local health personnel are seen as having a favorable or highly favorable attitude towards the expatriate work less than half the time, and they are very often unaware of the missionary’s contribution. these individuals scored the highest measures of both anxiety and depression of any of the groups surveyed. one third of those responding from this region are nurses, which was higher than the other regions. as in other regions, there is a perception among workers in south america that the health care system is improving. this perception that the local health care systems are doing relatively well along with the relative isolation of christian work from the local systems likely contributes to a sense that the missionary’s contribution is not needed, recognized, or appreciated. this sense may be partly responsible for high levels of distress experienced by these workers. healthcare missionaries in south american countries have excellent language proficiency, so efforts to improve ties with local health systems and personnel could reduce the experience of isolation and give personnel opportunities to bring their gifts to a larger undertaking, which is already perceived as being successful. africa there are more healthcare missionaries and a greater variety of health care work in africa than in the other regions surveyed. personnel in africa have a strong sense of being needed and appreciated. most of them work in english or in a combination of english and a local language. africa is attractive to surgeons. thirty-two surgeons responded from africa, compared to a total of 13 for all the other regions. in addition, many family doctors in africa perform surgery in their work settings. several factors may contribute to this affinity. of all the regions, african workers 33 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. enjoy the most favorable opinion of their local counterparts. the african medical environment is needy. obtaining permission for a surgeon to work is a complex process, so the combination of a needy situation and the high opinion of local coworkers helps to overcome the barriers to placing a surgeon in a productive work setting. the opportunity to contribute to the training of local surgeons is another attractive factor. most health care missionaries in this region work in explicitly christian health ministries. they perceive that local health care systems are slowly improving. in africa, christian ministries are likely to be incorporated into local and national healthcare systems, so missionaries are likely to feel that their personal and corporate input is partly responsible for gradually rising healthcare standards in their area. middle east historically, the middle east has enjoyed a rich history of christian medical ministry. the dedication of workers in this region is reflected by the fact that over half do their work in arabic. the majority of personnel work in explicitly christian settings in clinics or mission hospitals. many have a working relationship with flourishing local churches, but nearly one in five works in settings hostile to the expression of their christian faith. they work in a healthcare environment which is very needy and which, in some cases, is experiencing unprecedented pressures from refugees and immigrants. in some cases, health systems are deteriorating, yet the perceived level of external support for expatriate workers there is the lowest among the regions. in spite of the needs, it is getting more difficult for individuals to obtain permission to work in the nations where they serve. healthcare missionaries in the middle east have relatively high levels of depression and anxiety. this is understandable in the light of ongoing conflict in the region and their difficulty in getting help. the majority of healthcare missionaries in the middle east are family doctors, and the presence of missionary hospitals has made it possible for surgeons to make up the next largest group. there are relatively few nurses serving in this part of the world, though the presence of a number of christian hospitals and clinics suggests that there might be room for more. missiological strategies focusing on countries located in the 10/40 window have increased the sense of urgency in missionaries to take assignments in the middle east. “push factors” from the sending churches are toward the middle east, while “pull factors” of a positive work environment are the least of any region. this creates a tension, the greatest missiological need being out of sync with a hospitable work setting. high levels of anxiety and depression contribute to stress and attrition. the middle east presents an opportunity for individuals who have a robust support system, good language skills, and a desire to work in a particularly needy region. tolerance of physical danger, or perception of danger, to family and self is also important in many countries in this region. asia christian missionary healthcare personnel work in a wider variety of settings in asia than elsewhere. only about a third work in a private clinic or mission hospital setting, while nearly a fourth work in government facilities, and one in six work out of their homes. this is a result of several factors, including difficulty in obtaining medical licensure and securing a work position within a local healthcare institution, as well as the personal preference of some of the healthcare workers posted to these countries. of the half who work in secular settings, about half of those experience an environment that is not supportive of expression of their faith, an even higher proportion than in the middle east region. personnel in asia experience little external support for their work. therefore, a strong team made up of expatriate and local healthcare professionals is critical. four out of five respondents felt that local health services in the region are improving. this was the highest of any region. improving local health services and increasing difficulty obtaining permission for expatriate workers to work con34 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. tributes to a low sense of need for expatriate medical assistance. in spite of these factors, missionaries in asia score lower on measures of anxiety and depression than most other regions. asia had the second largest number of respondents after africa. as in other regions, the most prominent group is family doctors, at about 44%. about a third of the balance is composed of nurses and internists. the breadth of training these generalists receive lends itself to the varied settings in which healthcare missionaries in asia work. missionaries who specifically desire to work outside of christian institutions and who have the dedication necessary to learn the local language will do well to consider asia. these individuals will benefit from a level of self-confidence that allows them to thrive and to live a unique personal christian testimony as they contribute their gifts to a system that is functioning well without obvious need of expatriate support. it is extremely critical that a healthy and functional support system, made up of nationals and expatriates, be in place for workers is these contexts to thrive and be effective over the long term. many asian countries have re-emerging churches, so there are rich opportunities to contribute to the growth of a healthy church in those countries. south and south-east asia and pacific healthcare missionaries in this region of the world experienced the lowest levels of depression and anxiety of the regions studied. several factors may contribute to this relative contentment. in contrast to other regions, nearly half of those surveyed work in office or academic settings, sparing them the rigors of clinical work. nearly a quarter of these personnel work in the office of their organization. over 10% of personnel surveyed work in a university setting, which is the strongest academic engagement among the five regions. workers are unlikely to be very dependent on the local language, with two-thirds working in english or partly in english. the area has the highest percentages of family doctors of any region. it also has the highest percentage of pediatricians and the highest percentage of public health specialists. over two-thirds of respondents work in an expressly christian setting, and nearly nine out of ten find themselves in a setting that is at least tolerant to the expression of their faith. this region had the highest percentage of respondents who reported that the local health system had “greatly deteriorated.” the large number of respondents in this region from the countries of cambodia and nepal may explain this finding. such response bias is one of the weaknesses of the present study. overall, missionaries in this area are comparatively content, and they encounter fewer barriers to moving to this setting. they are very likely to work in a faith-friendly setting. they are less likely to be dependent on knowledge of the local language for their work and less likely to face the challenges, adjustments, and brutal hours associated with assuming a clinical role within the local healthcare system. general observations the reasons for the preponderance of family doctors among missionary personnel are varied and were not addressed by this study. it is notable that surgical and medical specialties such as dermatology, cardiology, endocrinology, obstetrics, plastic and neurosurgery, and public health are valued in the regions studied. surely individuals with these qualifications have an important role to play, but few people are exploiting those opportunities. it is possible that the sample used for this study is biased toward medical doctors, since two of the conferences at which surveys were done were heavily medical in nature. so these results affirm what can be done currently but are certainly not the limit of what can be done. national health systems in all regions of the world, although not necessarily all countries, are improving. ministries of health no longer look to expatriate medical missionaries to provide the bulk of medical services. respondents in this survey observe that getting permission for medical missionaries to serve is getting more difficult in almost all countries. this trend affects the role of the medical missionary. historically, medical 35 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. missionaries were keen to serve the most underserved people. while there are always underserved populations, perhaps a new era characterized by focus on other areas of need has arrived. the opportunity to strategically engage the national health system in its development and have a broader impact is a present possibility. following are several examples of such impact. seven christian denominations and non-governmental organizations in australia have a 10-year papua new guinea community partnerships program to invest long-term in building the country’s healthcare infrastructure. 15 north american family physicians associated with the in his image family medicine residency program have been instrumental in helping the ministries of health of several asian countries establish family medicine as a discipline. 16,17 others have successfully modeled family practice medicine and evidence-based chronic disease management in china’s own community-based clinics. 18,19 in africa many are engaged in improving undergraduate and graduate medical education in partnership with national and local universities and in concert with national ministries of health. 20,21 in africa and india, mission hospitals have served as centers of innovation for surgical procedures and training. 22,23 in other settings, expatriate healthcare workers have been instrumental in conducting collaborative research in a way that increases the research capacity of national partners. 24 all in all, medical missions work is facing increased regulation by the government health agencies in their countries of service. this should be a welcomed change, as it ensures the efforts are in line with national health priorities, and it might bring increased funding or legislation to help with sustainability and impact. individuals and ministries engaged with local or national healthcare systems in projects to improve healthcare education, delivery, or quality may also be less likely to face barriers to gaining permission to work. but it also has the potential to squeeze out small or unique missions efforts or add bureaucracy that the medical mission cannot sustain. mental health those who choose to make a long-term commitment to working in a country other than their “home country” are at risk for experiencing stress, including social isolation, cultural adjustment, and repatriation. 7,8,10 in a review of the literature, foyle and watson reported a high incidence of affective and adjustment disorders among career missionaries. 10,25 the prism study found 60.1 and 65.8% of men and women to have experienced a moderate to serious bout of anxiety, and 45.0 and 55.5% of men and women to have experienced a moderate to serious bout of depression. 26 as a baseline for comparison, the lifetime prevalence of depression among physicians in the u.s. is 12% for men age 45-54 and 19.5% for women, although the method of measurement used was different from that used in the prism study. 27 anxiety and depression are distinct but related psychological conditions, 28 with comorbid anxiety present in 50% of persons with major depression. 29 depression is a pervasive human disorder that affects all spheres of functioning. 30,31 depression has been shown to impact work performance and well-being. 32 research on missionary performance has shown anxiety and moodiness as key indicators of performance. 33-36 more research is needed in the area of mental health of missionaries. there are many factors contributing to dissatisfaction with the balance of work and ministry in the life of a missionary. external factors include long hours, frantic pace, grief, and emotional strain associated with clinical work in an under-resourced facility. lack of time for strictly spiritual ministry may lead to disappointment, frustration, and even guilt. internal factors may prevent a person from creating a satisfying balance. regardless, the attitude of the local health system affects both work satisfaction and mental health. a strong marriage and family are assets to flourishing on the mission field. missionaries need resilience and patience as they cope with the 36 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. challenges of working in that setting. good mental health and resources to cope with periods of stress and anxiety need to be in place ahead of time. the extent of depression experienced by respondents to this survey reflects a significant burden of disease. the small but significant negative correlation between depression score and years of service suggests that the depressive symptoms are not primarily due to endogenous factors such as primary depressive disorder. other factors either produce depressive symptoms directly or stimulate depressive symptoms in persons with a depressive vulnerability. anxiety, on the other hand, is more sensitive to the context in which one works. pre-field security training to include risk assessment, contingency planning, and measures to mitigate risk are strongly recommended. this study reveals a need for research that can inform strategic planning of healthcare missions and can help individuals make informed decisions about desirable settings for healthcare missions. such research could shed light on strategies to overcome challenges and to take full advantage of opportunities present in a given setting. a more complete description of what types of healthcare mission work is occurring in countries or regions of the world are needed. some measure of success is needed in order to evaluate which of the many healthcare mission approaches are effective, and what variables contribute to that effectiveness. the literature is virtually silent on the perceptions of officials or local healthcare workers in the host countries toward the value brought by expatriate workers and their organizations. research methods that include those individuals is very much needed. limitations the main threat to the validity of this study is selection bias. those who chose to participate were not randomly chosen and may not represent the broader healthcare missions community. additionally, the sample is made up of north american evangelical healthcare missionaries. therefore, the study is missing significant contributions from roman catholics, individuals serving in ecumenical organizations, and individuals who are working in secular global health organizations. furthermore, by limiting the study to english-speaking respondents, the input of healthcare missionaries from countries such as brazil, korea, and many others is absent. the researchers designed the instrument used in this study and limited external validity analyses were performed. this is a limitation of the study. it is the intention of the authors to use this instrument with other samples of medical missionaries to more rigorously test its validity. another limitation is the cross-sectional nature of the study, which does not allow the determination of a temporal relationship of anxiety/depression and other reported variables. there is significant country variability within a given region, so although regions have been generalized, one would need to look carefully at each individual country to understand the circumstances and details present there. additionally, the responses are the subjective opinion of the healthcare missionaries themselves, so the degree to which they accurately reflect the local situation is probably of varying validity. conclusion the work of global healthcare missions continues to have a large impact on the health of people in need. the challenges facing today’s health care professional working overseas are different than in the past. it is the intention of the authors to provide healthcare mission candidates and organizational leaders with an overview of the changing global context and current opportunities and challenges facing them. despite changes, with creativity, flexibility, and some specialized pre-field training, there remain large arrays of opportunities. for example, healthcare missions afford many opportunities, ranging from holistic ministry to healthcare system redesign. the healthcare missionaries surveyed were working in primary care or in private or government clinics, in most settings, with more surgery being performed in africa and the middle east. the 37 strand, paulson & myrick nov 2015. christian journal for global health 2(2): 23-38. work of healthcare missionaries occurs within a political context. while open opposition or hostility toward these expatriate healthcare missionaries is rare, the degree to which they are welcomed or understood varies by region. although the local healthcare systems are generally improving, the work of the healthcare missionaries is not associated significantly with the local healthcare system and has limited impact on it. this will need to change in order to increase the impact and strengthen the sustainability of this work. references 1. johnson t. christianity in its global context, 19702020: society, religion, and mission. southhampton, ma: center for the global study of christianity; 2013. 2. jaffarian m. the statistical state of the north american protestant missions movement. in the mission handbook, 20th edition. international bulletin of missionary research 2008;32:35-8. 3. panosian c, 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satisfaction-job performance relationship: a qualitative and quantitative review. psychol bull. 2001;127:376407. http://dx.doi.org/10.1037/0033-2909.127.3.376 36. cousineau a, lewis hall m, rosik c, hall t. predictors of missionary job success: a review of the literature and research proposal. j psychol chr. 2010;29:354-63. peer reviewed competing interests: none declared. correspondence: mark a strand, phd, north dakota state university, 118l sudro hall, fargo, nd, 58101. fax: 701-231-7606. mark.strand@ndsu.edu cite this article as: strand, ma, paulson, e and myrick, t. characterizing the global context for cross-cultural healthcare work by regions of the world. christian journal for global health (nov 2015), 2(2):23-38. © strand, ma, paulson, e and myrick t. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org http://www.globalsurgery.info/wp-content/uploads/2013/10/global-surgery-teaching-cases_rev2-2-copy.pdf http://www.globalsurgery.info/wp-content/uploads/2013/10/global-surgery-teaching-cases_rev2-2-copy.pdf http://www.globalsurgery.info/wp-content/uploads/2013/10/global-surgery-teaching-cases_rev2-2-copy.pdf http://dx.doi.org/10.1007/s12262-007-0034-0 http://dx.doi.org/10.1007/s12262-007-0034-0 http://journal.cjgh.org/index.php/cjgh/article/view/53 http://dx.doi.org/10.1001/jama.289.23.3161 http://dx.doi.org/10.1037/0021-843x.100.3.316 http://dx.doi.org/10.1016/s0006-3223(96)00440-4 http://dx.doi.org/10.1016/j.cpr.2011.07.004 http://dx.doi.org/10.2147/ndt.s19617 http://dx.doi.org/10.1097/jom.0b013e31816bae50 http://dx.doi.org/10.1080/13674670903312427 http://dx.doi.org/10.1037/0033-2909.127.3.376 mailto:mark.strand@ndsu.edu http://creativecommons.org/licenses/by/3.0/ original article nov 2014. christian journal for global health, 1(2):71-80. community health global network: “clustering” together to increase the impact of community led health and development marianne safe a , nathan grills b , elizabeth wainwright c , ted lankester d a mbbs, nossal institute of global health, university of melbourne, victoria, australia b mbbs, mph, dphil, nossal institute of global health, university of melbourne, victoria, australia c msc, ncta, managing director, community health global network, london, uk d ma, mb, bchir, mrcgp, fftm, rcpsglasg, community health global network, london, uk abstract background: community health global network (chgn) is a collaborative network, founded to strengthen collaboration between community-based health programs many of which are faith based initiatives. it seeks to address this in two ways: through its global network of players in community health and in the formation of “clusters.” chgn clusters are networks of community health programmes and individuals in specific geographical locations. this case report outlines the formation of the kenya cluster. aims: to describe the steps in the formation of the kenya cluster and to outline the primary outcomes and potential impact of the network. to discuss how learning from the kenya cluster may assist other established clusters and the initiation of new clusters. method: information for this case report was gained from meetings and consultations with various individuals including leaders and members of the kenya cluster, other national community health experts, chgn international staff and advisors to chgn uttarakhand cluster in india. in addition, information was gained from personal observation during in-country field work. results: the kenya cluster is emerging as a platform for community health programs to connect and network. these connections have led to transfer of information through stories, best practice, training, contacts and opportunities amongst cluster members. the cluster has also established links with government and multilaterals enabling greater access to support at the community level. conclusions: there is early indication that the formation of the kenya cluster is supportive of the cluster model as a unique way of strengthening collaboration between community health programs. clusters have the potential to improve the link between faith-inspired initiatives and secular and multilateral development organisations. lessons from the kenya cluster can progress the development of other clusters. further evaluation will be conducted to assess the impact of the kenya cluster and the overall impact of the cluster approach. 72 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. introduction one of the key barriers to universal health coverage is multiple actors poorly coordinated. 1 to counteract this weakness in global health, there is growing evidence that networking and intentional collaboration between community health programs can improve service delivery and promote greater impact. 2,3 a number of terms are used in the literature to describe the ways community health programs can work together. agranoff and mcguire define networks as “the process of facilitating and operating in multi-organisational arrangements to solve problems that cannot be solved, or easily solved, by a single organisation.” 4 the terms consortia and collaborative are typically used to describe similar organizations that benefit more from collective actions than as individual players. the term coalition tends to refer to groups of different organizations whose interests converge or overlap but who have separate agendas and interests. collaboration usually implies a closer working together and is often more intentional. 5,6 community health global network (chgn) was founded in 2005 in response to a perceived lack of collaboration between community-based health programs and initiatives. chgn works in two ways: 1) through a global network of over 700 community health workers (chws), programme managers, policy makers, faith-leaders, academics, students and others using this platform to circulate information, training, stories and expertise through regular bulletins, a website and social media and 2) through local community-centred movements or “clusters” of people and programmes involved in the diverse social determinants of community health. clusters have been established in india, bangladesh, zambia and kenya and are emerging in other countries including myanmar (burma). this article describes the formation of the kenya cluster including its outcomes and potential impact, and how experience gained can progress the development of other clusters. the cluster model according to observations by community health expert and chgn‟s co-founder, dr ted lankester, in any given area there were many small, struggling health programmes, mostly funded by outsiders, each doing their own thing . . . they are often not linked with other charities or local government services and usually unaware that 10 miles down the track another group are doing almost exactly the same thing for the population they are serving. in areas of great need there is overlap, competition, and ineffective coordination of ngos and other healthcare organisations. (personal communication, feb 2013) through its global network and local movement through clusters, chgn aims to connect health initiatives, ensure they are appropriately informed and increase their influence and impact on a local, national and international scale. chgn clusters are groups of community health programmes and individuals in specific geographical locations. representatives of programmes, as well as community health workers, faith leaders, community leaders and others, seek to collaborate on mutually agreed activities with the vision of improving health and well-being in the areas where they live and work. chgn has developed the “connect, inform, influence” concept to facilitate the cluster development process (figure 1). the intention is that cluster members focus on trustbuilding and connection, resulting in both mutual encouragement and effective collaboration. these connections can lead to transfer of information – through stories, best practice, training, contacts and opportunities amongst cluster members and beyond. the cluster has the potential to become the 73 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. “go-to” source for those involved in community health learning and action in the region where it operates. this enables the government and other actors to engage with one authentic voice from that community. through this process the cluster model can begin to influence health policy at a regional level (as seen in the chgn uttarakhand cluster). in turn this contributes to the strengthening of health systems, a priority in global health. we believe the cluster model is distinctive from other collaborative initiatives. the collaboration is „bottom-up‟ in that the clusters themselves define their operating principles, membership, agenda and action plans. it allows for highlighting local strengths and resources and helps grass roots responses to issues. figure 1: cjgh focuses on three key themes as a guide for cluster formation, growth and impact. rationale for a kenya cluster according to the kenyan ministry of health, “a large proportion of kenyans continue to carry one of the highest preventable burdens of ill health in the world. much of this burden can be lifted and prevented with existing knowledge and resources.” 7 why is this still the case despite the abundance of development agencies in kenya? sylvia ngatia, a missionary public health officer, believes that local programmes need to be working together effectively to have an impact: “if we truly want to help the community, why don‟t we hold hands?” (personal communication, april 2013) a leader in an international child health organisation commented similarly: “this is why we need to network. we can be working on the ground in our own corners and we may not realize an expert is close by." (personal communication, viva international, april 2013) consequently, there has been a growing desire for a platform to share ideas, resources and training, and to avoid overlap and duplication. with these principles in mind chgn was invited by leaders of community health programmes to seed a cluster in order to decrease programme isolation and promote connectedness. formation of the kenya cluster pre-cluster launch visits prior to the cluster launch chgn staff and associates visited kenya and met with key individuals who would act as potential cluster champions. two separate nationals had heard of the cluster concept by word of mouth and the chgn website and invited chgn staff to visit their communities. communication between chgn and these nationals continued and an initial two 74 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. week visit was followed up with a two month stay by a chgn staff member. these visits involved outlining the cluster vision and potential, identifying participants and exploring the wide variety of benefits. the time taken in developing trust and relationships has proven to be vital to the cluster model. in the analysis of the uttarakhand cluster by grills et al, the key pioneers are referred to as “brokers” and were found to be “crucial in network formation.” 3 . a similar pattern emerged in kenya. it was important that chgn associates stayed within the community and, if invited, lived with the potential members. this often involved travelling to remote areas. when discussing ways to build and sustain the cluster, one member, speaking to the chgn staff, said, “we value your opinion on this, you‟ve been here, lived with us and see how we work and now we have built trust.” (personal communication, mathew owili, education and health manager, world vision kolowa, oct 2013) coming alongside local change-makers and champions three key champions were identified on the basis of being trusted by their communities and linked to either government or local universities. chgn staff built relationships with these members, listened to their vision for a cluster in the region and brought them together. the champions also acted as connectors and networkers. identifying key champions who were respected and trusted members of their communities encouraged and motivated others to join the emerging cluster. 3 these champions and chgn staff met with a large cross-section of people of various programmes to discuss if and how they would benefit from being part of a cluster and to invite them to the cluster seminar. cluster seminar and launch in may 2013, a five-day planning seminar was held and this culminated in the launch of the chgn kenya cluster. over 30 community health workers, representatives of community programmes, faith leaders, community leaders, local and district government officials and university representatives from the tropical institute of community health and development gathered together to share personal experiences and jointly determine priority areas. the “connect, inform, influence” themes developed by chgn to facilitate the cluster process were introduced at the seminar. members used a self-assessment tool (provided by affirm associates) to analyse their current situation within these themes, and to develop their vision for moving forward. they also shared existing concerns and explored appropriate regional solutions. a significant proportion of the seminar was facilitated by the cluster champions. this increased local ownership and relevance. towards the end of the launch, a leadership team was elected by the members to progress the vision. salt methodology chgn worked with affirm associates to introduce the “salt” methodology during the seminar. salt is a widely used way of working based on identifying the strengths and assets of community members. it focusses on encouraging and measuring the way in which individuals and communities respond with hope and enthusiasm to shared challenges. salt is a mnemonic for stimulate, appreciate, learn and transfer. it is practised during household or neighbourhood visits, encouraging facilitators to be “learners” rather than “teachers” in order to identify strengths and concerns within a community. by identifying strengths at a household level these solutions can be transferred household to household to create a community movement and a locally relevant shared response to various issues (figure 2). 8 75 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. during the cluster seminar, members conducted salt visits in nearby households. this was a clear way of demonstrating how connections could be made, how neighbourhood strengths and concerns could be recognised and how “community owned” action plans could emerge. case study: tackling female genital mutilation jn is a chw in east pokot, north rift, kenya from the pokot tribe. using the salt methodology which she learned about through the cluster, the subject of female genital mutilation (fgm) was raised by the students during a secondary school visit. this was remarkable, in a place where fgm is widely practiced but rarely discussed. jn knows first-hand how the dangerous practice means girls are forced out of school and into early marriage. around four fifths of girls who undergo fgm are not in school, or drop out of school afterwards. as a result of this encounter, jn has committed to regular visits with the school to encourage the girls to remain in school and prevent further fgm practices in the current generation. she hopes to continue to talk to the girls about existing solutions, and to support the girls in identifying and achieving their hopes and visions. she will link the concerns there with the work of the chws and with other community health initiatives in the region. sub-clusters one of the unique features of the kenya cluster is the existence of sub-clusters. kenya cluster leaders introduced sub-clusters because members were spread geographically. this is referred to as low geographical homiphily in social network theory. 3 the sub-clusters helped provide geographically relevant connections, a platform for advocacy, mutual encouragement, and local communities of learning. local sub-clusters are represented in the larger kenya cluster, the platform where their voices could be heard (figure 3). ngoron sub-cluster members of the kenya cluster from the relatively isolated area of ngoron in east pokot requested sub-cluster facilitation in their area. this sub-cluster facilitation was done by a national facilitator and chgn international staff. acknowledging the challenges faced by the community in accessing medical services, the sub-cluster works together on community health programs based on the kenyan government‟s community health strategy. 7 this strategy identifies the need for a holistic approach to community health, where physical health is not separated from other facets of wellbeing, such as socioeconomic development, spiritual beliefs and education. therefore, the sub-cluster has chosen to include the region‟s church, agricultural and school leaders to work together with community leaders, ngos and health workers on the implementation of the community health programmes. figure 2: use of salt to stimulate community conversation at local level 76 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. figure 3: chgn clusters. arrows represent two-way sharing and learning cluster follow-up meeting six months after the launch of the kenya cluster, a meeting was held to consolidate and strengthen connections. stories were shared, and salt refresher training was given. kenya cluster leaders facilitated a discussion to develop draft vision and mission statements: draft vision: “to see holistically healthy and transformed communities.” draft mission: “to provide a platform to connect, inform and influence for positive change in our communities.” developing the vision and mission statements provided a foundation and general direction for the cluster and increased the unity of the group. a list of common concerns was also developed which included sanitation, community health worker provision, malaria, hiv, connectedness and farming/irrigation. these concerns will provide a framework for future training meetings and collaborative cluster projects. cluster members also initiated a communal cluster fund by each making a small contribution. chgn contributed hospitality for the initial cluster seminar and some subsidy for accommodation during the seminar. the cluster‟s leadership team directed current cluster activities and goals. they worked with the chgn international team who facilitated, supported, signposted, offered solutions and links, and disseminated information or trainings. outcomes the initial outcomes noted within the kenya cluster fit within the concept areas of “connect, inform and influence.” connect the kenya cluster is being used for networking between community-based organisations, pastors, health workers, non-governmental organisations, the university sector and the government. the cluster has put together a member directory, with information about roles and areas of knowledge. as an example, the kenya cluster has linked a health worker in east pokot to the 77 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. other members in the region. he is now assisting these members by providing immunisations to their community health programs. other members have plans to assist him with community health worker training. connections through the kenya cluster are facilitating links between faith based organisations, secular development agencies, and the government. kenyan community health professor charles wafula comments: "why is it we have good scientific health systems but when it comes to social implementation we fail? what is the missing link? so much has been invested in africa but the health outcomes are still poor is the african man trapped? and if so by what?” 9 among others, he believes one “missing link” is the addressing of african traditional beliefs within communities. through the cluster the tropical institute of community health, the africa gospel church, the community health empowerment (che) program and the government are planning to work together to implement aspects of the community health strategy. in addition, the various ways through which african traditional beliefs can affect health will be addressed. there are plans for the university to monitor the impact of this unique approach. in addition, recognition and appreciation from both community and colleagues is cited as a key factor in motivating and retaining health workers, sometimes over financial incentives. 10 similarly, many cluster members explained the benefits of connecting with those doing similar work and having their own work recognised. those working in remote areas emphasised that this motivated and encouraged them to continue in their workplace despite various hardships. inform the cluster model in kenya is being used to inform its members at various levels:  cluster members have been sharing stories, ideas and information with each other.  chgn staff have shared stories and learning from the uttarakhand cluster in north india, showing the value of global crosslearning.  the cluster forum will be used for training on thematic topic areas like irrigation and malaria, but also to share ways of working such as use of the salt methodology.  a toolkit of resources (e.g. best practices, fundraising, communication tools) is being compiled by chgn. members will be able to access the relevant tools both through cluster meetings and online. influence existing multilateral organisations in kenya, such as the world health organisation (who), have both direct and indirect engagement with community-based health initiatives. conversely, faith-based, ngo-related and community-based chw programmes often have their own arrangements for health workers. therefore, it is not uncommon for there to be barriers to communication between these two sectors. 11,12 with this in mind, the cluster as a collective provides a representational focus for the government and multilaterals to engage with civil society organisations at local and district levels. for example, the cluster has established links with the ministry of health, the international one million community health workers campaign (see below), and with the university sector, enabling greater support to be available at the community level. a prominent example of the kenya cluster‟s current influence is through their involvement in the one million community health workers campaign, an initiative of the united nations sustainable development solutions network and the earth institute of colombia university. this campaign seeks to train and support increased numbers of chws across subsaharan africa. 13,14 chgn is on the steering council for the campaign at an international level, and is linked with the campaign in-country, 78 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. through the kenya cluster. there is much enthusiasm amongst cluster members as the need for chws was identified as a cluster priority. the cluster feels their involvement can ensure the campaign reaches areas of need. the link is also meeting the campaign‟s intention to build on systems and initiatives which are already established. challenges the cluster includes diverse members from diverse organisations and, as expected, there were preconceived ideas about how chgn would operate. some prospective members presumed that attending the launch would lead to direct financial benefits to their program. others presumed that chgn would be rolling out a program according to its own agenda rather than accompanying and connecting established programs. time was taken to correct such mis-preconceptions. unlike other clusters, the kenya cluster is geographically wide-spread. this presented some logistical challenges regarding travel distances and cost and these issues may alter the frequency of future full cluster meetings. prospective members from various remote areas were invited intentionally in order to include those who were relatively isolated. despite this challenge, it is hoped that specific outcomes will be addressed at sub-cluster level and the national cluster will be used as a platform for strategic discussion and amplifying voices for important needs and challenges. lessons and recommendations 1. trust and relationships were key to the cluster formation and time should be taken to build these when initiating future clusters. 2. a cluster model can link primary health care programs working at the community level to larger, more traditional vertical programs e.g. national and international antimalaria or hiv programs. these smaller community led initiatives can become part of or stimulate a larger community movement, ultimately increasing the impact of the vertical programs. 3. a cluster can represent members of different disciplines of community health. over time, it can become a platform to address locally relevant social determinants of health. the importance of such holistic approaches to healthcare has been highlighted in the lancet and london international development centre commission‟s analysis of the millennium development goals. this analysis emphasized the need for, “local interventions in poverty reduction, health, education, and gender equality coming together for the same groups of people,” when setting goals post 2015. 11 4. only minimal start-up funds were provided in the formation of the kenya cluster. this has encouraged the members themselves to contribute financially and in directing the cluster. such an approach seems to promote local ownership and contributes to such a network becoming self-sustaining. 5. it is reported that 40% of kenya‟s health service is provided by affiliates of the christian health association of kenya (chak) and kenya episcopal conference (kec). 15 a cluster can be used, as is the case in kenya, to better understand the role of faithinspired initiatives and improve their linkage with secular and multilateral development organisations. there is opportunity for both groups to come together to share ways of working and best practices, and chgn will feed into this dialogue using learning that is coming from local community movements, and from the global network. chgn is founded on christian values and beliefs, and on humanitarian principles, and is inclusively open to all those who are committed to making the world a healthier, better and fairer place. 79 safe, grills, wainwright and lankester nov 2014. christian journal for global health, 1(2):71-80. conclusion the recently formed kenya cluster of chgn is emerging as a well-connected and informed platform that can support specific and tangible priorities in different regions through its sub-clusters. the cluster will continue to be accompanied and supported and its impact will be monitored. lessons learnt can be taken from the kenya cluster to bring new ideas to other established clusters and also to inform the initiation of new clusters. in 2015, members from three clusters will meet for further sharing and analysis of both community response and the overall impact of the cluster approach. references 1. tulenko k, et al. community health workers for universal health-care coverage: from fragmentation to synergy. bull world health organ. 2013; 91:847–852. http://dx.doi.org/10.2471/blt.13.118745 2. grills nj, porter g. networking between community health programs: a team-work approach to improving health service provision. bmc health services 2013 (under review). 3. grills nj, et al. networking for health: the uttarakhand case study bmc health services 2013;12:206 4. agranoff, r, mcguire m. collaborative public management: new strategies for local governments. 2003. washington, dc: georgetown university press. 5. kegler m et al. how does community context influence coalitions in the formation stage? a multiple case study based on the community coalition action theory. 2010. bmc public health, 10:90. http://dx.doi.org/10.1186/1471-2458-10-90 6. kendall e et al. collaborative capacity buidling in complex community-based health partnerships: a model for translating knowledge into action. 2012, 18(5). 7. kenya ministry of health. taking the kenya essential package for health to the community: a strategy for the delivery of level one services. ministry of healthhealth sector reform secretariat 2006. 8. salt approach [internet]. community life competence; [updated 2012; cited 2013 jan 20]. available from http://www.communitylifecompetence.org/en/pages/3 5-salt-approach 9. wafula c. plenary: outcomes of the implementation of the kenyan community health strategy. presented at: tropical institute community health and development annual scientific conference; 2013 april 29-may 2; kisumu, kenya. 10. willis-shattuck m, et al. motivation and retention of health workers in developing countries: a systematic review. bmc health services research. 2008; 8:247 http://dx.doi.org/10.1186/1472-6963-8-247 11. waage j, et al. lancet and london international development centre commissionthe millennium development goals: a cross-sectoral analysis and principles for goal setting after 2015. the lancet. 2010; 376: 991–1023. http://dx.doi.org/10.1016/s0140-6736(10)61196-8 12. grills nj. the paradox of multilateral organisations engaging with faith based organisations. global governance. 2009; 15(4):505-520. 13. singh p, sachs jd. 1 million community health workers in sub-saharan africa by 2015. the lancet. 2013; 382:363-365. http://dx.doi.org/10.1016/s01406736(12)62002-9 14. one million community health workers campaign. [updated 2014 jan 17, cited 2014 jan18]. available from: http://1millionhealthworkers.org/ 15. a key piece of the puzzle: faith-based health services in sub-saharan africa [internet]. usaid; [updated 2007 dec, cited 2014 jan 18]. available from: http://www.capacityproject.org/index.php?option=com _content&task=view&id=233&itemid=108 http://dx.doi.org/10.2471/blt.13.118745 http://dx.doi.org/10.1186/1471-2458-10-90 http://www.communitylifecompetence.org/en/pages/35-salt-approach http://www.communitylifecompetence.org/en/pages/35-salt-approach http://dx.doi.org/10.1186/1472-6963-8-247 http://dx.doi.org/10.1016/s0140-6736(10)61196-8 http://dx.doi.org/10.1016/s0140-6736(12)62002-9 http://dx.doi.org/10.1016/s0140-6736(12)62002-9 http://www.capacityproject.org/index.php?option=com_content&task=view&id=233&itemid=108 http://www.capacityproject.org/index.php?option=com_content&task=view&id=233&itemid=108 80 strand and cole nov 2014. christian journal for global health, 1(2):71-80. peer reviewed competing interests: none declared. supporting agencies: nick henwood, chgn; ian campbell, affirm associates; gillian porter, nossal institute of global health. correspondence: marianne safe, nossal institute of global health, melbourne, australia. mazsafe@hotmail.com for more information and to become a chgn member please visit www.chgn.org cite this article as: safe ma, grills n, wainwright e, lankester t. community health global network: “clustering” together to increase the impact of community led health and development. christian journal for global health (november 2014), 1(2):71-80. http://dx.doi.org/10.15566/cjgh.v1i2.9 © safe ma, et al. this is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/ www.cjgh.org mailto:mazsafe@hotmail.com http://www.chgn.org/ http://dx.doi.org/10.15566/cjgh.v1i2.9 http://creativecommons.org/licenses/by/3.0/